Global Health Challenges - European Health Forum Gastein

Congress report 

7th European Health Forum Gastein 

Global Health Challenges 

European approaches and responsibilities 

Bad Gastein, Austria 

6 to 9 October 2004 

Website: www.ehfg.org

Organiser: International Forum Gastein 

Co-organisers: Federal Ministry of Health and Women 

European Union Committee of the Regions 

Austrian Broadcasting Corporation 

With the support European Commission, DG Health and Consumer Protection 

of and in European Observatory on Health Care Systems 

collaboration with: Land Salzburg 

Organization for Economic Cooperation and Development 

World Bank 

World Health Organization, Regional Office for Europe 

Programme Paul Lincoln, National Heart Forum, UK (Chair of Advisory Committee) 

coordination: Paul Belcher, Royal College of Physicians, London; Eurohealth – LSE Health 

(Plenary Programme Adviser) 

Louise Sarch, National Heart Forum, UK (Plenary Programme Coordinator) 

Programme Maggie Davies, Health Development Agency 

organisers: Elizabeth Docteur, Organization for Economic Cooperation and Development 

Michael Hübel, European Commission, DG Health and Consumer Protection 

Michaela Moritz, Ingrid Rosian, Sabine Vogler, Österreichisches Bundesinstitut 

für Gesundheitswesen 

Matthias Schuppe, International Forum Gastein 

Hans Stein, European Observatory on Health Care Systems 

Publisher: Günther Leiner 

International Forum Gastein 

Tauernplatz 1, 

5630 Bad Hofgastein 

Austria 

Editors: Günther Leiner 

Alexandra Illmer 

Matthias Schuppe 

ISBN 3–9500989–7 

Produced in Austria, 2005

In memory of 

Louise Claire Frances Sarch 

7 October 1968 – 3 July 2004

We would like to thank the following institutions, organisations and companies for their expertise, 

generous support, sponsorship and fruitful cooperation which makes the European Health Forum 

such a successful event and without whom we would not have been able to realise our goals. We 

are looking forward to continue this partnership on our way towards 

Creating a better future for health in Europe 

Supporters: Austrian Broadcasting Corporation 

Federal Ministry for Health and Woman 

Communities Bad Hofgastein and Bad Gastein 

EU Committee of the Regions 

European Commission, DG Health and Consumer Protection 

European Observatory on Health Care Systems 

Land Salzburg 

Organization for Economic Cooperation and Development 

World Bank 

WHO Regional Office for Europe 

Sponsors, hosts Austrian Airlines, Lauda Air, Tyrolean Airways 

and organisers: Bureau of National Health Insurance of Taiwan 

EuroHealth 

F. Hoffmann - La Roche Ltd. 

Gasteiner Bergbahnen AG 

Gasteiner Quellversand 

Gasteiner Tourismus GmbH 

Kur- und Tourismusverband Bad Hofgastein und Bad Gastein 

Kur- und Vitalzentrum Bad Hofgastein 

Merck, Sharp & Dohme (MSD) 

The Nuffield Trust for Research and Policy Studies in Health Services 

Österreichische Ärztekammer 

Pago 

Pharmig 

Pfizer 

Telekom Austria 

World Health Organization 

Wirtschaftskammer Österreich 

Supporting Bureau of National Health Insurance of Taiwan 

and Associate Fachverband der chemischen Industrie Österreich, Gruppe Pharmazeutika 

Members: GlaxoSmithKline 

Hilfswerk Austria 

F. Hoffman - La Roche Ltd. 

Merck, Sharp & Dohme (MSD) 

Österreichische Ärztekammer 

Pharmig 

Telekom Austria 

Wirtschaftskammer Österreich

The International Forum Gastein would like to gratefully acknowledge the important contributions the 

following experts have made to programme planning and the overall organisation of the event 

through their work in the Advisory Committee of Experts or through providing individual support and 

advice: 

Sibylle Angele Gesellschaft für Versicherungswissenschaft und –gestaltung (GVG) 

Walter Baer European Commission 

Paul Belcher European Health Management Association (EHMA) 

Ulrich Bode Pharmig Austria 

Nick Boyd Department of Health (UK) 

Reiner Brettenthaler Standing Committee of European Doctors (CPME) 

Peter Brosch Bundesministerium für Gesundheit und Frauen 

Reiner Buchegger University of Linz 

Graham Chambers European Parliament 

James Copping European Commission 

Maggie Davies Health Development Agency (HDA) 

Paul de Raeve Standing Committee of Nurses of the EU (PCN) 

Rolf Engelbrecht European Federation of Medical Informatics (EFMI) 

Armin Fidler World Bank 

Josep Figueras European Observatory on Health Care Systems 

Marilies Flemming European Parliament 

Ursula Fronaschütz Bundesministerium für Gesundheit und Frauen 

Pascal Garel Fédération Hospitalière de France (FHF) 

Harald Gaugg Bundesministerium für Gesundheit und Frauen 

Frank George WHO Regional Office for Europe 

Erwan GICQUEL Europabio 

Flora Giorgio Pharmaceutical Group of the European Union (PGEU) 

Michael Hübel European Comission 

Andreas Kiefer Land Salzburg 

Virpi Köykkä European Parliament 

Eero Lahtinen Ministry of Social Affairs and Health 

Paul Lincoln National Heart Forum (NHF) 

Brigitte Magistris Bundesministerium für Gesundheit und Frauen 

John Martin World Health Organization (WHO) 

Kevin McCarthy European Commission 

Martin McKee London School of Hygiene and Tropical Medicine 

Elias Mossialos London School of Economics and Political Science, LSE Health 

Clive Needle European Network of Health Promotion Agencies (ENHPA) 

Martina Pellny Gesellschaft für Versicherungswissenschaft und –gestaltung (GVG) 

Eberhard Pirich Fachverband der chemischen Industrie Österreich 

Paulo Rocha Trindade EU Committee of the Regions 

Tamsin Rose European Public Health Alliance (EPHA) 

Magdalene Rosenmöller IESE International Graduate School of Management 

Anne-Marie Sacre-Bastin Ministère fédéral des Affaires sociales, de la Santé publique et de 

l'Environnement 

Xenia Scheil Adlung International Social Security Association (ISSA) 

Markus Siebert Eucomed 

Hans Stein Regierungsrat a.D. 

Brian Synnott European Federation of Public Service Unions (EPSU) 

Michèle Thonnet European Health Telematics Association (EHTEL) 

Eva Török Hungarian Mission to the EU 

Albert Van der Zeijden International Alliance of Patients Organisations (IAPO) 

Céline Vandoosseleare European Health Telematics Association (EHTEL)

Co-organisers 

Sponsors

Contents 

7th European Health Forum Gastein 2004 

Global Health Challenges: European approaches and responsibilities

Contents 

Preface 

��David Byrne 12 

��Maria Rauch-Kallat 13 

��Günter Leiner 14 

Gastein Health Declaration 2004 

��Günter Leiner A message from the President 17 

��General EHFG recommendations on the main theme: 18 

Global Health: Europe’s Approaches and Responsibilities 

Plenary session I: Opening 



��Anders Gustav 32 

Plenary session II: Global health – the 21st century challenge 

��Marc Danzon Text not available 

��Jacques Baudoy Text not available 

��Corinna Hawkes Avoidable chronic diseases: the neglected global 36 

epidemic 

��Indu Capoor Unveiling realities of the South Asian region to 39 

achieve Millennium Development Goals 

Plenary session III: Europe’s role – partners in world health 

��John Wyn Owen Chairman’s introductory remarks 54 

��Julio Frenk Health and global security: a perspective from 55 

the rest of the world 

��Roel Bekker Opportunities for developing policy at member 61 

state level and during the EU presidency’ 

��Ilona Kickbusch Global public health in the 21st century – 66 

a challenge for Europe 


Global Health Challenges: European approaches and responsibilities 2

Contents 

��David Byrne A global health strategy for the European Union 72 

Forum AI: Values, principles and objectives of health policy in Europe 

��Ilona Kickbusch The need for common values, principles and 79 

objectives for health policy in a changing Europe 

The rights of the European citizen: Balancing equity with choice 

��Ulrich Becker The rights of the European citizen: 96 

Balancing equity with choice 

��Yves Jorens The rights of the European citizen: 104 


��Theresa Petrangolini Text not available 

The European potential for value-orientated health policies 

��Simon Stevens The European potential for value-oriented 113 

health policies (abstract) 

��Josep Figueras Text not available 

��Manuela Messmer-Wullen Das ehrenamtliche Engagement von Individualisten 114 

in Patientenorganisationen und Selbsthilfegruppen 

auf nationaler und europäischer Ebene (abstract) 

Governance and health targetting experiences and future potential 

��Matthias Wismar Text not available 

��Luise J Gunning-Schepers Shaping the future to meet our needs (abstract) 116 

��Birgit Weihrauch Lessons from North Rhine-Westphalia 117 

The Madrid Framework – an instrument for consensus 

��Marshall Marinker The Madrid Framework 121 

The social Europe of the future – Moving from national to European solidarity 

��Mihaly Kökény National health improvement in the service of 126 

fighting inequalities (abstract) 

��Martin McKee The social Europe of the future – Moving from 127 

national to European solidarity (abstract) 

��Kimmo Leppo The social Europe of the future – Moving from 128 




Contents 

Panel and open discussion 

��Hans Stein Introduction: The potential for international cooperation 130 

in establishing common health values that can be 

embraced on all levels 

��Angela Coulter Values, principles and objectives of health policy 133 

in Europe 

��Bente Nielsen The need for common values, principles and 134 


��Andrzej Rys Summary 135 

Forum AII: Promoting social inclusion in Europe: putting mental health on the agenda 

Setting the scene: barriers to social inclusion 

��Judith Klein Disability Advocacy Programme 144 

Open Society Institute Budapest 

��Matthew Muijen Text not available 

��Ignacio Pérez Caldentey Mental health as a human rights issue 150 

��Rachel Jenkins Supporting governments to adopt mental health policies 153 

What do we want to achieve? What are the challenges? 

��Camilla Parker Mental health policy, human rights and the law 163 

��Hristo Hinkov Mental health reform in Bulgaria (abstract) 168 

��Andy Porter Reforming mental health services in England 169 

Meeting the challenges 

��John Bowis Focusing on the solutions: what should governments 172 

consider in developing mental health policies? 

��Martin Knapp Financing mental health reforms – what does it cost? 178 

��Toma Tomov Developing mental health policy and legislation 182 

Panel discussion 

��Petko Salchev Text not available 

��Clemens Huitink Text not available 

��Ann Tucker Text not available 

��Zsolt Bugarsky Text not available 

��Stefan Bandol Exploring normality 188 



Contents 

��John Henderson Text not available 

��Michelle Funk Promoting social inclusion in an enlarged Europe – 191 

International cooperation and involving stakeholders 

in the mental health reform process 

��Ignazio Perez Text not available 

��Dainius Puras Vicious circles of social exclusion – attempts to 194 

diagnose and cure mental health systems in 

Eastern Europe 

�� Armin Fidler Is the incorporation of public hospitals the ‘silver bullet’ 198 

Reinhard Haslinger to address overcapacity, managerial bottlenecks and 

Maria Hofmarcher resource constraints in the EU? 

Toomas Palu Examples from Austria and Estonia 

��Monalisa Norman Text not available 

��David McDaid Summary 206 

Forum AIII: Pharmaceutical policy in the enlarged Europe 

Part I: Pricing, reimbursement and innovation 

�Hugo Hurts Priority medicines and pharmaceutical 213 

policy under the Dutch EU Presidency 

�Paul Weissneberg Text not available 

�Imre Holló Text not available 

�Brian Ager Text not available 

�Kees de Joncheere Affordability of pharmaceuticals in the 218 

enlarged Europe (abstract) 


�Ingrid Rosian-Schikuta Introduction and overview 219 

�Paul Bundgaard The pharmacists’ perspective 220 

�Rui Santos Ivo The public health perspective 223 

�Greg Perry The availability of generic medicines in 226 

the European Union 

�Angelika Kiewel The insurance perspective 229 



Contents 

Part II: Health technology assessment (HTA) 

�Finn Børlum Kristensen Overview on HTA under a global dimension 230 

impact on policy and practice and scope for 

transnational cooperation 

�Iain Gillespie HTA – does it encourage or hinder innovation? (abstract) 232 

�Chris Henshall HTA from a political and ethical perspective 233 


�László Gulácsi National HTA strategies: the case of Hungary (abstract) 234 

�Alric Rüther HTA in Germany (abstract) 236 

�Antoinette Wenk Lang Text not available 

�Clare McGrath Pharmaceutical industry 237 

�Monica Burchell Patient involvement in NICE technology appraisals 239 

�Josef Probst Social insurance 241 

�Sabine Vogler Summary 243 

Forum BI: What determines health? 

The wider determinants of health: from theory to practice 

�Joop ten Dam The wider determinants of health: from theory 249 

to practice (abstract) 

�Sarah Wamala Tackling the wider determinants of health – 250 

developing practice (abstract) 

Climate change and extreme weather: new challenges for public health? 

�Bettina Menne and Tanja Wolf Climate change: risks for human health in Europe 251 

Health and the impact of the housing and the urban environment 

�Xavier Bonnefoy Text not available 

Tackling the social determinants of health: the role of the social partners 

�Howard Klee World Business Council for Sustainable Development 266 

(WBCSD) health programme (abstract) 

�Georg Ziniel Text not available 

�Jonathan Mogford Text not available 

�Ineta Pirpktina Text not available 



Contents 

National health promotion policy to address inequalities 

�Elizabeth Pott Text not available 

�Graham Robertson Text not available 

�Gerard Molleman Health policies to address inequalities: 268 

the situation in the Netherlands 

�Luigi Bertinato National health promotion policy to address 270 

inequalities: the Veneto Region 

�Katrin Saluvere Text not available 

�Tamsin Rose Text not available 

�Anthony Morgan Summary 271 

Forum BII: Towards high-performing health systems 

The context for reform: what is driving change in today’s health systems? 

�Elizabeth Docteur Towards high-performing health systems: 283 

challenges and opportunities for reform (abstract) 

In search of more value for money: can we improve quality and system performance without raising 

cost pressure? 

�Niek Klazinga Is there a business case for quality improvement 285 

in health care for governments? Reflections on 

the quality-cost relationship (abstract) 

�Alexander Macara Towards more cost effective care: is there scope 286 

for improving prevention and treatment for chronic 

conditions? 

�Karl-Jürgen Schmitt IT in healthcare – what is necessary to increase 294 

healthcare efficiency 

�Jui-fen Rachel Lu Is there a trade-off between cost control and equity? 302 

Evidence from a single-payer approach 

Stakeholder perspectives 

�Angela Coulter Implications of financial pressures and health system 306 

changes for patients 

Roundtable discussion 

�Diane Lequet-Slama Text not available 

�Peter Pazˇitný Addressing the demand side problems of health 311 

systems by intelligent co-payment scheme 

�Hong-Jen Chan Text not available 



Contents 

�Gaudenz Silberschmidt Text not available 

�Armin Fidler Text not available 

�Katrin Saluvere Text not available 

�Ellen Nolte Summary 313 

Pre-Conference Workshop 1: Issues in Pharmaceutical Policy 

�David McDaid Summary 315 

Pre-Conference Workshop 2: Addressing arthritis/rheumatism 

�David McDaid, Alex Watt The economic burden of musculoskeletal disorders 322 

�Birte Glusing Summary 325 

Workshop 1a: Workplace health promotion: healthy employees – successful companies 

�Martin Gleitsmann Towards high-performing health systems: 333 


�Georg Vana Health promotion is one of the key principles for Pfizer 335 

�Oskar Meggeneder The Austrian Network Workplace Health Promotion 336 

Tasks and offers 

�Ludwig Grillich A key to a healthy working life. Recommendations for 343 

workplace health promotion and age management 

in small and medium-sized enterprises 

�Brigitte Geißler-Gruber Age-oriented careers and work in medium-sized 354 

enterprises – from theory to practice 

Workshop 1b: The next five years of patient mobility and health systems in Europe 

�Berbard Merkel Text not available 

�Kimmo Leppo Text not available 

�Magdalene Rosenmöllerr Text not available 

�Nick Fahy Text not available 



Contents 

Workshop 2a: Meeting the challenges of a healthy heart for European women 

�Suzanne Wait Summary 357 

�Bengt Jönsson Health economics 372 

Workshop 3a: Private health insurance in OECD countries 

�Francesca Colombo Summary 373 

Workshop 4a: Survey of Health, Ageing and Retirement in Europe (SHARE) 

�Oliver Lipps Combining interdisciplinary information on 385 

ageing problems in Europe (abstract) 

�Rudolf Winter-Ebmer Health and health care ccross European countries 386 

(abstract) 

Workshop 5a: Improving health literacy in the European Union 

�Karl Krajic Summary report 389 

�Ilona Kickbusch Annex and figures 397 

Workshop 5b: Towards a European global health strategy 

�John Wyn Owen Chairman’s introduction 412 

�Graham Lister Europe’s current engagement with global health issues: 414 

A case for developing a European strategy 

�John Martin Text not available 

�Ted Schrecker Text not available 

�Martin McKee Text not available 

�Alan Ingram Summary report 423 

Workshop 6b: HIV/AIDS in Europe 

�Gabriel Ghitescu Bringing children new hope: 428 

Melinda Hanisch The value of partnerships in fighting 

Jeffrey Sturchio HIV/AIDS in Romania 

�Magdalene Rosenmöller Summary report 436 



Contents 

Lunch Workshop L1: Towards a health competent consumer 

�Rodney Elgie Health information: the patient’s perspective” (abstract) 442 

�Christine Marking Information to patients and EU policy initiatives 444 

�Peter Singleton The second ‘Informed Patient’ report: 451 

‘An EU Framework for Action’ 

Lunch Workshop L2: Cancer treatment 

�John Smyth Availability of treatment – who actually decides? 459 

(abstract) 

�Susan Knox Keeping breast cancer on the public Health agenda: 460 

the European Breast Cancer Resolution 

�Christian Ligensa Access to care for prostate cancer patients. 462 

A patients perspective 

�Catriona Moore Access to care for patients in England 463 

Lunch Workshop L3: Promoting social inclusion 

�David McDaid Promoting social inclusion, generating economic 468 

Alex Watt benefits: European action towards better 

musculoskeletal health 

�Eva Jané-Llopis Mental health promotion and mental disorder 471 

prevention: the benefits of intervening 

Lunch Workshop L4: International networking to address inequalities 

�John Kenneth Davies International networking to address inequalities 480 

Who’s Who – authors’ biographic information 485 



Preface 



Preface 

David Byrne 

In 2004, the European Health Forum Gastein focussed on issues related to 

‘Global health Challenges – European approaches and responsibilities’ and 

examined how global developments in health interact with the European 

situation, and vice versa. The discussions, I believe, demonstrated in a convincing way that health 

policy can only be successful if it manages to understand and integrate the social and the economic 

dimensions at national, European and global level. 

The plenary sessions and the five parallel fora documented in this volume looked at this topic from 

different points of view. My services hosted a parallel forum on What Determines Health which 

highlighted how wider determinants of health – such as social factors, housing and climate change – 

affect health status. In looking at these issues, it is important to look at lessons we can learn from the 

development and implementation of new ideas and concepts across Europe. 

Other sessions of the conference looked at values, principles and objectives, social inclusion, 

pharmaceuticals policy and the future of the health systems in Europe. 

As Europe is enlarging, we are sharing an important responsibility to keep the interaction of health 

and wealth in mind when developing policy. In my intervention during the Gastein Forum, I pointed 

out that health issues increasingly have a global focus – whether this is talking communicable 

diseases or fighting big tobacco, but are also playing a key role in the development of approaches to 

general global problems, ranging from trade and development and poverty relief through to issues of 

foreign policy and security. Moreover, health is at the very core of the human rights agenda. It is vital 

therefore that the European Union plays a full part in taking forward these discussions and in 

implementing world wide action. 

This is the last Gastein Forum I have had the privilege and pleasure to attend in my capacity as 

European Commissioner for health and consumer protection. Over time, I was able to see how the 

unique event bringing together high level speakers and participants from different sections of the 

health world across and beyond Europe has had an important impact on the health policy discussion. 

The Gastein approach to health – as an area embedded in and interlinked with how our citizens and 

societies develop – is always refreshing and opens up new avenues of debate. I can certainly say 

that the conclusions have been very useful in focussing our debates and supporting our work on 

developing EU health policy for the years to come. 

This is why I would hope that this book, which brings together the 2004proceedings, would have a 

wide audience within and beyond the health sphere in Europe. 

David Byrne 

European Commissioner for Health and Consumer Protection 



Preface 

Maria Rauch-Kallat 

For the last seven years, the European Health Forum Gastein has managed 

to combine continuity with topical health policy issues to a successful whole. 

The European Health Forum Gastein, however, has also managed to 

constantly develop itself throughout the years. Of course, most of the credit for this goes to the 

organisers who tirelessly work throughout the entire year to stage this event and, naturally, to all 

those individuals and organisations who have been actively shaping and supporting the program for 

years. My particular thanks go to the European Commission, the European Committee of Regions, 

the WHO, the World Bank, and the OECD that organised an entire forum for the first time in 2004. 

The European Health Forum has always considered itself to be European, but has at the same 

always looked over the European Union's fence. Although the perspective has slightly shifted as a 

result of the accession of new EU Member States, its basic principles remain the same. In the 

European Union, health issues primarily belong to the national agendas, yet the European 

momentum has meanwhile extended to the health sector as well. Examples for this development 

include the topics of patient mobility, the European Health Insurance Card, the creation of European 

information systems, and, of course, pharmaceuticals. The 2004 European Health Forum dealt with 

issues of European concepts and the European responsibility for global health, addressing a series 

of problems, and also proposing solution approaches. As one of the world's strongest economic 

regions, the European Union will have to take a more ambitious stance on these issues as well. 

For me, the fact that this year's forum has focused on basic issues of European health policy is 

symptomatic for this situation of transition that the European Union is going through since the major 

enlargement round. Most probably, it is the task of conferences like the one in Gastein to rack their 

brains over values, principles, and targets, to briefly step out of the turbulent daily business and ask 

fundamental questions. The high acceptance of this forum and the intensity of work in the forum 

showed me that, in this respect, the EHFG 2004 offered exactly the right concept. 

The great interest for health economy issues proved that, despite the different organisation of their 

health systems, all EU countries are facing the challenge of securing sustainable financing, and that 

we all can and should learn from each other. In this respect, the EHFG 2004 has made an important 

contribution to a mutual exchange of information and experience. 

This year's conference has established the European Health Forum Gastein as one of the most 

important European health policy events. I hope and I expect that the forum will continue on this 

successful course next year. 


Federal Minister for Health and Women's Issues 



Preface 

Gunter Leiner 

In recent years, the European Health Forum Gastein has shed light on the 

various aspects of Paneuropean health policy, triggering debates on several 

interesting topics and solution proposals. 

The 7th European Health Forum Gastein has proven the most successful in the history of this 

congress so far. As the President, it fills me with pride to see that so many important decision makers 

from the world of politics, business, and medicine from the world over have honoured us by 

participating and making remarkable contributions to this congress. This shows how much 

significance the European Health Forum Gastein has acquired throughout the years, and the extent 

to which it has become a discussion platform for European health policy discussions. 

The 7th European Health Forum, the main topic of which was "Global Health Challenges. European 

Approaches and Responsibilities" dealt above all with issues that relate to the values, principles, and 

objectives of health policy in Europe, and also discussed some highly topical issues such as the 

rather neglected topic of mental health or health at work, or even special issues such as women's 

health. The debates that took place during the Health Forum also focused on permanently "hot" 

health policy topics such as the pharmaceuticals market in an enlarged Europe, the financing of 

health systems, and the basic question of "What defines health?" These and other discussion items 

during the 7th European Health Forum lead to questions that urgently need to be considered today. 

The health sector in our times does not only constitute a global responsibility and a political 

challenge in general, but also an issue of financing and of ethical dimensions. 

The basic challenges to all national health systems are growing and an interregional, cross-border 

organisation and financing of health care seems to be the right solution especially in small member 

states, in border regions, and even in high-technology areas, since the development of integrated 

structures of health care coverage, including a better networking of outpatient and inpatient treatment 

could make health systems not only more affordable but also more humane. 

Next to a tighter organisation of the health sector, there is the issue of the ethical boundaries of 

health care. Very often we prolong a patient's life making considerable use of the technical means at 

our disposal, although it would be more essential to enable the patient to die in dignity instead. A 

European consensus on values should not be limited to bans on tobacco or alcohol advertisement, 

but should also apply to existential human needs. These needs include the creation of 

comprehensive palliative care in Europe. Another important ethical issue of current health policy 

deals with how society should handle biomedicine and in particular very sensitive topics, such as that 

of prenatal medicine and embryo research. 

Of course, the debate over these existential issues of current health policy leads to a contradiction of 

the values adhered to by our society today. For this reason, the possibilities and limits of the market 

need to be considered and reviewed thoroughly. We have even reached a point where costs and 

benefits in the health sector are being weighed against one another. The odds are that, in the long 

term, the debate will no longer be about whether we will have to accept compromises in quality in 



Preface 

order to save costs, but over the significant limitation of fundamental services that will eventually 

become evident for everyone. 

Societies in Europe and all over the world are facing great health policy challenges. In particular the 

students, who will bear the main responsibility in future societies, have a significant role to play. In 

future, their task will not only be to competently master the scientific disciplines, but also to consider 

their studies as a cultural and ethical mandate. It is about time to deliberate on these issues and 

carry out an honest debate, since, in the long term, we can no longer officially live with the white lie 

of maximisation of the "best medical care for everyone" promised by politicians in their Sunday 

speeches, and cannot escape the fact that resources are scarce. 

One of the main concerns of the EHFG must be to discuss all these concepts and take a step further 

toward possible solutions. 

Gunter Leiner 




Global Health Challenges: 

European approaches 

and responsibilities 

International Forum Gastein 

Tauernplatz 1 

5630 Bad Hofgastein 

Austria 

Phone: +43 6432 3393270 

Fax: +43 6432 3393271 

Email: info@ehfg.org 

Homepage: http://www.ehfg.org


A Message From the President 

The European Health Forum Gastein (EHFG) is a unique annual event, which brings together 

experts, interest groups and politicians from across wider Europe to debate topical health issues. The 

main stakeholders that form the pillars of Gastein are politicians, the health sector, civil society 

represented by NGOs, academics, International Organizations, and the private sector. A significant 

outcome of these events is a statement of observations, conclusions and recommendations 

emanating from the discussion by the EHFG president to those with governance responsibilities in 

Health Policy Development and Implementation. This statement is disseminated to key institutions 

such as those of the EU and member states and regions to maximise impact. Subsequently, these 

recommendations are supported by the publication of a full report of the scientific presentations. 

The organising theme this year was Global Health Challenges: European approaches and 

responsibilities. The main objectives were: 

1. To consider the health dimensions of foreign policy and global security; 

2. To consider the prospect of a global health strategy for the European Union and wider European 

alliances; 

3. To debate issues that are common and topical across wider Europe on values, principles and 

objectives of health policy, mental health and social inclusion, pharmaceutical policy, the 

determinants of health and sustainable high performing health systems. 

Five parallel fora were organised around global themes, providing participants with an opportunity to 

learn about the policy issues, practical developments, and to become more familiar with innovations. 

It enabled politicians and other stakeholders to review the evidence and seek perspectives across a 

broad range of sectors on recommendations of their interest. The Fora were organised around the 

following challenges: Determinants of health, Values, principles and objectives of health policy; 

Mental health and social inclusion; Health system performance and sustainable financing, 

pharmaceutical policies in an enlarged Europe. 

Each Forum considered the implications for health, health systems and services at the individual 

level as well as at the local, regional, national and supra-national levels. The EHFG includes the 51 

countries within the WHO European area i.e. the enlarged EU, Central and Eastern Europe and the 

EEA countries. Every effort is made to ensure that all of the different interests and perspectives are 

covered. 

The main observations of the Parallel Fora are grouped below. Our hope is that you will find them 

timely and useful iwith regard to your responsibilities for health policy development. 

Günther Leiner 

President, European Health Forum Gastein 

The EHFG declaration does not necessarily reflect the views of all participants. 

A publication of all scientific papers can be ordered from the International Forum Gastein. Abstracts 

and presentations are available at www.ehfg.org 




General EHFG recommendations on the main theme: 

Global Health: Europe’s Approaches and Responsibilities 

Recommendations 

1. As suggested in the “health futures reflection process” led by Commissioner David Byrne, the EU 

should publicly develop an EU global health strategy in collaboration with WHO and international 

development agencies to guide EU foreign policy. The Millennium Development Goals (MDGs) 

should be at the heart of this policy with particular attention given to the prevention of Non- 

Communicable Diseases (NCDs.) 

2. The priority consideration for an EU strategy should be the Millennium Development Goal 8 – 

developing a global partnership for development, with targets for aid, trade and debt relief, 

harmonisation of aid, supporting and strengthening the UN system, being a leader on women’s 

health in the International Conference on Population and Development (ICPD), applying the lessons 

of European public health history and supporting a strong civil society movement for global health. 

3. The application of the MDGs for Europe and Central and Eastern Asia should be redrawn to 

include reducing death, illness and disability from the avoidable chronic diseases (NCDs) and 

external causes such as injuries. 

4. The global MDGs should be reviewed to take account of the staggering increase in avoidable 

NCDs in developed and developing economies. International development agencies and health 

organisations such as the World Bank, WHO and EU and national development agencies should 

review their commitment to the prevention of NCDs. 

5. The importance of establishing effective and sustainable surveillance, vital registration and health 

information systems consistent with international standards should be a priority for health 

development. This will provide valid data for local decisions and international comparisons and is 

vital to supporting the achievement of the MDGs. 

6. Health development should be at the heart of the development and sustainable agenda in 

achieving the MDGs. New business models should be developed to grow economies, particularly 

developing economies that promote health and control the excesses of some industries that seek to 

exploit a lack of national and international controls on their products. 

7. The International community should fully honour its commitment to the promised ICPD funds of 

which only half has been provided to date. Europe should press other donor countries to honour their 

public commitments and global obligations. Public health services need to be more responsible and 

accountable to the poor, marginalised and those subject to discrimination, which bear the greatest 

burden of mortality, morbidity and lack of treatment. Health equity must be a central function of health 

system development. Gender equality and the empowerment of women are critical for achieving the 

IPCD and MDG goals. 

8. International organisations should invest more in facilitating policy dialogue and the communication 

of health improvement innovations between global regions. 




Specific Forum observations and recommendations 

Forum AI: Values, principles and objectives of health policy in Europe. 


1. The following issues should be recognised as key aspects of the Values debate: values in health 

and their application in future health reforms, health as a specific European value, values in health 

and the new European Constitution, European citizenship and health. European values on health 

services and systems should guide foreign policy on health and development. 

2. Some key issues which raise challenges in translating values into policy are democratic 

accountability, empowerment and participation, dignity, equity and exclusion. Governments must 

inevitably consider the optimum trade-offs that have to be made among agreed values. 

3. The twelve dimensions of health targeting developed in the Madrid Framework (2004) are a useful 

basis for establishing common values at all levels of policy making, and for considering optimal 

trade-offs. These dimensions are: Health gain, Equity and fairness, Choice, Responsiveness to 

society, Investment in health, Evidence, Efficiency, Intersectoral governance, Local empowerment, 

Sustainability, Interdependency, and Complexity and creativity. 

4. Patient and citizen involvement in health policy is a positive trend in Europe. Patient’s charters on 

the national and pan-European levels should include the following rights to: preventive measures, 

access, information, consent, free choice, and respect for patients’ time, quality standards, safety 

and innovation. 

5. There is a need for further debate on health and values in Europe in respect of the following 

issues: 

How is our notion of solidarity changing? Is it still strong enough to solve future challenges such 

as inequalities in health between countries and populations? 

How far do and should our notions of solidarity reach? To what extent are we willing to pay for 

others and in what circumstances? 

How is our notion of solidarity changing in terms of the following dimensions – national, European 

and global and risk, generational and distributive? 

How do we get health values higher on the political agenda? 

To what extent are we taking account of the health needs of future generations? 

To what extent and at what price are we willing to influence the determinants of health? 

Forum A2: Promoting social inclusion in an enlarged Europe – putting mental health on the 

agenda. 


1. There is an ongoing need to address not only the substantial poor health and socioeconomic 

consequences of mental health problems but also the issues of stigma, discrimination and social 

exclusion, especially in Central and Eastern Europe as human rights abuses continue to exist in the 




outdated psychiatric institutions and social care systems that remain the mainstay of some mental 

health systems. 

2. Human rights legislation and instruments are only useful to promote social inclusion if they are 

effectively monitored with adequate sanctions, where required, to effect change. They also need to 

move beyond a focus on the health and social care sectors and protect against discrimination in 

other sectors. 

3. A fundamental health goal should be to promote social inclusion throughout the life course in 

particular through developing mental health life skills, (beginning in school) social marketing, media 

engagement and empowering mental health service users. 

4. All European countries should have a national mental health (promotion) policy and action plan. To 

help ensure, given substantial health and socioeconomic impact, that an appropriate level of 

resources are targeted to mental health. 

5. Mental health services should move away from solely focusing on mental illness to include 

promoting mental health and well being, and participation in society. It needs to be understood within 

a broader social, environmental and cultural context. 

6. Mental health services should be community orientated wherever possible, and linked to 

individuals needs. These could include a one stop service to coordinate appropriate support across 

sectors and make users aware of welfare services and entitlements to health, social care, housing 

and wider social security benefits. 

7. The macroeconomic case for investing in mental health promotion should be made. 

8. Further build on existing international cooperation between agencies, donors and civil society, with 

an emphasis on considering long term sustainability of initiatives. 

Forum A3: Pharmaceutical policy in the enlarged Europe 

Recommendations at EU level 

1. The EU should boost non-competitive, translational research. 

2. The EU needs to establish a European Technology Platform within the 7th research and 

development framework. 

3. The EU should monitor the implementation of the revised community regulation. 

Recommendations at Member State level 

1. The member states who are the main addressees of the recommendations of the G10 process, 

are asked to implement these recommendations 

2. Member states should promote and reward true innovations. 

3. Member states should learn to understand and make use of tools for decision making such as 

health technology assessment and phamacoeconomics. 




Recommendations with regard to Health Technology Assessment (HTA) 

1. More investment in HTA is needed 

2. In the design of HTA reports, besides effectiveness, cost effectiveness and financial aspects, 

societal and ethical dimensions should be included. 

3. HTA is a tool for decision makers and should be policy driven and implemented 



1. EU public health strategy and legislation should be comprehensively assessed for action on health 

inequalities. 

2. European targets and indicators for health inequalities should be developed so that comparisons 

on progress can be made and the basis for common European actions established. 

3. An EU cross directorate strategy for health inequalities should be developed and include 

collaboration with international agencies 

4. Health impact assessment of EU policies should be routine to ensure that policy actions reduce 

and do not inadvertently increase health inequalities. 

5. International organisations should promote the development of innovative solutions to tackle health 

inequalities through the development of sustainable applied information systems. In particular, 

International organisations should develop shared learning on health inequalities to support the new 

member states. 

6. The emerging global changes and socioeconomic developments should be assessed for their 

health impacts and impacts on inequalities in Europe and a European strategy developed. 

7. The Luxembourg and UK Presidencies of the European Union (2005) should address the Gastein 

recommendations on health inequalities, in particular to establish a high level policymaking network 

and information systems to support competent and effective practice at all levels. 

Forum B2 Towards high-performing health systems: Value for money and sustainable 

financing 


1. Promote the generation of evidence that enables policy makers to assess the appropriateness of 

approaches and instruments to improve health system performance at national level. 

2. Establish opportunities for sharing at the international level – successful policies and practice that 

have relevance across Europe. 



Plenary I 

Opening 






��Anders Gustav 32 

Page 




Günter Leiner 

Sehr geehrte Damen und Herren, 

Werte Ehrengäste, 

Es freut mich außerordentlich sie zum 7. European Health Forum wieder so zahlreich begrüssen zu 

dürfen! 

Auch in diesem Jahr darf ich als Mitveranstalter die Bundesministerin für Gesundheit und Frauen, 

Maria Rauch-Kallat, Landeshauptfrau Gabriele Burgstaller für das Land Salzburg und Herrn Anders 

Gustav für den Ausschuss der Regionen begrüssen. 

Ein European Health Forum ohne EU Kommissar David Byrne ist inzwischen wohl ebenfalls kaum 

mehr vorstellbar 

Ich darf Ihn von dieser Stelle aus recht herzlich willkommen heißen. 

Viele Länder sind dieses Jahr durch hochrangige Entscheidungsträger repräsentiert. 

Meinen Gruss darf ich entbieten den Ministern: 

Herrn Chien-jen Chen aus Taiwan 

Herrn Duschan Keber aus Slowenien 

Herrn Mamytovich Mamitov aus Georgien 

Herrn Julio Frenk aus Mexiko 

Den Staatssekretären und stellvertretenden Ministern: 

Herrn Hong Jen Chang aus Taiwan 

Frau Romalda Baranauskiene aus Estland 

Herrn Imre Hollo aus Ungarn 

Herrn Levan Jugeli aus Kirgisien 

Frau Slobodanka Krivokapic aus Montenegro 

Herrn Petko Salchev aus Bulgarien 

Viele Länder sind durch hochrangige Beamte vertreten. Stellvertretend darf ich hier Herrn 

Generalsekretär Roel Bekker für die Niederländische EU Präsidentschaft begrüssen. 

In den Reihen unserer Unterstützer darf ich auch dieses Jahr wieder die WHO, vertreten durch 

Regionaldirektor Danzon, die Weltbank und erstmals die OECD begrüssen. 

Sie alle, als Vertreter der vier Säulen: 

Politik und Verwaltung 

Zivilgesellschaft und NGOs 

Wirtschaft und Industrie 

Wissenschaft und Forschung 




leisten einen wichtigen Beitrag zum Erfolg des Forum. Eine wichtige Multiplikatorfunktion 

übernehmen die Medien. Dem Österreichischen Rundfunk als Mitveranstalter und allen 

Medienvertretern entbiete ich ein herzliches Willkommen! 

In den vergangenen Jahren hat das European Health Forum Gastein die unterschiedlichsten 

Facetten gesamteuropäischer Gesundheitspolitik beleuchtet. Viele interessante Themen und 

Lösungsvorschläge wurden diskutiert. Vielfach krankt deren Umsetzung aber an der 

Finanzierungshoheit der Nationalstaaten. Hierbei möchte ich keiner Zentralbürokratie in Brüssel das 

Wort reden. Insbesondere in kleineren Mitgliedsstaaten, in Grenzregionen, aber auch in Bereichen 

der medizinischen Hochtechnologie erscheint aber eine regionenübergreifende Organisation und 

Finanzierung der Gesundheitsversorgung sinnvoll. 

So gibt es zum Beispiel eine Grenzregion, in der acht Schwerpunktkrankenhäuser in einem Radius 

von 30 Kilometer unterhalten werden. Die Schliessung eines dieser Krankenhäuser hätte weder 

negative Auswirkungen auf die Versorgung noch würde es zu erhöhtem Personal, oder Bettenbedarf 

in einem der anderen Krankenhäuser führen. Trotzdem wird dieses Einsparungspotential nicht 

genutzt. 

Der Aufbau grenzüberschreitend regional integrierter Versorgungsstrukturen, inklusive einer 

besseren Vernetzung ambulanter und stationärer Versorgung könnte die Gesundheitssysteme nicht 

nur finanziell günstiger, sondern möglicherweise auch menschlicher machen. 

Einsparungspotentiale sind zwar nicht unerschöpflich und können begrenzt sein, sie können aber 

trotzdem eine Kostenexplosion verhindern. Synergien zwischen ambulanter und stationärer 

Versorgung müssen genutzt werden. Medizinische Technologien und pharmazeutische 

Therapiemöglichkeiten sollen sinnvoll und ergänzend einsetzt werden. Neben einer strafferen 

Organisation des Gesundheitswesens stellt sich auch die Frage nach den ethischen Grenzen der 

Gesundheitsversorgung. Diese Grenzen müssen nicht unbedingt am Beginn, oder Endpunkt des 

Lebens liegen. Sehr oft wird das Leben mit viel technischem Aufwand nur geringfügig verlängert, 

wenn es stattdessen viel wesentlicher wäre ein Sterben in Würde zu ermöglichen. Die Würde und 

die Persönlichkeit des einzelnen Menschen in welchem Zustand er sich immer befindet, sollte für die 

Gesundheitspolitik und die Gesundheitsberufe oberste Priorität haben. 

Die Diskussion einer europäischen Verfassung verweist oft auf gemeinsame europäische Werte. Ein 

europäischer Konsens sollte nicht nur bei Vorsorgemassnahmen wie grenzüberschreitenden 

Regelungen zu Tabak- oder Alkoholwerbung gefunden werden, sondern auch für existenzielle 

menschliche Bedürfnisse erreichbar sein. Die Schaffung einer flächendeckenden palliativen 

Versorgung in Europa wäre eines dieser existentiellen Bedürfnisse. 

Die Öffnung der Grenzen und Globalisierung bedeutet auch bei uns allen eine geistige, seelische 

Öffnung, die getragen ist von Einfühlungsvermögen und grosser Verantwortung. Die Probleme der 

Beitrittsländer sind gross, aber nicht unüberwindbar. Die hohe medizinische Qualität, die in diesen 

Länder vorhanden ist, bedarf der Finanzierung neuerer Strukturen und Organisationen. Ein grosses 

Problem ist sicherlich die Emigration der Gesundheitsberufe aus diesen Ländern. 

Dies sind nur einige wenige Beispiele wo nationale Gesundheitspolitik auch zur europäischen 

Aufgabe wird. Mit grossem Interesse erwarte ich die Diskussionen und Ergebnisse des siebten 

Forums. Die hochkarätige Besetzung mit Teilnehmern und Sprechern lässt auf innovative Ideen und 

Vorschläge hoffen. Von der Idee zur konkreten Umsetzung ist es aber oft ein langer Weg. Es ist 

daher wichtig nicht nur Visionen zu entwerfen, sondern gleichzeitig deren Umsetzung mitzudenken 

und zu konkretisieren. 




Bei der Umsetzung kommt den anfangs erwähnten Regionen eine besondere Rolle zu. Die konkrete 

Leistungserbringung an den Endverbraucher liegt in vielen Ländern auf regionaler Ebene. 

Gesundheitspolitik sollte daher nicht nur aus Sicht der Zentrale gesehen werden, sondern erfordert 

das herunterbrechen auf die regionale Ebene. 

Eine zukünftige Aufgabe des EHFG wird die verstärkte Einbindung dieser regionalen Perspektive 

sein. Hierbei soll den Regionen nicht nur die Brüsseler Perspektive nähergebracht werden, sondern 

auch regionalen Belangen und Lösungsansätzen auf europäischer Ebene Gehör verschafft werden. 

Zu diesem Zweck wird das EHFG nicht nur seine Präsenz in Brüssel verstärken, sondern wenn 

notwendig auch zunehmend in den Regionen selbst aktiv werden. 





Over the past seven years, the European Health Forum Gastein has managed to successfully 

combine continuity and prevailing pan-European health issues.The European Health Forum Gastein 

has also developed steadily over these years and – if you will allow me this stretch of imagination in 

these beautiful surroundings – has since reached new heights. Substantial credit for this is naturally 

due the organisers, who have been working tirelessly all year round, as well as those persons and 

organisations who have supported the event with their contributions and concepts. I would especially 

like to thank the European Commission, the Committee of the Regions, the WHO and the OECD, to 

whom, who for the first time this year, an entire forum is dedicated. 

A conference on this scale also costs a lot of money, and I would like to take this opportunity to thank 

the various sponsors that supported the event. The sponsors are – legitimately, of course – not 

entirely selfless. However, the large number of sponsors indicates to me that the idea behind the 

European Health Forum Gastein, to bring together health experts, policy-makers and business 

representatives, continues to be a success. The business representatives here will also – maybe more 

so than others – know how to make the most of the event by making contact with other participants 

from the worlds of business, health and politics. A conference of this scale also requires local backing 

and support from both regional and national legislative bodies. I feel honoured that my ministry is 

participating as a co-organiser for the fifth time, thus contributing to the success of the event. 

The European Health Forum has always been a European forum, yet has always looked beyond the 

periphery of the EU. The enlargement of the EU has changed the perspective somewhat, but the 

general premise remains the same. Health issues in the European Union are primarily internal affairs 

of the individual member states; however a new European dynamism has emerged, which also 

tackles health issues. 

I would like to name a few examples from the last few years, issues such as patient mobility, the 

European Health Insurance Card, the creation of European IT systems, which allow policy decisions 

affecting health issues to be based on the data stored in the system, and pharmaceuticals, which will 

be the subject of a separate forum. 

The European Health Forum 2004 has decided to go a step further and to raise questions 

concerning pan-European concepts and Europe's responsibilities to global health. As one of the 

strongest economic areas in the world, the European Union needs to position itself more ambitiously 

on these issues. 

The focus of this year’s forum is on basic questions concerning European health policies, and I see it 

as symptomatic of the current upheaval facing the European Union after accepting a large number of 

new members to its folds. It is the duty of conferences such as this one in Gastein to deal with 

values, principles and aims, to leave the turbulence of everyday life behind and deal with the 

fundamental issues. 

I especially hope that both old and new members states, as well as participants from non-EU 

members, can contribute their ideas and insights to this process. Due to the large number of 

heterogenous health services, exchanging knowledge, as well as aims and visions for the future, can 

only benefit all participants. 

In 2002 and 2003, the European Health Forum Gastein had already placed greater focus on the 

financial aspects of health issues. The responses to this have been overwhelmingly positive. A 

discussion forum on the subject of sustainable funding is scheduled for tomorrow. 




This question is undoubtedly one that will remain high on the agenda, irrespective of how national 

health services are organised, and I am sure that all the policy makers present will agree with me 

here. This naturally also applies to Austria. Please let me therefore address the reformation of the 

Austrian health services, shortly to be completed. 

I like to describe my health reform programme as containing five core areas. I always consciously 

name raising public awareness of health issues first, then come to the areas of innovation and quality 

assurance, and only then come to the compulsory issues of structural reforms and funding. 

Health service reforms cannot focus solely on cost factors, cash flow and funding, or procedures for 

approving expensive pharmaceuticals. The core issue remains health; the health of the patients. 

In other words, the reform of the health service is just as concerned with the facts that 70% of 

Austrians still die of cardiovascular diseases; that the number of overweight and obese children is 

increasing alarmingly; and that only 21,000 of our citizens were treated for depression - even though 

we know that far more people suffer from the condition. 60,000 strokes and heart attacks are 

reported each year – where you, gentleman, are far more at risk than us ladies – and the number of 

patients undergoing kidney replacement therapy increased by 20% between 1998 and 2002. 

These figures are warning lights and obstacles for any health reform and provide motivation to 

produce results for the benefit of all. Today we know that the key to success lies primarily in 

preventive measures. 

Raising awareness 

Successfully promoting health issues needs to take place without a wagging finger. It needs to 

correspond to people's attitude to life. The situation in Austria is not very satisfactory. Only 10 

percent of all Austrians regularly visit their GP for a general check-up. We have therefore reworked 

the programme and aim to provide a personal consultation rather than a technical examination, 

aimed at motivating more people to take preventive measures. 

However, I see raising awareness as covering a much wider field; both qualitatively and 

quantitatively. We need to create an all-encompassing movement that generates an appetite for 

healthy living amongst all members of society. Talks with ministerial colleagues – from the USA to the 

Netherlands - reveal that these countries are also placing the emphasis on raising public awareness. 

We have started a campaign using cartoons to motivate people to more physical exercising. The 

cartoon character we use has already found admirers internationally and my Dutch colleague has 

asked if his experts can have a closer look on the Austrian model. 

I aim to raise health awareness amongst Austrian citizens, to inform and to motivate them to change 

their behaviour and live a healthy lifestyle. 

Healthy living should be chic and fun. 

The issues raised need to be comprehensive, and are divided into 5 areas: nutrition, exercise, 

relaxation, accident prevention and classical prophylactic methods. Relaxation, stress reduction, 

stress prevention – or as I like to call it: inner balance – is what I hold to be the most important issue 

of our time. 

We aim to reach as many Austrian citizens as possible in the coming years by means of activities 

targetted at specific age and demographic groups as well as the two genders. We have defined 

target groups for this purpose: children and adolescents, the working population above and below 40, 

senior citizens, men, women and high-risk groups, such as diabetics and smokers. 




Various public and private partnership models and cooperation with the private sector have allowed 

us to transgress the boundaries of traditional communication channels and to gain public exposure: 

The introduction of a vegetarian burger to McDonalds, including health tips on the burger's packaging 

in cooperation with Professor Dr Kurt Widhalm, as well as a large-scale media campaign in 

cooperation with Iglo featuring Stefan Eberharter, with the slogan "Pay heed, eat your greens", have 

successfully contributed to raising public awareness. 

A campaign aimed at improving mobility has been running since last Autumn in cooperation with the 

Austrian Health Promotion Foundation, and just last week we started a campaign focussing on 

reducing stress and improving mental health. 

There will be four different information brochures: One for 13-and 14-year-olds, one for the work 

force aged under 40, one for those over 40, and one aimed at senior citizens aged 60 and over. This 

brochure calls on senior citizens to make the most of this new stage in their life to ensure they live 

long and fulfilling lives. 

Quality assurance 

The second area, quality assurance, is no less important. The focus here is on securing current 

medical standards and further optimising clinical, nursing and therapeutic services. We need to 

guarantee that every patient is provided with the exact treatment they require, and to the highest 

possible standards. We are not only concerned with establishing assessment criteria across all 

areas, meeting our goals on the education and vocational training of health workers, but also with 

establishing an effective system for tracking errors and establishing control mechanisms – both 

intramurally and extramurally. 

This is a key area and we have tackled these issues with the comprehensive law on quality 

assurance. 

Innovation 

Twenty-first century health reforms rely on ‘innovation’; both medical and organisational. 

New medical conditions, such as psychosomatic complaints or undefinable pains and aches require 

new responses. We are therefore setting up several psychosomatic clinics in Austria that are soon to 

begin operation. A centre of excellence for orthopedic pain treatment is being established in Vienna, 

in order to deal with the growing number of patients suffering from ailments of the locomotive system. 

From the point of view of technical innovations, the fields of telematics and telemedicine offer new 

and previously undreamt-of opportunities. These new techniques require the necessary environment 

to develop positively, but also to be practised. We have therefore drawn up our own telematics bill. 

Structures and finances 

I would now like to turn to the compulsory areas affecting health policies, those of structuring medical 

services and their funding. 

The health sector is naturally an area of growth. There are several reasons for this: We live in an 

ageing society. We naturally require more intensive health care as well as constantly increasing 

investment in social services. And the commercial sector is constantly making technological 

progress. What is possible nowadays was unthinkable thirty years ago, from a cost perspective as 

well. 




Consequently, more people rather than less will be employed in the areas of prevention, health care 

and nursing. The health sector is also a key area for the future, when seen from an employment 

perspective. 

When it comes to costs in the health sector, we politicians are ill-advised to agree to discussions that 

will lead to a rationing of health services. We are also ill-advised to think of cutting back on public 

health services. If we are going to beat about the bush discussing what the health service should be 

providing, and what not, years will pass without anything changing. 

As politicians charged with overseeing health issues, it is our mission to develop concrete plans to 

improve management and organisational structures affecting the health services, in order to – and 

this is the heart of the issue – tackle spiralling costs and attain equilibrium. Tackling costs is the issue 

– and not saving blindly and cutting back on social services! 

These tasks are imperative: structural reforms and tackling spiralling costs, and not reducing services 

available to patients. 

I wish to demonstrate this point using an important example from Austria: 

Austria's health services differ from those in other countries in one crucial way: the services provided 

by general practioners and specialised doctors are directed and funded by the national health 

insurance scheme, while the financing of hospitals is mainly the responsibility of the provincial 

governments, which have access to funds from social security contributions and from the state, 

provincial and local level for this purpose. 

All experts agree unanimously that this causes a dualism in the system; meaning that the intramural 

and extramural areas have developed diverging priorities, affecting health services in a negative way. 

A central weakness of our system is the duality of services available; for example specialist practices 

located next to a hospital department dealing with the same field of expertise. Other problems 

include missing links in the health care chain, such as a lack of aftercare for patients released from 

hospital, or the familiar question of double diagnoses. 

One thing is important to me: experts from across the political spectrum agree that the independent 

administration and funding of these two fundamental areas create dramatic financial frictional losses 

and are tying up a substantial amount of our taxes and contributions without providing any medical 

benefits. 

The key to overcoming these hurdles lies in all the concepts known to me for dealing with the 

disjointed planning, directing and funding of these intramural and extramural areas. 

In other words: in future the most important contributors – health insurance schemes, local 

authorities and the provincial and federal governments – should coordinate the planning, directing 

and funding of both intramural AND extramural areas of the health service. The process will involve a 

panel, providing a platform for all parties involved – doctors, nurses and other health workers – to 

become as involved as possible in developing common planning and quality control targets. 

We are currently negotiating the concrete implementation. As you can see, we are dealing with a farreaching 

reform, and it is therefore no surprise that some participants are not ready to immediately 

change their traditional stance in order to achieve common goals. 

I remain optimistic, however, that we will nonetheless succeed in placing the interests of patients 

above those of the party and agree on a common solution for the Austrian national health service. 




But now, enough about our reform of the health services. I am sure that one or other of these 

concepts are familiar to you from your own countries. And that is exactly the reason we are all here 

in Gastein; representatives from almost 50 countries. Health services are no longer insular, with their 

obligations only reaching to the nation's borders. 

We all have to face the same global challenges and can learn from eachothers’ experiences and 

must find common strategies to meet these challenges. 

On that note, I would like to welcome you to the seventh European Health Forum and wish us all 

pleasant, interesting and successful days together; and the strength to master the global health 

challenges which are the focus of this event. 




Anders Gustav 

Excellences, ladies and gentlemen, 

I’m glad and honoured to be participating for the second time in the Health Forum in this healthy 

environment. The Committee of the Regions is a partner of this event for sixth time and I must 

transfer my deepest recognition for the organisers for the good organisation and for the remarkable 

results and for our good cooperation. 

The Committee of the Regions is the sub-national level representative in the decision making 

process in the European Union. 

Moving quickly to some of the positions of the CoR concerning public health. The Committee of the 

Regions has stressed that health discrepancies within the population and the aging population are 

amongst the biggest challenges facing many of the Member States and the Community. This is why 

the Committee is particularly pleased to see that the European Commission places great emphasis 

on the need for a high level of health protection within the Community. 

Another challenge is the fact that such a lot of health care has never produced before and with such 

a high quality. The problem is the increasing gap between the expectations among the citizens and 

the economy in the bodies responsible for the health care system. And this gap will widen even more 

if we stick to the old European models for financing and producing health care. Public expectations 

are one of our common challenges and is our driving force for reform. 

In most Member States local and regional authorities are responsible for public health issues and 

health and medical policy. The Committee of the Regions and the regions responsible for these 

policy areas wish to participate in and contribute to the development drive, and must be guaranteed 

a say in Community health policy. But we must also be the ones who take the lead of reforming the 

models and the systems. That’s our responsibility and that’s another challenge for us. 

The Committee of the Regions has therefore recommended to the Commission, the Council and the 

European Parliament, that they should encourage regional players to become actively involved within 

the range of opportunities offered by both nationally managed health care systems and health 

systems of the self-managing kind existing in some Member States in the fields of public health. This 

applies particularly where public health and health care functions are assigned to different bodies and 

levels. Being close to the ‘grass roots’ the local authorities have an important role to play. Their social 

service departments are responsible for identifying problems, taking preventive action and offering 

assistance, particularly to sections of the population which are at risk or experiencing difficulties. 

The Committee of the Regions believes it is important to be able to learn and to have access to high 

quality, comparable data. We strongly support the patient mobility. For our citizens the first step must 

be to provide them with clearer overview of the existing EU legal framework regarding the access to 

health care and the reimbursement of the costs incurred in another member state. 

In the view of the Committee of the Regions, cross-border cooperation between regions, 

municipalities, towns and Member States is another important part of improving health protection and 

public health. For this reason the Committee of the Regions has advocated that it is extremely 

important that the EU should use new support structures and practical initiatives to help encourage 

cross-border cooperation. This would promote development within the Community and in the field of 

health. 




The issue of training and mobility of health professionals is also significant, like legal and 

administrative barriers to be overcome. Attention should be paid to possible ways of promoting the 

provision of training for health care professionals on an inter-regional basis and promoting mobility of 

these professionals between regions. This is in the general context of the population trends in 

Europe, where it is clear that as the age of the population rises, the need for public health increases. 

Exchange of the best practices within this field is at the moment at the most importance. 

To have successful trans-regional cooperation in the field of Health its clearly necessary that Europe 

as a whole and member states in particular provide the means in order that there are no legal and 

administrative barriers making mobility of health care professional difficult. 

Another area of importance raised by the CoR in relation to public health is information technology. 

The Committee of the Regions believes that information technology is of considerable importance in 

the area of public health, and has called on the Commission to take account of the impact of IT on 

public health operating models and structures. 

Finally I would like to introduce you some of the latest works of the Committee of the Regions in the 

areas of the Health. 

Recently, the Committee of the Regions has adopted opinions on the new European Commission 

initiatives, namely on the patient mobility and health-care developments in the European Union and 

on the modernising social protection for the development of high-quality, accessible and sustainable 

health care and long-term care. 

Our rapporteur, Bente Nielssen, from the Arhus county council, from Denmark is among you in this 

conference and she will later intervene in parallel forum A1 to express the view of the Committee of 

the Regions. 

This year the Committee of the Regions adopted an opinion on the equal treatment in the access to 

and supply of goods and services, which was also in connection with health questions. The 

rapporteur was Monalisa Normann, politician from Jämtland County Council, Sweden and she will 

later intervene here on the parallel session. 

Finally, the Committee of the Regions opinions on the Social Dimension of the globalisation are also 

in preparation. You could also meet the rapporteur of this work Ulrike Rodust, from Germany, here 

among the participants. 

The Committee of regions is also preparing at the moment the opinions on the Services of General 

Interest and Services in the Internal Market, linked with the health care problematics. 

So in conclusion, Europe is currently facing the demographic problems with increasingly elderly 

population. This will turn into a double problem in the middle term – the sustainability of pensions 

and social security. We must therefore be creative and find out the best solution to ensure that high 

standard of health care are provided. As I already underlined, we must find new models and 

possibilities for reforming present systems. Health care must be regarded not only as a budget 

problem but more as a sector for economic growth and new possibilities. We must promote much 

bigger involvement from the private sector. We must encourage new partnerships such as Public 

Private Partnership and launch more and flexible systems. 

And also I would like to invite you to contact Committee of the Regions rapporteurs present here in 

Gastein to have fruitful exchanges and possible inputs to the opinions to influence the European 

Health policies in connection with global challenges. 



Plenary II 

Global health – the 21st 

century challenge 




��Marc Danzon Text not available 

��Jacques Baudoy Text not available 

��Corinna Hawkes Avoidable chronic diseases: the neglected global 36 

epidemic 

��Indu Capoor Unveiling realities of the South Asian region to 39 

achieve Millennium Development Goals 

Page 




Avoidable chronic diseases: the neglected global epidemic 

Corinna Hawkes 

The burden of chronic diseases 

According to the World Health Organization 

(WHO), the leading ‘killing’ chronic diseases were 

responsible for almost half of all global deaths in 

2002 (Table 1). These diseases comprise cardiovascular 

disease (CVD), malignant neoplasms, 

other neoplasms, diabetes, asthma and chronic 

obstructive pulmonary disease (COPD). 

The percentage of deaths has increased from 

46.3% since 1990, despite the epidemic of 

HIV/AIDs. Death rates have remained about 

stable during this period, at around 450 per 

thousand, counter to the generally downward 

trend over past decades. Percentage mortality is 

predicted to increase to over 60% by 2020 (this 

does not take into account HIV/AIDs, but neither 

the cumulative impact of risk factors). 

Chronic diseases have not simply replaced infectious diseases. Countries now experience a dual 

burden of disease. For example, India not only has the most people with diabetes in the world (32.7 

million), but also has the second highest burden of HIV/AIDS (4.6 million), and 2.5 million child 

deaths annually from acute respiratory infections, diarrhoea and neonatal infections. In South Africa, 

chronic diseases account for 25% of years of life lost, while infectious diseases account for 28%. 

Europe has a particularly high burden of leading chronic diseases. As shown by Figure 1, they 

caused 7,345 million deaths in 2002 in the WHO European region. All chronic (non-communicable) 

diseases account for 86% of deaths and 77% of the burden of disease in the region. CVD accounts 

for the greatest proportion of deaths (58%), followed by cancers (33%), COPD and asthma (7%) and 

Figure 1: Mortality from leading chronic diseases, by region 

Mortality, millions 

8,000 

7,000 

6,000 

5,000 

4,000 

3,000 

2,000 

1,000 

0 

Europe Africa Americas South East 

Asia 

Table 1: Percentage mortality, by cause, 2002 

Cause of death % deaths 

Communicable diseases 32.3 

Leading chronic diseases* 48.8 

Neuropsychiatric disorders 1.9 

Injuries 9.1 

Other chronic diseases 6.5 

* CVD, malignant neoplasms, other neoplasms, 

diabetes, asthma and COPD 

Eastern Med Western 

Pacific 

High child, very high adult 

High child, high adult 

Low child, high adult 

Low child, low adult 

Very low child, very low adult 

WHO Region 




diabetes (2%). Overall, mortality from CVD has been declining overall in Europe, but is rising in parts 

of the region, notably in the Newly Independent States. In fact, of the deaths from leading chronic 

diseases in the European Region, 60% occur in the Newly Independent States (all of which fall into 

the high adult mortality country category). And throughout the whole region, chronic disease mortality 

falls disproportionately on the poor. 

Globally, high and increasing mortality from leading chronic diseases can in large part be explained 

by the global prevalence and spread of key risk factors: tobacco (the number of cigarettes smoked 

has nearly doubled since 1960); alcohol (consumption has increased by 19% since 1990) and diet 

(intake of fats, sweeteners, salt and processed foods is increasing) and physical activity (which is 

declining). The spread of these risks is avoidable, yet under current conditions, they are resulting in 

the proliferation of intermediate risk factors for chronic diseases: high blood pressure and high 

cholesterol, which, according to WHO, were two of the leading mortality risk factors in 2001. 

Another important intermediate risk factor is overweight / obesity. In many European countries, over 

half the population is 

overweight, while obesity 

among children has 

reached 10% worldwide 

(Figure 2). The obesity 

trend is clearly upward. In 

the UK, for example, the 

prevalence of overweight 

children grew from about 

13% to 20% between 1994 

and 1998. Obesity among 

children is particularly 

worrying because it 

portends serious health 

problems later on in life. 

And obesity is not just a 

problem for wealthy 

countries: it is rising 

everywhere, leading to a 

dual burden of under- and 

over-nutrition in Latin 

America, Asia, the Middle 

35 

30 

25 

20 

15 

10 

East, and in some countries in Africa. 

Figure 2: Children overweight and obese, % by region 

% children 

5 

0 

Worldwide Americas Europe Near/mid east Asia Pacific SS Africa 

Obese 

Chronic diseases and their risk factors are a significant cost burden. Coronary heart disease costs 

the UK over £7 billion per year in 1999, and diabetes incurred 6% of the health care costs in Sweden 

in 1998. According to estimates made between 1998 and 2003, obesity accounts for 2–6% of 

national health care spending in OECD countries. 

Response of key players to the threat of leading chronic diseases 

Overweight 

The threat of leading chronic diseases has now been well documented, but the global policy 

response has been more patchy. In many OECD countries, where these diseases have been leading 

killers for years, there have been considerable efforts to reduce death rates. But new threats, 

particularly around diet, are worsening, and relative to the burden, chronic diseases are still given 

inadequate attention by key players in the global health arena. 




Taking a financial perspective, three key players are worthy of note: the WHO, bilateral agencies and 

the World Bank. The WHO has passed 56 resolutions on the leading chronic diseases and their risk 

factors since 1956 (the first was a call by India for more action against CVD). In the past two years 

there have been two particularly significant resolutions: the Framework Convention on Tobacco 

Control and the Global Strategy on Diet, Physical Activity and Health. There has also been action 

from the WHO to establish regional networks to address chronic diseases, such as the CINDI 

network in the European Region. But these commitments have not been backed by sufficient 

financial support. Although the WHO spends more than any other agency on chronic diseases – US$ 

44.2 million on chronic diseases in 2002 (headquarters and regional offices, not including salaries), in 

real terms this means (at headquarters only) just US$2.4 million for the prevention and control of 

leading chronic disease, US$1.1 million for risk factor prevention and surveillance, diet, physical 

activity and health and CVD management. In fact, just, 3.5% of WHO’s budget is spent on chronic 

diseases, including mental health, out of a total budget of US$ 1.237 billion. 

From the bilateral agencies, Official Development Assistance (ODA) for health was $US 2.9 billion in 

2002; just 0.01% was allocated to chronic diseases (US$ 3.2 million). Of the $US 4.25 billion loaned 

by the World Bank to health in 1997–2001, 2.5% went to chronic diseases (excluding health 

services). The leading chronic diseases are also largely excluded from Millennium Development 

Goals (although part of the MDG+), the WHO Commission on Macroeconomics and Health (except 

for tobacco), and from other major UN initiatives. 

On the brighter side, many initiatives are moving forward. But, from a global perspective, not enough 

is being done to prevent chronic diseases becoming more prevalent among the global population 

over the long-term. This trend is reducing the potential for prevention and creating treatment 

demands that may permanently skew resource allocation. In Europe, it is now clear what a burden 

chronic diseases can be – for health, for economies and for the poor. It is clearly worth investing in 

more concerted policy action to address this global health threat. 

Global economic development: the greatest challenge to the prevention and control of 

chronic diseases 

To move forward, policy makers face many challenges, not least because they often do not possess 

the up-to-date evidence about the threat and are not familiar with the process of developing health 

systems oriented towards managing chronic conditions. But, arguably, the most fundamental and 

difficult challenge is this: chronic diseases are associated with more economic development, not less 

(unlike infectious diseases). This creates a very difficult tension for those concerned with health. It 

means that on the one hand, economic development is to be welcomed since, historically, it has 

resulted in higher life expectancy – good for health. But on the other, it means that growth must be 

viewed with caution because it brings with it risks for chronic diseases – bad for health. 

The policy challenge 

Promoting chronic disease prevention thus means confronting economic forces. This is a serious 

challenge for policy makers. How, on the one hand, can they promote economic development as the 

key to poverty alleviation and good health, and then, on the other, challenge economic development, 

since it also poses risks to health? This is more than a policy dilemma; it is a policy barrier. Chronic 

disease policies are actually now perceived by some as a threat owing to concerns they will dampen 

economic growth. To overcome this barrier, policy makers need to at once recognize they need to 

tackle economic processes underlying chronic diseases while also reaching to develop policy that 

balances common interests and agendas. The opportunities are there to take more action to address 

a global health threat. 




Unveiling realities of the South Asian region to achieve Millennium 

Development Goals 

Indu Capoor 

Executive summary 

In 2003, the world has seen violent conflicts, accompanied by heightened international tension and 

fear of terrorism. This makes it even more imperative to focus on the root causes of achieving the 

MDGs which reflect the vision of the Millennium Declaration. 

The principles outlined in the Declaration and defined into a set of eight MDG are a series of timebound 

and measurable targets that range from reducing extreme poverty to halting the spread of 

HIV/AIDS and reproductive cancers through advocacy of Reproductive and Sexual Health and Rights 

as well as providing universal primary education for children all over the world. 

However the international community will succeed in meeting these goals only if the needs, concerns 

and expertise of women and girls are fully integrated into national and international plans as stressed 

by the UN Secretary, General Kofi Annan, “Where women are fully involved, the benefits can be 

seen immediately: families are healthier and better fed; their income savings and reinvestment 

grows. Development of families extrapolates into development of communities, nations and the 

world.” 

MDG3 deals specifically with gender equality and the empowerment of women and sets as a target 

the elimination of gender disparity in primary and secondary education, preferably by 2005, and at all 

levels, no later than 2015. The health of women and girls outlined in MDG 4 of reducing child 

mortality and 5 of improving maternal health, are a key factor in improving the general health of the 

community in a broadened perspective. Therefore, the issue of gender equality and the 

empowerment of girls and women cannot, be limited to a single goal. Achieving gender equality is 

the key ingredient in achieving all the accomplishments of all eight MDGs. 

It has been found that Health systems in poorer countries, especially South Asian countries are 

severely under funded for meeting the goals. No high income OECD country spends less than 5% of 

GDP on public health services. But developing countries rarely exceed this share – most spend 2- 

3%. The WHO estimates that $35–40 per capita is the bare minimum required for basic health 

services. In the poor countries of South Asia, it is basically impossible to pay international prices for 

life-saving medicines and almost criminal to expect poor people to do so. In most South Asian 

countries, the poorest 20% of households benefit from much less than 20% of health spending. 

Countries with higher allocation to poorer households have lower child mortality rates and lower 

MMRS transcending into better levels of subsistence and facilities. 

As outlined by MDG goal 8 of developing a global partnership for development, South Asian 

countries cannot on their own tackle the structural constraints that keep them in poverty traps. The 

partnership framework of the Millennium Declaration makes clear that the primary impossibility for 

achieving goals 1–7 lies with the developing countries. But the millennium development compact 

makes clear the critical role of developed countries as reflected in goal 8. 

Reproductive and Sexual Health Rights being an integral part of Human Rights as stipulated by 

progressive governments all over the world, the focus of MDG should not steer away from 




addressing the root causes of achieving their objectives, especially in the developing countries of 

South Asia. Financial support to strategic and innovative initiatives provided by the developed 

nations of Europe as intrinsic support at programmatic levels in South Asia would work as an 

impetus to the process of progressive developments in effect. 

South Asian realities 

Rachel is a 35-year-old graduate from a 

premier university in Western Europe. The 

enabling environment in her country has 

equipped her with knowledge on sex and 

sexuality. She has chosen to remain single, to 

pursue an active career in politics: although her 

family and country would like her to produce 

children, but in absence of an 

institutionalised marriage system, she is 

unsure of doing so. 

She takes for granted the availability of clean 

and safe drinking water, accessible and cost 

effective health facilities and an enabling 

environment that guarantees her all human 

rights and comforts for health and well being. 

Rachel has a lump in her breast and is being 

treated by experts for which she has 

insurance.She wishes to rise in her career. 

She wishes that her husband would stop drinking 

and beating her up daily. 

These social, economical and cultural 

disparities between the women of two regions 

present some harsh realities. Today, the challenge that lies before us to bridge this gap, so as to 

achieve the ambitious objectives outlined by the Millennium Development Goals. MDGs, which aim 

to transform the lives of the people world wide and essentially includes, reducing by half the number 

of people living in extreme poverty. 

About Millennium Development Goals 

Rami is a 35-year-old primary school dropout in a 

South Asian community where “sex” is a taboo 

word. Rami was forcibly married off in her teens 

and works tirelessly in the fields, at home and 

community level. Compelled to survive on meagre 

leftovers, she often goes hungry. 

She takes for granted the economic, social and 

nutritional deprivation and the unclean 

surroundings. She has five children and has had 

three miscarriages. She has a lump in her breast, 

but no one knows about it except her due to the 

widely prevalent culture of silence in her society. 

In the year 2000, representatives of 189 nations, including 147 heads of state and government, 

gathered at the United Nations for a historic Millennium Summit. They adopted an ambitious set of 

goals, the Millennium Development Goals (MDGs). Achieving them by the target date of 2015 was 

expected transform the live of the world’s people, including reducing by half the number of people 

living in extreme poverty. 

The Millennium Declaration concludes, “We therefore pledge our unstinting support for these 

common objectives an our determination to achieve them. “The next decades offers a historic 

opportunity for all stakeholders – including governments, civil society and international organisations 

– to unite behind the Millennium Development Goals. 

Access to reproductive and sexual health services including family planning : All countries should 

strive to make accessible through the primary health care system, reproductive health to all 

individuals of appropriate ages as soon as possible and no later than the year 2015. 




The eight goals and 18 targets to combat poverty, hunger, disease, discrimination against women, 

degradation of land and illiteracy adopted during year 2000 by 189 United Nations members states 

demand unity among all the stakeholders including governments, civil society and international 

organisations. 

It is equally true that practical efforts to eradicate poverty rest directly upon the enforcement of basic 

human rights, which were emphasised during the ICPD programme of Action. Therefore, poverty 

cannot and will not be eradicated without achieving ICPD goals. 

About the International Conference on Population and Development 

The 1994 International Conference on Population and Development (ICPD), Cairo, provided a major 

milestone in the population debate of various countries which placed population in the broader 

context of sustainable development to be achieved through improved quality of life, ecological 

security and women’s empowerment. It also advocated a paradigm shift from a demographic target 

oriented programme to a client centred approach for delivery of services and recommended placing 

individual needs at the centre of all family planning and reproductive health programmes 

One of the key actions for the further implementation of the Programme of Action of ICPD was, 

governments should strive to ensure that by 2015 all primary health care and family planning 

facilities are able to provide, directly or through referral, the widest achievable range of safe and 

effective family planning and contraceptive methods: essential obstetric care: prevention and 

management of reproductive tract infections, including sexually transmitted diseases: and barrier 

methods, such as male and female condoms and microbicides if available, to prevent infection. By 

2005, 60% of such facilities should be able to offer this range of services, and by 2010, 80% of them 

should be able to offer such services. 

Meeting the ICPD goals will pave a straight smooth path directly towards reaching the MDGs. 

This paper brings forward the broad reproductive health issues and suggestive recommendations to 

achieve the objectives outlined in the ICPD platform of Action and MDG in context of the developing 

countries of South Asia. The South Asian region has diverse socioeconomic realities. It ranges from 

Nepal to Sri Lanka to Japan. This region also has wide range of geographical variation and size. 

Therefore it is not easy to provide an absolutely accurate picture of the region in a limited time. Some 

of the points discussed here may not pinpoint the realities of all the countries in the region. An effort 

has been made to cull out the commonly faced issues discussed here. Keeping the MDGs as a 

reference point, the health scenario of the South Asian countries is discussed. 

MDG: Promote gender equality and empower women 

Promoting gender equality and empowering women is one the MDGs which targets at eliminating 

gender disparities in primary and secondary education, preferably by 2005 and in all levels of 

education no later than 2015. Reviewing the South Asian reality to achieving this goal, we need to 

accept that social, cultural and economic constraints include early marriages, early and repeated 

pregnancies in the hope of producing a male child. The early initiation into motherhood along with 

other household responsibilities limits women’s access to education. In addition, a high prevalence of 

violence against women inhibits women’s wider social and political participation, which are essential 

aspects of empowerment. Poor access to reproductive health services inhibits women in taking 

control over their own fertility and hence hinders the educational opportunities for women. 

Early marriage a south Asian reality 

“I do not want to send my daughter for higher secondary school because she has to 




travel 2km from our village to reach the school. I will remain in fear of her sexual 

harassment while commuting. I prefer to get her married.” 

A mother of a 12-year-old daughter from one of the villages of Gujarat state India 

Similar realities exist in other South Asian countries. The reasons may be different in different 

countries, but it cannot be denied that early marriages of adolescent girls in South Asian is a grim 

reality bringing to light other bitter home truths. 

High fertility in a sociocultural milieu 

The total fertility rate of South Asian countries is almost double that of European countries. Following 

are the data for the years 2000–2005 indicating fertility rates of different countries. On the other 

hand, we also come across the expressions such as: 

“I wish that this time I would deliver a male child. This is my fourth pregnancy and I am 

fed up of going through the repeated pregnancies in the hope of producing a son.” 

Surveys repeatedly reveal that even poor women do not want to 

have many children. For example, in order to assess women’s 

ideal number of children, India’s National Family Health Survey 

2 of 1998–99 asked each woman the number of children she 

would like to have if she could start all over again. Almost half 

(47%) of ever-married women in India consider two to be the 

ideal number of children and 72% consider two or three to be 

ideal. The survey also revealed that 72% with two living children 

and 86% of women with four or more living children do not want 

to have any more children. 

The lack of access to family planning interventions combined 

with poor knowledge and limited freedom to make choices leads 

to a grave situation of unwanted fertility. It is important to enlarge 

the contraception mix, expand the provisioning of quality health 

care and services, and simultaneously empower women and 

communities to make informed choices. Many women are left 

with no choice but to resort to abortion adding to the greater 

risks of maternal morbidity and mortality. 

Reviewing the data of Human Development Report 2004 on 

contraceptive out reach of women, it highlights the poor 

percentage of contraceptives usage in many of the South Asian 

countries. The statistics reveal that only 28% population of 

Pakistan, 48% of India and 54% of Bangladesh uses 

contraceptives as against 81% of population of Spain and 82% 

of Switzerland uses contraceptives. 

Poor use of contraceptives is also a result of political will and 

availability of resources. A regional overview done by ARROW- 

Malaysia narrated an example which says that Iran with political 

will and sufficient resources deployed women’s voluntary use of 

A 38-year-old rural Indian woman. 

Total fertility rate: 

number of births per woman 

Name of country Fertility rate 

Italy 1.2 

Japan 1.3 

Germany 1.4 

Singapore 1.4 

Switzerland 1.4 

UK 1.6 

Belgium 1.7 

China 1.8 

France 1.9 

Indonesia 2.4 

India 3.0 

Bangladesh 3.5 

Nepal 4.3 

Pakistan 5.1 

Source: Human Development, 2004 




contraceptive, which increased substantially. Iran now, has a high contraceptive prevalence rate of 

73% compared to Philippines, Malaysia and Indonesia, which are around 55% only. This figure is 

particularly low for Malaysia, which has achieved a very good level of socioeconomic development 

Women are empowered when they begin to enjoy and exercise greater freedoms – economic, social, 

political and cultural freedoms. This occurs with higher levels of education, improved health and 

nutritional status, greater economic freedoms, improved access to employment and higher earnings, 

and taking decisions to take care of her own health and fertility. Empirical studies reveal that, of 

these factors, better education and increased employment opportunities for women have the 

strongest impact in terms of lowering birth rates. 

MDG: Improve maternal health 

Improving maternal health is another critical goal of MDGs, which highlights the urgent need for 

better access to reproductive health care, including family planning, care in pregnancy, during and 

after childbirth and emergency obstetric care. Ensuring access to these services will reduce 

unwanted pregnancy, unsafe abortion and maternal death. 

It is a bitter reality of developing countries in the South Asian Region, that MMR in many South Asian 

countries has not declined since the last decade. Maternal Mortality Ratio per 1,000 live births – India 

(540), Pakistan (500), Indonesia (230), Nepal (740), Bangladesh (340). These figures are very low in 

the developed nations – Germany (8) and Switzerland (7) and Italy (5). 

Looking at the picture closely, an average woman in South Asia is 28 times more likely to die from 

maternal causes than an average woman in Europe. 

It is a fact that to improve maternal health one needs to lower down the high levels of fertility rate. 

High fertility rates in South Asian regions are due to two main reasons. The first one is extremely 

limited access that women have to decent health care and reproductive health services and the 

second one is the preference for a male child perpetrated by patriarchy which has already been 

highlighted earlier. 

Access to affordable health care 

in general is a major concern of 

this region. The reasons for poor 

access to health care services in 

the region are poor infrastructure 

and non availability of medical 

personnel in the rural and tribal 

areas. Data from the Human 

Development Report (2004) 

reveal that in European countries 

where the access to affordable 

essential drugs is 95–100% ,in 

South Asian countries like India 

and Nepal, it is inexcusably low at 

0–49%. In Pakistan there is low 

access (50–79%) and in 

Indonesia there is medium access 

(80–94%). Therefore, access to 

such essential services in all the 

diversities and irregularities of the 

Access to maternal health care 

Women receiving 

pre-natal care 

(%) 

Birth attended by 

skilled personnel 

(%) 

Abortion 

policies 

India 62 35 B 

Pakistan 27 18 C 

Bangladesh 26 8 B 

Indonesia 82 36 E 

Belgium 90 100 A 

Germany 98 100 A 

UK 99 98 B 

A = Available on request 

B = Permitted on broad social and health grounds 

C = Permitted on limited health grounds 

E = Illegal or permitted grounds to save only women’s life 

Source: Population Action International (PAI) 2001 




South Asian nations cannot be viewed in totality as being constant all over. Maternal health is a 

major concern, as a lack of availability of life-saving drugs is a contributing factor for poor maternal 

health and high maternal mortality in South Asia. 

Besides, Pakistani and Bangladeshi women receive as low as 27% and 26% of prenatal care. 

Available data reveals that as few as 8% of women in Bangladesh are attended by a skilled birth 

attendant. Maternal death due to unsafe abortion is also a major concern of this region. The policy 

related to abortion has influences of sociocultural, religious and political factors making the service 

limited for women. The data given above are the reflection of the access to poor maternal health 

care. 

Violence against women 

The lesser-discussed issue of violence against women also has major consequences on maternal 

deaths. Various studies around the world indicate that, at least one woman in every four is physically 

or sexually abused during pregnancy, usually by her partner. In the Indian subcontinent, violence 

may be responsible for a sizeable but under-estimated proportion of pregnancy-related deaths. In 

India verbal autopsies from a surveillance study of all maternal death in over 400 villages and 7 

hospitals in three districts of Maharashtra state revealed that 16% of all deaths during pregnancy 

were due to domestic violence. In rural Bangladesh homicide and suicide, motivated by dowryrelated 

problems or the stigma of rape and/or pregnancy outside of marriage, accounted for 6% of all 

maternal deaths between 1976 and 1986 and 31% of maternal deaths among women aged 15 to 19. 

The risk of injury – related death was nearly three times higher for pregnant teenagers than for notpregnant 

teenagers or for older pregnant women. 

MDG: Combat HIV/AIDS, tuberculosis, malaria and other diseases 

The MDG, Combat HIV/AIDS, tuberculosis, malaria and other diseases targets to halt the spread of 

HIV/AIDS and has begun to reverse the spread of HIV/AIDS by 2015. Similarly the aim is to halt and 

begin the reversal process of the incidence of malaria and other major diseases by 2015. 

Achievement of this target including universal access to reproductive health care is critically 

important in the fight against HIV/AIDS. It is important to note here, that half of new HIV infections 

are among young people. Preventing infection means enabling young people to protect themselves 

from sexually transmitted infections. This includes teaching abstinence outside marriage, fidelity 

within it and responsible behaviour at all times, including the responsible use of condoms. South 

Asian countries need an adequate supply of reproductive health commodities, including male and 

female condoms, and strengthened systems for their supply and distribution. 

The ICPD Programme of Action emphasises that all countries should strive to make reproductive 

health services accessible through the primary health care system including the entire range of 

affordable health services to all individuals of appropriate ages in the shortest possible period of time. 

To achieve this, a major shift was required to change policies, which were targeted towards 

population control. The review of the progress towards the policies, reveals that in the South Asian 

Countries, there is a shift from a population control goal to comprehensive reproductive health to 

even a broader human rights approach. In India. for example, all family planning incentives and 

disincentives were removed in 1996. The 1997 Reproductive Health Programme abolished all 

demographic determination targets and adopted a client centred demand driven quality service 

approach. China’s policies have clearly stated that the reproductive rights of the citizens include the 

right to informed contraceptive choice and the right to receive basic services in health care. India, 

Pakistan, Indonesia have developed new population policies and laws. Preliminary analysis indicates 

that although broad reproductive health approach has been taken with a focus on gender equality 

and women’s empowerment, emphasis continues to be on reducing population growth and 




encouraging couples to consider smaller families. Further data revealed that out of the 18 World 

Bank supported SRH Projects of Asia; only seven listed some of the SRH services as components 

most of which were on family planning. 

The ICPD notes that better information on HIV/AIDS can prevent transmission of HIV and other STIs. 

A conceptual agreement on this fact noted that, the South Asian countries are facing major sociocultural, 

religious and at some extent political barriers to implementing the reproductive and sexual 

health awareness programmes in totality. Many Asian countries have policy statements on 

adolescents’ health for e.g. China, Indonesia, Malaysia, Nepal and Philippines that were developed 

in the last decade or included in the National population policy (India and Pakistan). Most countries 

cited government reluctance to address socio political and religious conservatisms as the main 

barrier in providing services to unmarried adolescents. 

In Iran, 13,000 biology teachers and school physicians are being trained as they can educate nearly 

1.5 million students in high schools. A special course on HIV/AIDS has been designed as an 

appendix to biology books for the first grade high school students. Besides, cultural issues have 

been considered in designing the course to avoid the possible negative reaction by the families of the 

student. Consultation centres have been set up to cover community to increase public and patients 

contribution in the preventive education programme. 

Lack of funds is another concern in most South Asian countries. This is despite a clear trend towards 

the early onset of sexual relationships. Formal teaching of sexual and reproductive health and rights 

issues affecting adolescents normally termed sexual health education or sex education can be found 

in some form in the school curriculum. Sex education is also integrated into different types of 

subjects such as physical education biology and 

moral/religious study. In countries where sex 

education is available, the contents vary in 

accordance with government sociocultural 

values in each country. There is no formal sex 

education in Pakistan. Though Pakistan NGOs 

have made efforts to disseminate materials on 

sexual and reproductive health and rights to 

adolescents. 

South Asian countries are going through a 

transitional phase. At one end they have to 

achieve a lot to prevent communicable 

diseases, while on other hand the noncommunicable 

disease are increasing in trend 

especially reproductive cancers and diseases 

related to heart. The data of 2002 on TB cases 

in European countries ranges from 6 cases to 

14 cases per 100,000 people, whereas, in 

South Asian countries it as high as 609 per 

100,000 population in Indonesia. With a trend of 

increase in prevalence of HIV/AIDS. South 

Asian countries face the major challenge of 

halting the spread of both HIV/AIDS and TB. 

Incidence of Tuberculosis, 2002 

Number of cases per 

100,000 people 

Belgium 11 

Switzerland 8 

UK 12 

France 14 

Italy 6 

China 272 

Sri Lanka 73 

Indonesia 609 

India 344 

Bangladesh 447 

Nepal 71 

Pakistan 379 

Source: Human Development Report, 2004. 




MDG: Achieve universal primary education 

An MDG target to ensure that by, 2015, children all over the world, boys and girls alike, will be able 

to complete a full course of primary schooling. This target can only be achieved if the gender gap 

among girls and boys is reduced. 

Net primary enrolment, 2000/01 

Female ratio % Ratio of female to male 

This can be supported by 

the empowerment of 

women especially in the 

Germany 84 1.02 

South Asian nations, 

UK 101 1.00 

training teachers to be 

gender sensitive, promoting 

China 93 1.01 

the value of educating girls, 

postponing early marriage 

India 76 0.83 

and childbearing, allowing 

pregnant teens to continue 

Bangladesh 88 1.02 

studying, providing 

Nepal 66 0.88 

scholarships, providing 

universal access to 

Pakistan Data unavailable 

reproductive health, and 

lowering fertility, morbidity 

Source: Human Development Report, 2004. 

and mortality rates. 

According to Human 

Development Report 2004, there are 27 top priority countries including the countries of South Asia 

where developments have not been made in achieving gender equalities especially in primary 

education. They require the world’s attention and resources if they are to achieve the Millennium 

Development Goals. 

Collectively put, this translates into 40.8% of women and 67% of men being literate in South Asia as 

against 75.9% of women and 88% of men in the developed European Countries. 

MDG: Eradicate extreme poverty and hunger 

Eradicating extreme poverty and hunger is a major and crucial MDG. Under this goal it is targeted 

that between 1990 to 2015 both, the proportion of people whose income is less than one dollar a day 

and the proportion of people who suffer from hunger will be halved 

To achieve this, universal access to reproductive health care for men and women is imperative. The 

ICPD Programme of Action and ICPD+5 benchmarks aim for universal access to voluntary 

reproductive health services, including family planning. Access to these services will give their users 

fundamental choices that will change the repetitive cycle of poverty. With access to family planning, 

women and men can freely decide if, when and how many children they want. Lower fertility results 

in slower population growth and opens a ‘demographic window’ of opportunity for economic growth 

and poverty reduction, as the ratio of dependants to working-age people declines. 

MDG: Develop a global partnership for development 

Develop a Global Partnership for Development, the final Millennium Development Goal, targets 

towards trading and financial systems, sustainable development, good governance, debt relief etc. 

However, the population and reproductive health programmes have lagged behind in the least- 




developed countries, especially those with high levels of mortality and unwanted fertility. These 

countries will benefit most from higher international assistance and debt forgiveness, as well as 

domestic resources for health and education. They need universal access to reproductive health care 

coupled with affordable prices for essential drugs for treating HIV/AIDS, malaria and tuberculosis, 

and a secure supply of contraceptives and other reproductive health commodities. 

The ICPD called on international donors to provide one third of the support needed for reproductive 

health programmes in developing countries worldwide: $5.7 billion (of the $17 billion total 

requirement) in 2000, rising to $7.2 billion by 2015. Current international support is less than half of 

this required level. 

This indicates an urgency to call upon the governments of the region, international agencies and 

non-governmental organisations to pay serious attention to these challenges to build on the positive 

experience and lessons, and to work in close cooperation to make this possible. 


Gender sensitivity, access, equity, quality of services, accountability and responsiveness through 

strengthened public health systems 

Public health services need to be more responsible and accountable especially to the poor, 

marginalized, and those subject to discrimination, who bear the greatest burden of mortality, 

morbidity and lack of treatment. Thus, ‘health equity’ must be a central function of health system 

development. 

South Asian countries need to: 

• Strengthen public primary health care and referral systems to ensure universal and 

comprehensive, effective, efficient, and gender sensitive health services. 

• Increase allocations and expenditures in real terms for strengthening public health services 

including sexual and reproductive health services including through innovative measures such 

as access for health improving cuts in military 

• Ensure that, where health insurance is introduced, it should be on a universal basis and 

include priority sexual and reproductive health services such as those for pregnancy and 

delivery, abortion and in-patient gynaecological care. 

• More effective monitoring and regulation of the private and public sector. 

• Strengthen accountability of health providers through institutional mechanisms involving local 

bodies, and informing communities about relevant laws and rights to services so as to enable 

people to make informed choices: 

• Ensure gender sensitivity and responsiveness at all levels from policy makers, managers, 

programme implementers to field health workers through regular capacity enhancement. 

Gender equality, women’s empowerment and male responsibility 

Gender equality is critical for achieving ICPD goals and MDGs. The past decade has seen a number 

of pilot and experimental programmes move forward. The lessons from these need to scaled up 

where appropriate and systematised. 




The South Asian countries need to concentrate on: 

• Ensuring systematic efforts to learn from successful programmes and interventions in different 

sectors and to scale them up. 

• Integration of gender programmes through a bottom-up approach across relevant sectors. 

• Institutionalising gender training at all levels to replace ad hoc training programmes. 

• Expanding government, and NGO programmes and effective use of the media in order to 

sensitise households and communities, including both women and men, girls and boys on the 

harmful effect of gender bias, and to respect women’s human rights. 

• Recognising that the scope of male responsibility according to the ICPD, POA goes beyond 

male contraception to include gender sensitisation of men and behavioural change towards 

responsibility for women’s health well-being and human rights including sexual and 

reproductive health and rights: 

• Enacting and implementing legislation to bring gender-based violence under the purview of law 

such as domestic violence honour killing, dowry-related violence and workplace harassment: 

• Ensuring fair judicial recourse for victims of gender based violence 

• Instituting special measures to protect victims of violence through ensuring the right to abortion 

for rape and incest victims: setting up safe shelters and half-way houses. And removing 

discriminatory laws, rules and regulations that reinforce the low status 

Maternal mortality, unsafe abortion, and family planning in rights’ framework approach 

Although some countries in the region have made significant progress towards reducing maternal 

mortality, in others maternal mortality rates and ratios have stagnated or even regressed. Unsafe 

abortion contributes significantly to this, even in those countries where it is legal. Tackling maternal 

mortality on a priority basis is essential to reaching both ICPD and MD goals. 


• Recognise the close links between growing impoverishment, continued gender bias and poor 

nutrition for women as a major long-term cause of maternal and neo-natal mortality, and 

ensuring food security for poor women and girls on a priority basis 

• Go beyond the debate over the relative merits of TBAs versus institutionalised delivery to 

identify the circumstances under which each may be able to contribute to safe maternal and 

child outcomes 

• Ensure adequate funding, staffing, and facilities for safe, affordable and accessible delivery 

and emergency obstetric and neo-natal care: 

• Ensure accountability for safe maternal outcomes through focused training of health personnel 

for zero tolerance of maternal deaths and illness including measures such as identifying the 

medical officer to be made responsible. 

• Provide information about the prevention of unwanted pregnancy including all safe and 

appropriate legal methods. And the pros and cons of different methods including side-effects 




• Expand the availability of quality and low-cost family planning services and ensuring access 

and follow-up services. 

• Make abortion legal, safe, accessible and affordable by reviewing restrictive abortion laws and 

amending them, introducing new legislation as appropriate and ensuring implementation 

• Provide clear and full information about the legality of abortion, and rights to confidential 

services 

HIV/AIDS and sexual and reproductive health 

The alarming spread of HIV infection in the region and continuing neglect and lack of recognition, 

point to a looming crisis. HIV prevention programmes are often isolated from other health services 

and departments, and this lack of integration requires urgent attention. 


• Recognise that a rights-based approach is the basis of HIV/ Aids prevention, treatment and 

care policies and programmes. 

• Ensure strategic integration of HIV with sexual and reproductive health and right policies and 

programmes for women. Men and young people as a critical vehicle for stemming HIV 

transmission. 

• Pay particular attention to increasing women’s ability to exercise their sexual and reproductive 

rights through sensitisation, training information and services. 

• Focus on improved surveillance. Treatment and care of STIs/RTIs as a key entry point for 

reducing HIV transmission and initiating early treatment. 

• Create mechanisms for the meaningful involvement of people living with HIV/AIDS in the 

design, implementation and evaluation of policies and programmes. 

• Reorient family planning approaches to emphasise dual protection contraceptive methods that 

are the best proven methods for reducing HIV/AIDS transmission. 

• Emphasis comprehensive, quality and accessible sexual and reproductive health information 

and services as critical to addressing the distinct needs of people living with HIV/AIDS, 

especially HIV positive women. 

Access to Education 

Education, both formal and non-formal is a key pre requisite to empowerment of women. However it 

needs to be gender sensitive and emphasize on life skills. As an effort to prevent reproductive and 

sexual health infections, promotion of health literacy programmes is of prime importance. 

The south Asian countries need to: 

• Ensure primary and secondary education accessible to both girls and boys. 

• Review school education curriculum, curriculum of medical education, nursing and other health 

training from a gender perspective. 

• Create gender sensitive health literacy by developing health education and training material for 




different levels of government and non-government functionaries. 

The south Asian countries need support from international agencies in following areas: 

• Design and implementing innovative programmes in line to achieve ICPD and MDG with a 

vision to upscale innovation. 

• Improve public health infrastructure and access to maternal health care services including 

Obstetric Health Care 

• Create networks and partnerships both within and across countries in the region to enable the 

sharing of best practices and experience. 

• Enhance Health literacy especially for behavioural change communication programmes, 

especially for young people. 

• Facilitate policy dialogue within and across countries in the region in context to reproductive 

health including maternal health and young people’s reproductive and sexual health. 

Conclusion 

Central to achieving Millennium Development Goal is women’s empowerment so that they take care 

of their own health and fertility. It is a hard fact of South Asian countries that millions of women 

continue to die while giving birth, suffer from reproductive and sexual health problems including 

sexually transmitted infections (STIs) which include HIV/AIDS, other gynaecological and urological 

problems. It is a reality that socio-economic and cultural conditions in a backdrop of patriarchy 

leading to the low quality of life of women in these regions and contributes at large to the poor health 

statistics of the South Asian countries. 

While the South Asian countries must continue to invest in sexual and reproductive health services, it 

is time for the developed countries to live up to the commitments made towards the goals of ICPD 

and the MDGs. 

Given the advancement and commitment to human rights issues at global levels, the most needed is 

strengthening global partnerships through enriching initiatives and greater financial assistance to the 

governments of South Asian countries, women’s groups and non-governmental organisations. On the 

programmatic level, a strong monitoring of the integration of gender perspectives in the policies and 

programmes is non-negotiable. It is important to recognise that moving forward with a focus on 

strategies for action by civil society actors including NGOs whether engaged in advocacy or 

programme implementation is crucial. 

Bibliography 

ARROW. Women’s, Gender and Rights Perspectives in Health Policies and Programmes 

2004;10(1):1–12. 

Astra Network. Sexual and Reproductive Health and Rights in the European Union. Present Status 

and Potential Directions for Advancement. ICPD on 10 June 2004. pp. 2–7. 

Fauveau V , Blanchet T. Deaths from injuries and induced abortion among rural Bangladesh women. 

Social Science and Medicine 1989;29(9):1121–27. 

Francis V, Heggenhougen K. Integrating Sexual and Reproductive Health and Rights into a Sector 




Wide Approach to Danish International Development Assistance – A Multi-Sectoral Responsibility. 

Royal Danish Ministry of Foreign Affairs, Danida, June 1999. 

Freedman LP. Reflections on emerging frameworks of health and human rights. Health and Human 

Rights. 1995;1(4):314–49. 

Ganatra B, Coyaji KJ, Rao VN. Community cum hospital based case-control study on maternal 

mortality in rural west Maharshtra, India. Bulletin of the World Health Organisation 

1998;76(6):591–98. 

International Union for Health Promotion and education South East Asia Regional Bureau. Health 

Education in South East Asia. 2000;XV(2–3). 

Islam M. Maternal and Newborn Mortality: The Shame of the Century. New Delhi: WHO, (year not 

known). 

Kumar Shiva AK. Population stabilisation: The case for a right-based approach. (year not known). 

Ronsmans C, Khlat M. Adolescence and risk of violence death during pregnancy in Matlab, 

Bangladesh, Lancet 1999;354:1448. 

Sen G, Batliwala S. Empowering women for reproductive rights. In: HB Presser and G Sen, Women’s 

Empowerment and Demographic Processes: Moving Beyond Cairo. New York: Oxford University 

Press Inc., 2000. pp. 15–36. 

UNFPA. Population, Reproductive Health and the Millennium Development Goals. How the ICPD 

Programme of Action Promotes Poverty Alleviation and Human Rights. December 2000. pp. 9–16. 

United Nations. Key Actions for the Further Implementation of the Programme of Action of the 

International Conference on Population and Development adopted by the twenty-first special session 

of the General Assembly. New York: United Nations, 30 June – 2 July 1999. pp. 14–20. 

United Nations Development Programme. Human Development Report 2003. Millennium 

Development Goals: A Compact Among Nations to End Human Poverty. New York; Oxford University 

Press Inc., 2003, pp. 1–24. 



Plenary III 

Europe’s role: partner in 

wolrd health 




�John Wyn Owen Chairman’s introductory remarks 54 

�Julio Frenk Health and global security: a perspective from 55 

the rest of the world 

�Roel Bekker Opportunities for developing policy at member 61 

state level and during the EU presidency’ 

�Ilona Kickbusch Global public health in the 21st century – 66 

a challenge for Europe 

�David Byrne A global health strategy for the European Union 72 

Page 




Chairman’s introductory remarks 

John Wyn Owen 

This session builds on some of the issues raised at the very first plenary, Global Health in the 21st 

Century, which began with Marc Danzon setting out the challenges of the future and the importance 

of evaluation and being able to demonstrate results. Jacques Baudouy from the World Bank set out 

the Millennium Development Goals and why they offer an excellent opportunity for concerted action 

to improve global health and how national and international organisations are addressing 

achievement of these goals. Carina Hawkes from the International Food Policy Research Institute in 

Washington DC addressed avoidable chronic disease and neglected global epidemics. And finally 

Indu Capoor gave an example of global issues of reproductive health from an NGO perspective. 

The second plenary session was on values and principles and objectives of health policy in Europe 

introduced by Ilona Kickbusch during which we heard about the Madrid Framework and the twelve 

dimensions of health in Europe. The Madrid Framework is designed to enhance potential for 

European cooperation in establishing common values that can be embraced and implemented at all 

levels. One of the 12 is interdependency and I quote: “In our globalised world no country, region or 

locality is an island. There are interdependencies at every level. Health and health services are 

influenced by global concerns such as workforce mobility, air quality, international agreements and 

other factors that transcend national boundaries. Local and national health policies can have 

unintended effects beyond their own borders. The number of international agreements is growing and 

increasingly there are links being recognised between health and other policies”. 

This session will consider the health dimensions of foreign policy and global security. What 

constitutes a foreign policy and where are the opportunities and options for health. To consider the 

impact of European trade and health and development policies on global health. And to consider the 

prospect of a global health strategy for the European Union and wider European alliances. And to 

consider how can Europe marshal its unique resources in a more focussed and concentrated way. 

And we hope there will also be an opportunity for us to consider some policy proposals. 

The first session will be Health and Global Security, a perspective from the rest of the world, which 

will be a presentation by Julio Frenck, Minister of Health for Mexico. The second presentation will be 

Opportunities for developing policy at member state level and during the EU Presidency. This will be 

a presentation by R Bekker, Secretary-General of the Ministry of Health, Welfare and Sport of the 

Netherlands who now hold the EU Presidency. The third plenary speaker will be Professor Ilona 

Kickbusch and she will address the issues of Facing the European Policy Challenges: ensuring 

success for global health. And the session will conclude with EU Commissioner David Byrne and in 

introducing him I think it would be most appropriate that we all recognise the contribution that he has 

made to develop health policy in Europe and that the theme of this session, Partners in World 

Health, is a very appropriate testimony to his concerns. 

Later in the day at Workshop 5b there will be an opportunity to consider how we progress towards a 

European global health strategy. 




Health and global security: a perspective from the rest of the world 

Julio Frenk 

In keeping with the main theme of the two plenary sessions at this Forum, I will discuss the impact of 

globalization on health and the use of international cooperation in health as an instrument of foreign 

policy. Though I have part of my immediate roots in this great continent, I am a non-European, and 

as such I would not dare to discuss in any detail Europe´s role in global health. Nevertheless, I will 

venture to share with you some reflections that are based on almost one quarter-century of research 

and action on the critical relationship between global forces and health. I hope that some of my 

comments, which will necessarily have a general nature, may help you shape the strategic vision you 

are looking for. 

Let me start by stating the obvious: globalization is evolving at such speed and with such complexity 

that it challenges our ability to grasp it in its full extent. Obvious as it may be, this is a good reason to 

constantly renew, as you are doing now, the discussion about this crucial process. 

The shift of human affairs from the restricted frame of the nation-state to the vast theatre of planet 

Earth [1] is affecting not only trade, finance, science, the environment, crime, and terrorism; it is also 

influencing health. 

In 1997, an influential report by the US Institute of Medicine stated: “Distinctions between domestic 

and international health problems are losing their usefulness and are often misleading.”[2] This is so 

because of what Eric Hobsbawm, the great European historian, has called the virtual annihilation of 

time and distance.[3] 

I do not mean to say that intense international contact is new. From time immemorial the forces of 

trade, migration, war, and conquest have bound together persons from distant places. After all, the 

expression “citizen of the world” was coined by the Greek philosopher Diogenes in the fourth century 

BC. What is new is the pace, range, and depth of integration. Like never before, the consequences 

of actions that are taking place far away show up, literally, at our doorsteps. 

The degree of proximity in our world can be illustrated by the fact that the number of international 

travellers has tripled since 1980, and it now reaches three million people every day. In addition, last 

year the traffic on international telephone lines reached 120 billion minutes and the number of 

internet users grew to 580 million from 450 million in 2000.[4] 

The antiglobalization movement itself went global in 2001 when activists gathered in Porto Alegre, 

Brazil in the first annual meeting of the World Social Forum. 

We cannot underestimate the implications of these changes for health. In addition to their own 

domestic problems, all countries must now deal with the international transfer of risks and 

opportunities.[5] 

The most obvious case of the blurring of health frontiers is the transmission of communicable 

This presentation is based in part on the following paper: Frenk J, Gómez-Dantés O. Globalization and the 

challenges to health systems. Health Affairs 2002;21(3):160–65. 




diseases. Again, this is not a new phenomenon per se. The first documented case of a transnational 

epidemic was the Athenian plague of 430 B.C, which reached the heart of ancient Greece in grain 

boats.[6] The Black Death of 1347, which killed one third of the European population, was the direct 

result of international trade. In the 16th century, the Spanish conquest of the Aztec and Inca empires 

was an early example of involuntary microbiological warfare through the introduction of smallpox to 

previously unexposed populations. More recently, the global spread of the influenza pandemic of the 

early 20th century accounted for far more casualties than World War I. 

What is new, as I said before, is the scale of what has been called ‘microbial traffic’. The explosive 

increase of trade and world travel produces thousands of potentially infectious contacts daily, and jet 

planes have made even the longest intercontinental flights briefer than the incubation period of any 

human infectious disease. The latest addition to the list of global epidemics is, of course, the Severe 

Acute Respiratory Syndrome, SARS. 

The radical changes in our environment and life styles have led Arno Karlen to speak of a new 

biocultural era.[7] Indeed, to make matters more complex, it is not only people, microbes, and 

material goods that travel from one country to another; it is also ideas and lifestyles. 

Take smoking as an example. As tobacco companies increasingly operate at a global scale, they 

take advantage of uneven national legislations, expanding into markets with less stringent 

regulations. Already about five million people are dying of smoking-related causes every year. By 

2020 that number will grow to ten million, making tobacco the leading killer worldwide. This shows 

why effective national policies must be coupled with global action, like the Framework Convention on 

Tobacco Control, aimed at curbing tobacco-related deaths and diseases, which was unanimously 

adopted by the World Health Assembly last year. 

Furthermore, the globalization of health goes beyond diseases and risk factors to include also health 

care and its inputs. Careful regulations on access to prescription drugs in one country, for example, 

may be subverted when its neighbour allows the unrestricted purchase of antibiotics, thereby 

stimulating the appearance of resistant microbes that show up in the first country. 

The movement of providers across international borders is another example, which will probably 

increase as nations advance towards harmonization of their licensing and certification criteria. This is 

one of the many areas where Europe has been a pioneer. As you well know, since the 1970s the 

European Community adopted directives for harmonization among its member states of licencing 

rules for physicians and nurses.[8] The North American Free Trade Agreement also contains 

provisions that allow the governments involved in this agreement to encourage professional groups 

to discuss the criteria that might eventually be applied in the region with regard to the licensing and 

certification of health service providers.[9] 

The movement of providers across regions is also increasing, as shown by the steady flow of nurses 

from the Philippines, India, and Africa to the United Kingdom, and from the Philippines and the 

Caribbean to the United States. This flow has the potential risk of depleting the supply of qualified 

nurses in many developing countries, a problem that is demanding solutions from both host and 

recipient nations. Among the measures that are being discussed to confront this problem we can 

mention additional investments in nurse education by importing countries both in their own and the 

developing countries from which they recruit this workforce, and the establishment of ethical 

recruitment guidelines, such as those adopted by the United Kingdom in 1999.[10] 

Interdependence has also opened up new avenues for international collective action. For instance, 

initial efforts in the 1990s to secure cheaper drugs for AIDS victims in poor countries yielded only 

modest results. A couple of years ago, however, strong international mobilization persuaded several 




major multinational drug companies to establish agreements with developing countries to sell AIDS 

drugs at heavily discounted prices. 

Forces related to globalization prompted the organization of the UN General Assembly Special 

Session on HIV/AIDS in June 2001, which approved a historical Declaration of Commitment. This 

was the first time in UN history that a session of the General Assembly was devoted to a health 

topic, thus underscoring the growing link between pandemics such as AIDS, economic development, 

and global security. 

The growing complexity of health systems has also made information and knowledge, two very 

important global public goods, more valuable than ever. Given the enormous economic and social 

impact of policy decisions, countries can benefit from a process of shared learning, such as is 

enabled by the European Health Policy Forum. 

In fact, the contribution of Europe to the generation and dissemination of knowledge on health policy 

is enormous. From Bismarck to Beveridge, Europe gave the world the basic blueprints for national 

health systems. Since then, European countries have continued to be a source of innovations that 

have inspired the development of health systems worldwide. 

In my own country we are in the middle of a structural reform that seeks to provide universal health 

insurance through the establishment of a system of Social Protection in Health which will cover those 

people, most of them poor, who have hitherto been excluded from the formal social security system 

because they are self-employed, unemployed or work in the informal sector of the economy. The 

evidence that supported this reform initiative was gathered through instruments that were designed 

as global public goods, including the National Health Accounts methodology, developed, among 

other institutions, by the OECD, and the WHO framework for the assessment of health system 

performance. 

The Mexican reform is a clear example of how the process of globalization can turn knowledge into 

an international public good that can then be brought to the centre of the domestic policy agenda in 

order to address a local problem. Such application, in turn, feeds back into the global pool of 

experience, thus generating a process of shared learning among countries. 

In addition to the models offered by health systems innovations within European countries, your 

region has also influenced health policy in the rest of the world through its long-standing tradition of 

development assistance. Bilateral aid agencies in many of your countries have played a key role in 

financing many of the success stories in international health. 

The performance of local health systems can also be enhanced by one of the most potent motors of 

globalization: the telecommunications revolution, which is opening vast perspectives for improving 

access to care by underserved populations. Telemedicine points the way to a future when physical 

distance may no longer be a significant barrier to health care. 

The challenge, of course, will be to make sure that the distance divide is not merely replaced by the 

digital divide, and that the new technologies do not generate new forms of social exclusion. The 

magnitude of this challenge becomes clear when we realize that the 80% of the human population 

living in developing countries represents less than 10% of internet users.[11] Canada, the United 

States, and Sweden rank among the most wired nations, with 40%of their population regularly 

connected to cyberspace.[12] In contrast, a large number of African countries can count just a few 

hundred active internet users. 

The new forms of social exclusion feed on the old scourges of poverty and inequality. The 1.2 billion 




people who survive on one dollar per day and the death from preventable causes of 10 million 

children per year are reminders of the enormous gaps that must still be overcome within and 

between countries.[13] 

Exclusion and inequality are one dark side of globalization. Insensitivity to local cultures is another. 

Together they may explain a painful paradox of our days: precisely when technology has brought 

human beings closer to each other than ever before, we are witnessing the reappearance of 

intolerance in its ugly guises of xenophobia, ethnic cleansing, and oppression. 

And with intolerance, as a Siamese twin, comes terrorism, traditionally the instrument of offended 

fanatic minorities that resist to believe in persuasion. At its essence, terrorism is the worst form of 

dehumanization, as it turns innocent people into mere targets. 

We must move beyond the false dilemma between two extremes: on the one hand, a sort of ‘unipolar 

globalization’ based on exclusionary trade, military might or cultural uniformity, which would 

undermine global security by fostering marginalization and resentment; on the other, a sort of 

‘multipolar isolationism’ based on protectionist trade barriers, internal oppression of dissent or 

xenophobic nationalism, which would also undermine global security by fostering poverty and 

human-rights violations. 

The only way of avoiding either of these extremes is to develop a new model of globalization. In fact, 

the current debates on globalization are reminiscent of those that surrounded structural adjustment 

policies in the late 1980s. Then, like now, positions were highly polarized. A virtuous middle course 

was at that time proposed by Cornia, Jolly, and Stewart from UNICEF as “adjustment with a human 

face.”[14] What we now need is “globalization with a human face.” 

Indeed, globalization is (and has been for a long time) an inescapable reality. But we can try to 

device a process of global integration that protects the vulnerable, reduces its ill-effects, produces a 

fair distribution of its benefits, and respects identities. As stated in the latest World Development 

Report, devoted to the topic of cultural liberty: “Globalization can threaten national and local 

identities. The solution is not to retreat to conservatism and isolationist nationalism-it is to design 

multicultural policies to promote diversity and pluralism.[15] 

More generally, the challenge we have before us is to build a world order characterized by peace in 

the midst of diversity. Instead of asserting one’s identity by rejecting or destroying what is different, 

we must try to soften collisions, balance claims, and reach compromises.[16] In this way, we may try 

living according to what Vaclav Havel, former president of the Czech Republic, has called a basic 

code of mutual coexistence.[17] 

Health may contribute to this pursuit because it involves those domains that unite all persons. It is 

there, in birth, in sickness, in recovery, and ultimately in death that we can all find our common 

humanity. In our turbulent world, health remains one of the few truly universal aspirations. It therefore 

offers a concrete opportunity to reconcile national self-interest with international mutual interest. More 

today than ever, health is a bridge to peace, a source of shared security, a way to give globalization 

a human face. 

But for this to happen, we must renew international cooperation for health. I suggest three key 

elements for such renewal, three ‘Es’: exchange, evidence, and empathy. 

First, exchange of experiences around common problems. This is what gives such great value to 

meetings like this one. 

Second, evidence on alternatives, so that we may build a solid knowledge base of what works and 




what doesn´t. This is why global public goods such as methodological tools, comparative analysis, 

and systematic evidence are so important. Angus Deaton, from Princeton University, recently argued 

that the health of most people in the world depends mostly on their ability to adopt health knowledge 

and health technologies that have been discovered and developed elsewhere.[18] 

But there is another value. The great European philosopher Sir Isaiah Berlin has proposed the 

comparative studies of other cultures as an antidote against intolerance, stereotypes, and the 

dangerous delusion by individuals, tribes, states, and religions of being the sole possessors of 

truth.[19] And this leads us to the third element, empathy, that human characteristic that allows us to 

mentally participate in a foreign reality, understand it, relate to it and, in the end, value the core 

elements that make us all members of the human race. 

As we engage in this process of renewal, I would like to leave you with the words of a universal 

leader, Dr Martin Luther King Jr, who in 1968 wrote the following: 

“It really boils down to this: that all life is interrelated. We are all caught in an 

inescapable network of mutuality, tied into a single garment of destiny. Whatever affects 

one directly, affects all indirectly.”[20] 

I am certain that Europe will continue to play a leading role as we all weave together the destiny of 

better health for every person in our interdependent world. 

References 

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3. Hobsbawm E. The Age of Extremes: A History of the World, 1914–1991. New York: Pantheon 

Books, 1994. p. 12. 

4. AT Kearny Inc. Foreign Policy. Globalization index 2003 (www.foreignpolicy.com). 

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international health. British Medical Journal 1997;314(7091):1404–47. 

6. Chen LC, Evans TG, Cash RA. Health as a global pubic good. In: Kaul Y, Grumberg Y, Stern MA, 

(eds). Global Public Goods: International Cooperation in the 21st Century. New York: Oxford 

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7. Karlen A. Man and Microbes. Disease and Plagues in History and Modern Times. New York: 

Simon and Schuster, 1995. 

8. McKee M, Mossialos E, Belcher P. The impact of European law on national health policy. J 

European Social Policy 1996;6:263–86. 

9. Gómez-Dantés O, Frenk J, Cruz C. Commerce in health services in North America within the 

context of the North American Free Trade Agreement. Pan American J Public Health 

1997;1(6):460–65. 

10.Aiken LH, Buchan J, Sochalski J, Nichols B, Powell M. Trends in international nurse migration. 




Health Affairs 2004;23(3):69–77. 

11. United Nations Development Programme. Human Development Report 1999. New York: Oxford 

University Press for the United Nations Development Programme, 1999. 

12. Prescott-Allen R. The Wellbeing of Nations. A Country-by-country Index of Quality of Life and the 

Environment. Washington DC: Island Press, International Development Research centre, 2001. 

13. United Nations Population Fund. State of the World Population 2002. People, Poverty and 

Possibilities: Making Development Work or the Poor. New York: United Nations Population Fund, 

2002. 

14. Cornia GA, Jolly R, Stewart F. Adjustment with a Human Face. New York: Oxford University 

Press, 1987. 

15. United Nations Development Programme. Human Development Report 2004: Cultural Liberty in 

Today’s Diverse World. New York: UNDP, 2004. p. 10. 

16. Berlin I. The pursuit of the ideal. In: Berlin I. The Crooked Timber of Humanity. New York: Vintage 

Books, 1992. pp. 1–19 

17. Havel V. A courageous and magnanimous creation. Harvard Gazette 1995;June 15:9–10. 

18. Deaton A. Health in an Age of Globalization. Research Program in Development Studies, centre 

for Health and Wellbeing, Princeton University (working paper, July 2004). 

19. Berlin I. Nacionalismo: notas para una conferencia futura. Letras Libres 2001;3(34):105–6. 

20. King Jr ML. The Trumpet of Conscience. New York: Harper, 1968. 



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Opportunities for developing policy at member state level and 

during the EU presidency’ 

Roel Bekker 

There are clear indicators that health is priority number one: at a personal level, at the national level, 

in the EU and globally. 

I can make this clear by a simple example: 

If you use a search engine on internet like google and look at the number of internet hits worldwide, 

you can see that health – with 236 million hits - has the highest number of hits, more than work (216 

million hits), sport (175 million hits) and even sex (171 million). Also, the circulation speed in which 

new health ministers are assigned is an example of the intensity of the political debate around health. 

Health is invaluable to all of us and therefore leads to fierce national policy struggles. That explains 

why in many countries “confusion” is the most striking phenomenon when you have to describe the 

state of health. 

What is the international health picture? 

The confusion is the same, but as the scope is broader, the picture becomes even less sharp. 

Let’s first have a look at the global health picture. On the global level we face big health problems: 

infectious diseases, more especially HIV/Aids, nutrition problems and starvation, child mortality and 

all kind of lifestyle diseases. Developing countries are increasingly facing the so-called double 

disease burden: they still cope with the traditional disease-pattern of malnutrition and infectious 

diseases, while being rapidly confronted with emerging life-style diseases, such as cancer and 

cardiovascular diseases. 

In 2003, the Commission on Human Security stated and I quote: “Poverty related health threats are 

perhaps the greatest burden of human insecurity. Most preventable infectious diseases, nutritional 

deprivation and maternity related risks are concentrated among the world’s poor people. Poverty and 

disease set up a vicious spiral with negative economic and human consequences.” 

At EU-level the main challenge also lies in the field of public health. The EU has taken a lot of very 

important steps in prevention: tobacco, alcohol, nutrition and food safety. Infectious diseases are also 

more and more at the forefront of the debate in Europe. A third element at EU-level is the impact on 

health of policies in other fields in connection with court decisions regarding internal market and 

freedom of traffic and trade, followed more recently by a general concern in the EU about the 

sustainability of our health systems. 

How are these health policy challenges being addressed? 

First, the WHO has its mandate at the global level for health and an important standard-setting and 

normative function. Notwithstanding this mandate its focus is and should be primarily on public health 

issues. Priorities of the WHO are mainly set by the global burden of diseases. Although it provides 

important advice on health systems and the creation of primary health care services in developing 

countries, the organisation of health care in developed countries is and should not be its first concern. 




For a lot of developed countries around the world, the OECD deals, through its Health Project, with 

the difficult subject of the performance of health systems and the question of financial sustainability, 

this in connection with the economic aspects of health. 

The EU is, as I said, very active in prevention and public health, and the interest for health care 

systems and their European aspects is increasing. Health care in its strictest sense, insurance, 

doctors, hospitals, reimbursement and pricing of pharmaceuticals, are and will nevertheless remain a 

primarily national responsibility. 

Is this all there is? Is this a clear and sustainable division of labour? And do we just have to wish the 

international organizations and the national governments the best of luck, or is there more, now and 

in the future? 

The answer is: yes and no. Let me start by emphasising the importance of national efforts regarding 

health and health care. All EU-countries are reforming their health care systems by for instance 

introducing more financial incentives to improve efficiency while respecting solidarity and stimulating 

more personal responsibility. At our informal EU council held in September in Noordwijk it became 

clear that in all member countries a new balance is needed between personal and public 

responsibility in order to safeguard affordable, accessible and sustainable health systems. 

Furthermore, it was stressed that upstream prevention strategies need to be promoted. We should 

invest in primary and integrated care and focus more on medical innovation, health education and 

empowerment of the patient. 

It is clear that we should not want to prescribe at European level those things that are better dealt 

with nationally. But boundaries, especially in Europe, are disappearing. Patients and professionals 

travel more frequently. Supply of health care is no longer restricted to frontiers. In a sense this makes 

it necessary to develop an integrated, international or European agenda. This agenda should be 

more than just an exchange of best practices. 

Let me confine myself to the EU in an attempt to sketch an EU agenda as a part of the international 

agenda. This EU agenda has in my view four main compartments: 

1. Health in relation to other policy areas 

Health care in itself is not autonomous, but strongly influenced by developments elsewhere, like 

taxation, the internal market, patent protection and the Lisbon agenda. It is essential for the 

European health community to develop a common view on impacts from this kind of policy areas on 

health. 

Commissioner Byrne recently proposed a new EU Health strategy, in which he stated that “Achieving 

good health for all means not just reacting to ill-health, but proactively promoting health, preventing 

diseases and helping people make healthy choices.” We very much underscore the idea that health 

is a key element in the social and economic development of society and that it demands more 

attention than from the health world alone. 

2. Developments in public health. 

Newly emerging infectious diseases and food safety issues must be at the heart of our minds. Also, 

obesity becomes the new focus of the health community. The real challenge is how we protect 

ourselves against disasters and be prepared for the unexpected. Because of its inherent vulnerability, 

the EU should develop coherent European policies to deal with all communicable diseases and 

define clear instruments of those policies. Import restrictions, quarantine, travel advice, stamping out 

and vaccination, etc. 




Furthermore, as became clear during our EU presidency conference on zoonoses, the world of 

veterinarians – which is by the way much better organized within the European Union, animal health 

seems in this respect to be a higher priority than human health – and the world of human medicines 

should cooperate more closely together in the battle against zoonotic diseases. On top of this, a new 

vision for human security is badly needed. To capture the more complex determinants of human 

insecurity, it will not be enough to limit the concept of security exclusively to military or geographical 

definitions. 

3. Developments in health care 

As I said: patients, professionals and suppliers of health care cross borders. Therefore there is a 

pressing need to design common EU policies. For instance, for professionals crossing borders and to 

refine the recognition of educational degrees. Patients travel to neighbouring countries to undergo an 

operation or take a course of treatment, and physicians more easily decide to work in another country 

for a while. The purpose of our EU Presidency conference on EU health care professionals crossing 

borders starting from the 9 December in Amsterdam, is to improve cooperation and information 

exchange between member states on the registration and supervision of health care professionals. 

Another very important development concerns the question how to deal with the enormous and 

fascinating development of technology in health care, medical equipment, pharmaceuticals and 

biotechnology. I think it’s essential to develop at the EU-level strategies to cope with these 

developments in order to guarantee that they will produce benefits for health and not only profits for 

the industry. 

In that respect, let me also look ahead shortly to another big event of our EU Presidency: our 

conference on priority medicines the 18 November. Here we aim to identify the gaps in the 

development of pharmaceuticals and provide input for a well-founded R&D agenda for medicines, 

vaccines and biologicals, taking into account the specific needs of the new member states and the 

real needs of our citizens. To capture the latest in health care I am a firm believer in health technology 

assessment (HTA) at EU level as it aims at improving the quality of care by promoting the use of costeffective 

technology and protecting patients from ineffective and harmful health interventions. 

4. Bench mark development and best-practices 

The very successful OECD Health Project clearly demonstrates the usefulness of updated indicators 

and the results of policy analysis on health and health care. This is essential and a prerequisite for 

new policy initiatives. As you may have noticed in the Background Paper of the Informal Health 

Council, the Netherlands EU Presidency used many significant health data and results of health 

policy analysis from the results of the OECD Health Project. These updated data on health and 

health care systems facilitated our discussions effectively and give all member states a lot of 

inspiration to improve their systems. International comparisons are always a very effective incentive 

for political action. 

The next step: what to do in practice when developing this international or European Health 

Agenda? 

To me, it seems wiser to be selective and optimal, than to be broad and sub-optimal. The question is 

what to select? Let me open the discussion by proposing to focus within the EU on four topics: 

1. Health impact assessment 

Or, how are developments in other policy areas or other parts of society affecting health and health 

care? And how can we use these developments to improve the quality of health? I think that it is a 




fascinating field of exploration in which the health community should play an active role and not a 

modest role, waiting for whatever may come from the outside. 

I mention a few examples. I have already mentioned the paper of Commissioner Byrne, clearly 

indicating that health is more than just health. The high level group on health fits perfectly in this 

approach. 

I am also encouraged by, for instance, the intentions recently made public by Gunter Verheugen, the 

future Commissioner for Enterprise and Industry. Proposals from his side which promote innovation 

and make it financially rewarding are very welcome. New approaches to pricing and reimbursement 

should on the other side not be left undiscussed and certainly not left to the economic policy makers 

only. We also read with great interest the answers by Mr Kyprianou about public health and the 

Lisbon process. 

Prevention could benefit a lot from this, look at our policy neighbours, look at for instance 

environment policy, the close ally of health. 

2. The further development, extension and expansion of the European CDC 

To me this is crucial. The ECDC is the European gateway to assess in a coordinated way, all 

currently available and newly emerging public health risks related to communicable diseases. All 

member states should collaborate closely with the institute as it will function as the source for 

independent scientific information and advice. We all should nourish this emerging pool of expertise 

which becomes our crucial lifeline when a new outbreak strikes Europe. Furthermore the finalization 

of the International Health Regulations and the implementation thereof in the EU is yet another major 

step towards fighting infectious diseases. 

3. Planning and assessment of (medical) technology, pharmaceutics and ICT 

All countries are facing the influence of the huge developments in technology, either in medical 

devices or in pharmaceuticals or biologicals. That creates fascinating, far reaching perspectives. But 

also a rapid increase of dilemmas, since most technological progress goes hand in hand with a huge 

increase of costs. We have to be aware that not all developments are useful and need careful 

consideration. That could be an immense challenge for cooperating at EU-level but will also create 

opportunities for big rewards for society as a whole. With our EU presidency conference on priority 

medicines our strategic imperative is to contribute to a better European, and possibly global, R&D 

agenda in the health sector. 

A health innovation powerhouse, as David Byrne said, is a most inspiring ambition. 

4. Database development and updating 

The follow up of the OECD Health Project deserves to my opinion strong political, technical and 

financial support from the member states of the European Union. Such information is in my view 

indispensable for our highly significant and necessary debate in the EU on one of the major 

challenges for all EU member states: good, efficient and affordable health care in view of an ageing 

EU society. Also the introduction of the EU Health portal contributes to the access of reliable 

information. Information is absolutely crucial to make the system work. 

As I said, one can see a kind of ‘natural’ division of labour between global, European and national 

levels. This division determines the activities carried out and the attention we give them. The 

discussion should not be about territories, but about cooperation and added value. From that 

perspective I see great opportunities for a European Health Agenda. They are very promising but it 




will not be easy. I hope I gave some observations for developing such an agenda. I also emphasised 

that we have to choose our priorities carefully to come to a successful agenda. Making choices is the 

hardest thing to do, as any child in a candy-shop knows. But making them could result in a good, 

lean and mean but convincing health agenda for Europe which could also be of great benefit to the 

rest of the world. That is what we owe to the citizens in Europe and in the world. 




Global public health in the 21st Century – a challenge for Europe 

Ilona Kickbusch 

The challenge: global health disparities 

The post modern health societies of Europe stand in stark contrast to the situation in the poorest 

countries where health is a matter of survival. Particularly in rural areas of poor countries, the 

predominant pattern is still that of infectious diseases engendered by the natural environment, such 

as malaria, tuberculosis and infant diarrhoea, as well as AIDS and high rates of maternal deaths. Life 

expectancy is falling in many African countries but also in some parts of Eastern Europe. In the face 

of a lack of access to even the most basic primary health care services the poorest people are forced 

to spend a significant amount of their meagre income on medical treatments thereby enhancing a 

cycle where poverty breeds ill health and illness leads into poverty. 

Health remains a neglected arena of national politics where – frequently reinforced by the 

conditionalities of international loans – it is not considered an investment in development but as a 

burden and expenditure. The message of the report of the Commission on Macro Economics and 

Health that health is not only a significant outcome but an essential input factor for development still 

has to be turned into policy practice – of national governments in developing countries as much as of 

international donors and of development banks and other actors. 

People of developing countries are now experiencing what was a key element of the first public 

health revolution and a consequence of European enlightenment and medical and social progress: 

health and disease are no longer considered natural states. Health becomes do-able; solutions exist, 

be they medical, economic or social. In Europe, throughout the 18th, 19th and 20th century public 

health became part of the big social reform project of the first wave of modernity. The focus was on 

addressing the key health determinants of the industrial revolution: water and sanitation, air, housing, 

education, safe work, better food, shorter work days, maternal care and access to family planning. 

Health is now beginning to play a similar role in the global arena. As was the case historically in 

Europe the key health determinants need to be addressed. But in the 21st century issues of the 

do-ability of treatment arise – for example with the advent of ARV Drugs HIV/AIDS is no longer a 

death sentence – and issues of availability and access are raised that drives a new debate on 

human dignity, equity and social justice spearheaded by global advocacy and global social 

movements. 

At a global level we need to ask: can the world continue to accept forty years of difference between 

the average life expectancy in Somalia and in Japan? How should we frame this human neglect in 

new terms? How should responsibility be divided between the rich and the poor, between the 

international community and the nation states, the individual citizen and the state, the public and the 

private sector? Europe needs to grasp the opportunity to be at the forefront of developing a new 

global mindset and exploring the potential of a global social contract on health for the beginning of 

the 21st century. 

European and global solidarity 

Europe of course is leading the experiment of creating something new: a common orientation for all 

its members not only in the field of economics but also of values, ethics and solidarities – as 

expressed in the new European constitution. It is essential though that Europe focuses not only on 




the challenges it faces in the integration process of new Member States and many more applicants . 

The success of the European experiment will also be measured by the role Europe plays in the world 

and the approach it chooses for international development. Europe is only at the very beginning of 

defining this common approach. 

The external objectives of the European Union are formulated as upholding and supporting European 

values and interests. They are: peace, security, respect for the UN Charter, sustainable development 

for the earth, respect for international law, protection of the rights of the child, protection of human 

rights, eradication of poverty, fair and free trade, mutual respect between peoples and solidarity. In 

principle this is an important list that differs from other concepts in the international arena – such as 

those of the United States of America – that are primarily defined by national interest and are much 

more restrained in their commitment to international law and in their support to the United Nations. 

Developing nations look to Europe to actively support and defend approaches to development that 

are based on human rights and social justice. 

Of particular importance is the concept of solidarity. In the 19th century in Europe with the social 

conflict around health and citizen’s rights, solidarity entered health governance as a new principle 

and as an integrative force for both social movements and for identity and cohesion within the nation 

state. Public health was understood to be a social enterprise. Today it needs to be redefined and 

filled with new meaning within European nation states (How will we share risk? How will we pay for 

health? How will we treat the old? Who has a right to care?) but also at a global level. At this point in 

history Europe needs to resolve a new combination of challenges that can be expressed as the three 

plus three solidarities: risk solidarity, generational solidarity, distributive solidarity need to be balanced 

within a national, European and global context. Interdependence is a fact of policy in a global world 

European societies are presently engaged in trying to resolve the new challenges of solidarity within 

their own borders as well as between members of the European Union. At the same time a new 

challenge in global solidarity has been accepted by the global community. In the year 2000, the 

United Nations at its Millennium Summit adopted a Millennium Development Declaration [1] and a set 

of eight goals to fight global poverty. A recent analysis by the Global Governance Initiative of the 

World Economic Forum, which brought together leading experts on crucial global governance issues 

and asked them to focus on these goals, came to the conclusion that “the world is doing barely a 

third of what is necessary to fulfill the goals it has set.”[2] The Initiative gives the world a score of four 

out of ten (clearly less than 50%) for the direct health-related Millennium Development Goals 

(MDGs), which aim to accomplish the following by 2015: 

• Stop and begin to reverse the spread of HIV/AIDS, tuberculosis and other diseases; 

• Reduce by two thirds the under-5 mortality rate; and 

• Reduce by three quarters the maternal mortality ratio. 

An index developed by the Center for Global Development, called the Commitment to Development 

Index, ranks 21 of the world's richest countries based on their commitment to policies that benefit the 

five billion people living in poorer nations. The index brings together seven issues: aid, trade, 

investment, migration, environment, security and technology. Its results show: “no wealthy country 

lives up to its potential to help poor countries.”[3] Recent new initiatives such as the Africa focus of 

the British presidency of the G8 and the expressed intention of the United Kingdom to include global 

issues in its agenda of the presidency of the European Union in the second half of 2005 are 

important steps and signals that Europe is becoming increasingly aware of its global responsibilities. 

In many European countries a new understanding of health development has been accepted which 

underlines that health is a central component of poverty reduction and economic development of 

nations.[4] 




This thinking has brought the health agenda firmly into the economic development agenda and close 

to ministries of finance. For example, Gordon Brown, the British Chancellor of the Exchequer, has 

proposed an International Finance Facility, which would double annual aid to poor countries. The 

Facility is aiming to move to a new premise of financing through collateral bonds issued in the 

international capital market. After years of debate this proposal is gaining more acceptance among 

European nations. In particular the experience with the Severe Acute Respiratory Syndrome (SARS) 

epidemic demonstrated both global health interdependence and the enormous global economic 

impact a regional health crisis can have. It is estimated that the economic toll of SARS was roughly 

US $30 billion, largely from cancelled travel (thus impacting the service industry and airlines) and 

decreased investments in Asia.[5] 

The importance of values in the global arena 

Yet one of the most important contributions that must come from Europe is related to the value base 

that drives global health and development. The value base of global health action has become 

increasingly vague and unclear. The Health for All orientation of the 1980s was replaced with an 

investment in health perspective in the 1990s, headed by the World Bank, which brought an 

economic investment paradigm to the center of the health debate. The acceptance of health as an 

integral part of the poverty reduction and social safety net strategies of the international community 

has meant that the acceptance of health as an end – as reflected in the human rights approach – 

has been overshadowed by the approach to health as a means. The external objectives of the 

European Union – to uphold and support European values and interests – need to be reflected in its 

global health strategy. These values need to be reflected and clarified in discussions around the 

impact of globalization, the protection of human rights, the provision of global public goods, and the 

development of global solidarity and global social contracts. This is why the debate on a new global 

financing mechanism is basically one about values: According to what principles should wealth be 

shared at the global level? And what role is Europe willing to play? 

Europe’s global health strategy must build on its own public health history. Too often rich societies 

have chosen to forget, what laid the basis for their health and life expectancy – and in consequence 

wealth – gains in the first and second public health revolutions. In many cases, development 

agencies and lending institutions have not been willing to support those very tenants of success in 

the developing world: a strong state, public policies, laws and regulation, public health, public 

education and the understanding that health is part and parcel of a citizen’s right. 

One element of the global systems failure has been the tendency to be wedded to a charity model, 

which focuses on the ‘deserving’ and the ‘undeserving’ poor. Global health means that the health of 

the poorest and most vulnerable has direct relevance for all populations because of the interconnectivity 

that increasingly brings the world closer. From this perspective, the underlying basis of 

health sector aid should shift from providing charitable handouts to ensuring appropriate and sufficient 

resources for a global health system that meets the common needs of the human species.[6] 

Inge Kaul, in her work on Global Public Goods, emphasizes the need to develop a new global policy 

model. “The pervasiveness of today’s crises suggests that they might all suffer from a common cause, 

such as a common flaw in policy making, rather than issue specific problems. If so, issue specific 

responses typical to date, would be insufficient – allowing global crises to persist and even multiply.” 

Steps towards a new conceptual map 

Europe should be at the forefront of the challenge formulated by Peter Singer, in his Yale lectures on 

“One World”:[7] to adopt a radically new mind frame of global ethics, global citizenship and global 

responsibility that goes beyond health as an issue of the nation state and utilitarianism. “Implicit in 




the idea of ‘globalization’ rather than ‘internationalization’ is the idea that we are moving beyond the 

era of growing ties between nations and are beginning to contemplate something beyond the existing 

conception of the nation state.” Five action areas could be considered as a road map for European 

action: 

1. Health as a Global Public Good and human right 

Health must, first and foremost, be seen as a global public good (GPG). GPGs are defined as 

‘having non-excludable, non-rival benefits that cut across borders, generations, and populations’.[8] 

The GPG concept implies that society must ensure the value of health, understand it as a key 

dimension of global citizenship and keep it high on the global political agenda. It means defining 

common agendas, increasing the importance of global health treaties and pooling of sovereignty by 

nation states in the area of health. “The GPG perspective demonstrates that today’s global health 

challenges require not just good national policies, but also strong global responses, the focal point 

thus being international collective action.”[9] This means that all sectors must recognize their 

interdependencies and work together with accountability and transparency intact. 

2. Health as a key component of global human security 

Global integration has proven that disease outbreaks are a threat to global human security. Europe 

should be at the forefront of efforts to create a global health surveillance infrastructure as well as an 

early warning system and rapid response structure. It should help strengthen international health law, 

as reflected for example in the International Health Regulations and the International Framework 

Convention on Tobacco Control. The European concept of security must include social and economic 

inequities, which in turn must rigorously be addressed at the international level through sustained 

action on Goal 8 of the MDGs. Rich nations must not only increase their foreign aid to the minimum 

0.7% GNP, but also reduce poverty via trade, investment, migration, environment, security and 

technology. 

3. Strengthening global health governance for interdependence 

Health must not only be viewed through the lens of development, but also through the reality of 

interdependence. Strong governance must accompany the changes occurring among global health 

actors and lead to increased accountability among all global health actors. Europe should support 

and protect multilateral health organizations and first and foremost, give the World Health 

Organization a new and stronger mandate and strengthen its financial base. 

4. Accepting health as a key factor of sound business practice and social responsibility 

Increasingly, sound business practice is being understood in terms of corporate citizenship, which 

makes companies more accountable for public goods – in particular, those that improve health and 

the environment. Accepting health as a key factor of corporate social responsibility means that 

business must invest in health. Avenues for corporate investment in health can be outlined on four 

levels: workplace, marketplace, community and policy. Many European companies have already 

shown strong involvement in health in developing countries – particularly in the area of HIV/AIDS. A 

European initiative of corporate citizenship in health could significantly strengthen global action (such 

as the Global Compact) that is already under. 

5. Accept the ethical principle of health as global citizenship 

Ethical norms must apply to international relations. As inequities in health become increasingly 

obvious, the notion of health as a human right is gaining support. In particular, this implies a common 

notion of social justice and a system of international law where human rights constitute a legal claim. 




Global health action has begun to expand into the legal territory of rights and global citizenship. The 

litigation cases against the tobacco companies are a case in point, as is the debate around TRIPS in 

the WTO. Very important is the push by global social movements that aim to change the rules of 

globalization and use the most tangible example, the access to HIV/AIDS treatment. 

A greater push towards health as global citizenship is essential. Accepting the ethical principle of 

health as global citizenship requires challenging the dominant neo-liberal paradigm in the world 

today. “Tension persists between the philosophy of neo-liberalism, emphasizing self-interest of 

market-based economies, and the philosophy of social justice that sees collective responsibility and 

benefit as the prime social goal. The practice of public health, with its underlying community and 

population perspective, sits more comfortably with the latter philosophy.”[10] Europe should be at the 

forefront of advancing the principle of social justice as the lead value in global health. 

Create a European Council on global health 

One way to take this agenda forward and develop a uniquely European approach to support 

development and social justice would be to create a European Council on Global Health. It would 

consider mobilizing support for a concrete set of actions around: 

• The Millennium Development Goal and in particular Goal 8 

• Putting health at the centre of European development policy 

• Actively moving towards harmonisation of aid 

• Supporting and strengthening the UN system 

• Be a leader on women’s health and ICPD 

• Apply the lessons of European public health history 

• Support a strong civil society movement for global health 

This year 2004 is the the 200th anniversary of Immanuel Kant’s death. He was one of the first 

European philosophers to reflect on a possible world society and global citizenship. His words are a 

guiding light for public health action: “to act that you treat humanity whether in your own person or 

any other person never merely as a means but as an end in itself.” (1785) Immanuel Kant’s thinking 

leads us beyond the state towards our obligations of citizens in a global world and highlights our 

obligations to any human being anywhere in the world. Indeed, it is a guiding phrase for the 

beginning of a new European policy on global health. 

References 

1. United Nations, A/res/55/2, United Nations Millennium Declaration. United Nations, 2000. 

2. World Economic Forum. Independent Report Gives Failing Grades to Efforts to Improve the State 

of the World, press release, 15 January 2004. 

3. Ranking the Rich 2004. Foreign Policy, May/June 2004. 

4. WHO. Macroeconomics and Health: Investing in Health for Economic Development, WHO 

Commission on Macroeconomics and Health, December 2001. 

5. United Nations Secretariat. Severe Acute Respiratory Syndrome (SARS), UN Secretariat Report, 

23 January 2004. 




6. Buse K, Drager N, Fustukian S, Lee K. Globalisation and health policy: trends and opportunities. 

In: Lee K, Buse K, Fustukian S (eds.) Health Policy in a Globalising World. Cambridge: Cambridge 

University Press, 2002, p. 277. 

7. Singer P. One World: The Ethics of Globalization. New Haven: Yale University Press, 2002. 

8. Kaul I, Grunberg I, Stern M (eds.) Global Public Goods: International Cooperation in the 21st 

Century. UNDP, 1999. 

9. Smith and Beaglehole, p. 271. 

10. McMichael T, Beaglehole R. The Global Context for Public Health. In: Beaglehole R (ed.) Global 

Public Health: A New Era. Oxford: Oxford University Press, 2003, p. 10. 




A global health strategy for the European Union 

David Byrne 

I am delighted to be here at the 7th European Health Forum, in Gastein. This is my last ‘Gastein’ as 

European Commissioner for Health and Consumer Protection. I have had the great privilege over the 

years to see this event grow – both in size and significance. Let me pay tribute to Dr. Günter Leiner 

and his team for creating this unique forum. I was very honoured to receive an award from the Land 

of Salzburg on Wednesday. But in reality, Dr Leiner, placing Gastein at the centre of European health 

debate is due to your determination, your dedication and your hospitality. 

Sometimes, health policymaking at EU level is a little like Gastein – many steep slopes and some 

very deep valleys! But because of the effort required, sometimes we do not see the potential 

international significance of what we are working together to achieve. 

The title of this session addressing ‘Europe’s role as partners in world health’ bears testament to a 

timely ambition. In our bitterly divided world, Europe is increasingly being called upon to develop 

imaginative approaches to healing these divisions. At a decisive moment in the definition of Europe’s 

foreign policy and security identity, I would like to explore the vital role which health could play in 

shaping a progressive relationship between Europe and our global partners. In short I would like to 

underline that greater European leadership on global health could prove vital in healing global 

divisions. 

Before examining the nuts and bolts of this approach, I would like to set out a few basic ideas which 

my five years at the decision-making table, have brought home to me. First, despite all the academic 

debate about an emerging European foreign and security identity, the issue is no longer whether 

Europe should have a global role, but how we intend to act. We have now to step up to the mark and 

meet our responsibilities to work for peace, prosperity and security on the global stage in new and 

effective ways. 

There are signs that we have not lost our strategic optimism. As this week’s decision on Turkey’s 

future confirms, we Europeans continue to believe in a progressive and inclusive political future. We 

are committed to the belief that our ambitions for peace, prosperity, well-being, democracy, human 

rights and equality before the law, are common human ambitions. They are the global essentials. We 

are convinced that they are a universal birthright – not subject to cultural or religious endorsement or 

so-called “civilisation clash”. As Europeans, our progressive belief that these rights are both universal 

and achievable is unfashionably optimistic. But if ever our troubled world needed optimism, now is 

the moment. 

But our optimism, is hardened by our experience. Our convictions that peaceful transitions are 

possible between radically different peoples, is shaped by our familiarity with where we have come 

from our own history to get here. On our path to European reconciliation, for centuries, we have seen 

and done it all – wars of religion, famine, mechanised warfare, and ethnic cleansing. Europe’s 

development from once being the charnel-house of the world, to peaceful continental reunification, is 

nothing short of a modern political miracle. From the ashes of the past we are building a domain of 

freedom, justice, security, prosperity, good health and equality before the law. Given the price paid by 

our ancestors for this precious insight, it should guide and illuminate our future actions abroad. 

Future EU behaviour in the world abroad, should reflect that we have learned the lessons of our own 

history. Lessons about interdependence; diversity; mutual respect, consensus and the rule of law. 




Lessons above all, about how improving the health, wealth and welfare of ordinary people, delivers a 

stable and durable consensus for progressive inclusive politics. 

In place of the old-world muscular ideology of force, Europe needs to find more innovative ways to 

work with our partners to avoid conflict, deepen interdependence and make economic and social 

progress. In acting abroad, Europe must show the courage of our own hard-won convictions. We 

must continue to define our approach by addressing the structural causes of conflict wherever they 

arise – rather than reaching for simplistic solutions to the symptoms. This means turning all our 

policies to tackle the age-old origins of conflict in hunger, squalor, ignorance, idleness and disease, 

wherever they arise. 

By placing the improvement of global health at the centre of our emerging foreign policy agenda, we 

could transform our international partnerships, tackle a root cause of instability and make a 

persuasive case for the practical benefits of progressive politics. By placing a well-resourced health 

diplomacy at the centre of our foreign relations, Europe’s progressive ambitions for our partnerships 

could be quickly understood and clearly demonstrated in very visible and practical ways. Very often 

conflict is the child of despair. By working to improve global health, we can help to give many people 

a real stake in the future 

At present, we hear a lot of comment about security. But as each one of us knows, security begins 

with getting the small things in life right, for the individual. Our health. Our welfare. Our access to 

knowledge and work. It then grows into a collective culture of confident development. A concentrated 

effort to improve global health would transform individual perceptions and collective behaviour on 

security fundamentally. We need to be obsessed with addressing poverty and disease which are the 

real weapons of individual destruction. We need to focus on what we can do to close the global 

health-gap, to increase life expectancy, to reduce infant mortality and to improve maternal health. To 

increase healthy life years for the global many as well as for the European few. If we want to make a 

real difference to global security in the long term, we should start here with global health. 

For many of our fellow global citizens, such changes would allow them to lift up their eyes from the 

dust of despondency to consider a future horizon. To consider the things which we take for granted – 

the prospect of seeing their children grow up. Or the dream of completing an education. Or the 

opportunity to capitalise on decades of development, by preventing killer diseases like HIV/Aids, TB 

and Malaria from wiping out a whole generation. Because, you must first have a future, before 

working with others to secure it. 

Looking across the EU policy horizon from Trade and External Economic Relations to Development, 

it is striking just how active the EU already is on health matters with our global partners. We have 

taken a leading role in tackling communicable diseases, in mainstreaming health care in poverty 

reduction, and in the development of vital clinical research platforms. We have worked hard with our 

partners to secure the Doha declaration on TRIPs and public health, to facilitate access to essential 

medicines in less-developed countries. 

In all of this, we can begin to see the outlines of a coherent overarching EU global health strategy. 

But first things first. Any such strategy abroad, should reflect our strategy at home. And just such a 

European Health Strategy is beginning to take shape. 

European health strategy 

Health is taking its place at the centre of European policymaking, from competitiveness to structural 

funds. We have an integrated public health programme in place. We have also strengthened the 

institutional structures for health, the establishment of the ECDC (European Centre for Disease 

Prevention and Control). 




But this is only a start. Good health should be nothing less than a defining aim and benefit of EU 

citizenship for every European. In the future, every Commissioner should be a Commissioner for 

health. This is why I have launched a reflection process on how to enable good health for all. Good 

health needs to be defined in much broader terms than simply the prevention of illness. The concept 

of good health embraces the life-long physical and mental well-being that is essential for people to 

lead meaningful, enjoyable and productive lives. This is also part of the foundation on which modern 

economic progress is based. 

Good health for all 

Achieving this means doing more than just attempting to mitigate and cure sickness when it arises. It 

requires a more positive and forward-looking approach to actively promote health for the future. 

The importance of good health is certainly recognised by citizens. Health is consistently rated 

amongst the top questions of concern to people throughout Europe, and health-related stories 

feature heavily on the news agenda. Yet good health for all is far from being a reality in today’s 

Europe. Depending on where you live, your average male life expectancy may vary between 64 and 

78. With the recent enlargement of the Union, the internal ‘health gap’ has widened even further. 

However, in some of the poorest nations of the earth, life expectancy is only a little over half that of 

Europeans. And even for our near neighbours, the gap is striking – the average life expectancy for 

Russian men is under 60. If we really believe in an interdependent world, our health strategy must 

tackle these issues. We must aim to make the European Union a leading global partner for health. 

Health threats – a shared challenge 

We are now living in an era where the concept of global health security and global health defences 

are a reality. Whether we are considering bioterrorism, malaria, influenza pandemics, or the impact of 

HIV/Aids, global threats require global health security responses. We cannot and should not 

therefore attempt simply to create a healthy corner of an unhealthy world. The borders of the EU 

should not be seen as a new cordon sanitaire. 

We are already putting in place joint initiatives with our neighbours on health-related issues. Take the 

example of HIV/AIDS. The ministerial conference on HIV/AIDS in Europe held in Vilnius last month 

endorsed a strategy bringing together the European Union, neighbouring countries, other 

stakeholders and international organisations. This is a model for wider future cooperation on health 

issues. I would like to take this opportunity to congratulate my colleague, Pavel Telička, for his 

leadership on this issue. 

Health as a driver of economic growth and sustainable development 

On the theme of health generating overall wealth, this is even more pertinent to less developed 

countries. Sustainable development hinges on extending healthy life years. Compare the 

development of the East Asian ‘tiger economies’ with the less-developed countries of Africa. Life 

expectancy in East Asia increased from 39 years in 1960 to 67 years in 1990. Improved health 

increased the labour supply which helped to drive development. In contrast, more than half of Africa’s 

growth shortfall is due to disease burden, demography and geography. High levels of malaria 

morbidity alone are a substantial brake on growth; and are associated with a reduction in economic 

growth of 1% per year. 

EU’s role as a global partner for health 

The case for pursuing health at a global level is clearly a powerful one. But what should Europe’s 

role be as a partner in this initiative? I believe that we must do more to actively promote health and 




to prevent threats to health before they materialise. 

We are working with the WHO and other partners on the revision of the International Health 

Regulations, in order to put in place a modern global framework to control the spread of 

communicable diseases. The ECDC will provide a key liaison function with the WHO on future health 

threats. I am delighted that during my mandate we have fundamentally strengthened our cooperation 

with the WHO: The WHO continue to show the way on global health leadership. Our ongoing work 

together to deliver the Framework Convention on Tobacco Control the world’s first public health 

treaty is a clear model for future action. 

We now need to consolidate and further this leadership in relation to other issues – such as working 

on nutrition, physical activity and obesity alongside the WHO global strategy on diet, physical activity 

and health. But this means getting our own house in order on internal policies from the Common 

Agricultural Policy to recruitment of health professionals. 

Overall position of health at world level 

Perhaps most importantly, we can act as advocates for a long-term vision for health at global level. 

In the reflection process that I have launched for the European Union, I set out my vision for health in 

twenty years time – a vision where politics, money and modern technology are all geared towards 

good health, and where citizens live longer, happier and more productive lives. This vision also needs 

to be constantly restated and promoted at global level. We have also been putting health on the 

agenda in our work in other international groupings, such as our work on bio-terrorism within the G7. 

Beyond governments, we will need our other stakeholders in civil society, professional organisations, 

and all those active in the field of health and health care to take forward this ambitious global health 

agenda. And here I would like to take this opportunity to express my appreciation for the support, 

advice and commitment of my hardworking officials in SANCO. It is a real tribute to you –- how far 

we have travelled with so few resources. Thanks to your achievements, my successor, Markos 

Kyprianou, will have the wind at his back and a clear course ahead! 

Conclusion 

In conclusion, I would accept that this is an ambitious agenda. But at a moment in world history when 

a progressive global consensus on the rights of all women and men is increasingly fragile, we need 

to be bold. We must continue to mobilise the international community to address the causes of global 

conflict, which arise in the agony and despair of so many human lives. Europe needs to raise a new 

progressive voice in international diplomacy. We need to find a common language through which we 

can open a common dialogue for hope with those who are often sceptical about our values and our 

intentions. 

The shared concern for our own health and the health of our children, is a common language of 

human progress understood by all peoples and cultures. Global action will speak louder than any 

words. Placing a European global health strategy at the centre of our foreign and security policy 

agenda, will help to change the context. If we can show global leadership in closing the health-gap, 

in increasing healthy life years, and in reducing infant mortality, we would have our own living 

ambassadors of progress in every corner of the world. 

Our European vision of enabling good health for all, is a global duty. Especially at this moment in 

world history. Because global healing needs global health. 



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PROJEKT21:

Forum AI 

Values, principles and 

objectives of health 

policy in Europe 




��Ilona Kickbusch The need for common values, principles and 79 


The rights of the European citizen: Balancing equity with choice 

��Ulrich Becker The rights of the European citizen: 96 


��Yves Jorens The rights of the European citizen: 104 


��Theresa Petrangolini Text not available 

The European potential for value-orientated health policies 

��Simon Stevens The European potential for value-oriented 113 

health policies (abstract) 

��Josep Figueras Text not available 

��Manuela Messmer-Wullen Das ehrenamtliche Engagement von Individualisten 114 

in Patientenorganisationen und Selbsthilfegruppen 

auf nationaler und europäischer Ebene (abstract) 

Governance and health targetting experiences and future potential 

��Matthias Wismar Text not available 

��Luise J Gunning-Schepers Shaping the future to meet our needs (abstract) 116 

��Birgit Weihrauch Lessons from North Rhine-Westphalia 117 

Page 




The Madrid Framework – an instrument for consensus 

��Marshall Marinker The Madrid Framework 121 

The social Europe of the future – Moving from national to European solidarity 

��Mihaly Kökény National health improvement in the service of 126 

fighting inequalities (abstract) 

��Martin McKee The social Europe of the future – Moving from 127 


��Kimmo Leppo The social Europe of the future – Moving from 128 


Panel and open discussion 

��Hans Stein Introduction: The potential for international cooperation 

130 

in establishing common health values that can be 

embraced on all levels 

��Angela Coulter Values, principles and objectives of health policy 133 

in Europe 

��Bente Nielsen The need for common values, principles and 134 


��Andrzej Rys Summary 135 



Forum AII 

Promoting social inclusion 

in an enlarged Europe: 

Putting mental health on 

the agenda 




Setting the scene: barriers to social inclusion 

��Judith Klein Disability Advocacy Programme 144 

Open Society Institute Budapest 

��Matthew Muijen Text not available 

��Ignacio Pérez Caldentey Mental health as a human rights issue 150 

��Rachel Jenkins Supporting governments to adopt mental health policies 

153 

What do we want to achieve? What are the challenges? 

��Camilla Parker Mental health policy, human rights and the law 163 

��Hristo Hinkov Mental health reform in Bulgaria (abstract) 168 

��Andy Porter Reforming mental health services in England 169 

Meeting the challenges 

��John Bowis Focusing on the solutions: what should governments 172 

consider in developing mental health policies? 

��Martin Knapp Financing mental health reforms – what does it cost? 178 

��Toma Tomov Developing mental health policy and legislation 182 


��Petko Salchev Text not available 

��Clemens Huitink Text not available 

Page 




��Ann Tucker Text not available 

��Zsolt Bugarsky Text not available 

��Stefan Bandol Exploring normality 188 

��John Henderson Text not available 

��Michelle Funk Promoting social inclusion in an enlarged Europe – 191 

International cooperation and involving stakeholders 

in the mental health reform process 

��Ignazio Perez Text not available 

��Dainius Puras Vicious circles of social exclusion – attempts to 194 

diagnose and cure mental health systems in 

Eastern Europe 

�� Armin Fidler Is the incorporation of public hospitals the ‘silver bullet’ 

199 

Reinhard Haslinger to address overcapacity, managerial bottlenecks and 

Maria Hofmarcher resource constraints in the EU? 

Toomas Palu Examples from Austria and Estonia 

��Monalisa Norman Text not available 

��David McDaid Summary 206 




Mental Disability Advocacy Programme, Open Society Institute 

Budapest 

Judith Klein 

Open Society Mental Health Initiative 

The Open Society Mental Health Initiative (MHI) aims to ensure that people with mental disabilities 

(mental health problems and/or intellectual disabilities) in Central and Eastern Europe and the former 

Soviet Union are able to live as equal citizens in the community and actively participate in society 

with full respect for their human rights. 

The Mental Health Initiative uses the term 

‘mental disabilities’ to describe people with 

intellectual disabilities and also people with 

mental health problems (see box). While 

some individuals are diagnosed with both 

intellectual disabilities and mental health 

problems, and, many of the problems faced 

by both these groups of people are similar – 

such as serious human rights abuses, social 

exclusion, stigma and prejudice, there are 

also significant differences between the two 

groups. 

Context 

Traditionally, government policy across the 

region has been to segregate people with 

mental disabilities in long-term residential 

institutions, such as psychiatric facilities, 

social care homes and orphanages. The 

children and adults with mental disabilities 

who are isolated in institutions, regardless of 

their age, sex or type of disability are too 

often subjected to the most severe forms of 

cruel, inhuman and degrading treatment and 

other human rights violations. Behind closed 

doors, children and adults with mental 

disabilities are too commonly subjected to 

the most severe forms of cruel, inhuman and 

degrading treatment. 

The Mental Health Initiative has been 

working in the region for almost ten years. 

During this time, the Mental Health Initiative 

has visited hundreds of institutions and has 

seen people with mental disabilities 

Intellectual disability (also described as ‘learning 

disability’ or ‘mental retardation’) refers to a lifelong 

condition, usually present from birth or which 

develops before the age of 18; is a permanent 

condition that is characterized by lower than average 

intellectual ability; results in significant functional 

limitations in intellectual functioning and in adaptive 

behaviour as expressed in conceptual, social and 

practical adaptive skills. A person with intellectual 

disabilities usually requires support in three or more 

of the following areas of major life activity: self-care, 

receptive and expressive communication, and 

economic self-sufficiency. 

Mental health problems describes a broad range of 

mental and emotional conditions. Mental health 

problems are different from other conditions such as 

intellectual disability. The term ‘mental health 

problems’ is used when an individual’s mental 

condition significantly interferes with the 

performance of major life activities, such as thinking, 

communicating, learning and sleeping, among 

others. Someone can experience mental health 

problems over many years. The type, intensity and 

duration of symptoms vary broadly from person to 

person. Symptoms can come and go and do not 

always follow a regular pattern, sometimes making it 

difficult to predict when symptoms and functioning 

will worsen. Although the symptoms of mental health 

problems often can be controlled effectively through 

medication(though some people experience 

negative side effects from medication) and/or 

psychotherapy, or may even go into remission, for 

some people the condition continues to cause 

periodic episodes that require lifelong attention. 




throughout the region living under appalling conditions. A typical situation is: 

The institution is situated in an isolated and rural area where there is no public transportation. 

Men and women, young and old, are placed in the same ward, whatever their diagnosis. The 

wards are bleak. There are no pictures or carpets, no clocks or calendars to mark the passage 

of time. Some windows have no glass in them. In winter there is minimal, if any, heating and 

often there is not enough food. Beds are old and rusty, some with no mattresses, and are 

crammed into rooms with little or no space between them. Some beds are shared by two 

people. Blankets and other bedding are filthy because they rarely are washed. Small 

possessions are kept by residents on their person, and many residents sleep with whatever 

items they have, because there is no secure place to keep them. There are too few bathrooms 

for the number of residents, and toilets have no dividers or doors. Often there is only a cold 

water tap and a hose serves as the shower. Residents are washed irregularly by staff hosing 

them down in groups. Residents are filthy and unkempt, clothing is rarely washed and those 

who are incontinent have to wear clothes that are soiled with urine and feces. Diagnosis is 

overly broad, and there is no review of placement decisions. Once people are admitted to the 

institution, they will stay until they die. Staff are poorly trained. Attendants simply stand guard, 

intervening only when necessary. There are no individually oriented treatment or 

(re)habilitation plans. Often, inappropriate levels of restraint, force and/or aggression are used 

on residents to manage them. There is no possibility for residents to complain about staff 

abuse or to have their rights redressed in any way. Residents have no means of 

communication with the outside world. There are no telephones, and most residents have long 

had no contact with their families. Relatives who do have an interest in visiting are likely to be 

unable to afford the long journey. There are no investigations into deaths. Individuals who die 

are buried in communal, unmarked graves. Because of the climate and inadequate clothing, 

residents spend most of the year indoors. There are no activities for residents whatsoever- no 

education, no rehabilitation, no recreation. In fact, there is nothing to do all day, every day, but 

stare at the wall. 

The Mental Health Initiative’s experiences in the field are borne out by recent reports of international 

human rights organizations that have highlighted gross human rights violations against people with 

mental disabilities in institutions. For example: 

• People with mental disabilities are locked in cages for extended periods of time, sometimes for 

years, in part because of the lack of adequate staff to provide basic care;[1] 

• Institutionalized women and children are routinely subject to rape and other forms of sexual 

abuse, often with the knowledge of staff;[2] 

• Psychotropic medications are misused and overused, and can have life threatening side effects 

which are not monitored;[3] 

• Conditions are generally appalling, with patients in one institution stating that “they were always 

hungry and that in the winter they were very cold”;[4] 

• Unmodified electro convulsive therapy (ECT) is still used. The Committee for the Prevention of 

Torture and Inhuman and Degrading Treatment (CPT) states that unmodified ECT (without 

anaesthesia or muscle relaxants) “can no longer be considered as acceptable in modern 

psychiatric practice. Apart from the risk of fractures and other untoward medical consequences, 

the process as such is degrading for both the patients and the staff concerned. Consequently, 

ECT should always be administered in a modified form.”[5] 




While monitoring and exposing human rights abuses in institutions is very important, it is not enough. 

Too often, government response to embarrassment by international organizations is to renovate the 

institution. For example, in response to concerns raised by Amnesty International about appalling 

conditions in a psychiatric hospital in Romania,[6] the Romanian government has committed to 

investing substantial funds to renovate the kitchen, the morgue and the central heating.[7] However, 

no matter what resources are poured into making institutions look better, the very fact of 

institutionalization is a human rights abuse. Segregating people, barring them from access to 

education and employment, denying them the right to choose where and how they live, what they 

wear, and who they associate with solely on the basis of a mental disability label is unacceptable. 

The situation for people not living in institutions in the region is not much brighter: they tend to be 

isolated at home due to the lack of community-based services, societal prejudice, and the shame of 

relatives. In order to address this unacceptable situation, the Mental Health Initiative has been 

supporting the development of alternative community based services and other initiatives to facilitate 

the reintegration of people with mental disabilities into the community, and to prevent their 

institutionalization in the first place. 

The Mental Health Initiative’s role: 

OSI has been and continues to be, the only donor that seeks to address the issues of people with 

mental disabilities on a sustained basis across the region. The key to changing the situation 

described above lies in supporting the development of alternatives: Community-based alternative 

services are essential to ensuring the full and equal participation of people with mental disabilities in 

society. They must have access to education, housing, employment, leisure and cultural activities in 

addition to health care and social support. However, community based alternatives remain severely 

underdeveloped throughout the region. As a first step, governments must recognize the rights of 

people with mental disabilities by elaborating policies and financing mechanisms that make the shift 

of resources from institution to community realistic and possible. With this in mind, throughout the 

region, the Mental Health Initiative supports NGOs that are providing community based alternatives 

as well as promoting the social inclusion of people with mental disabilities by advocating for changes 

in governmental policies. While a number of Mental Health Initiative grantees have been successful 

in promoting positive change, for the reasons stated above, there is much more to be done 

throughout the region. For example: 

• In the new Central and Eastern European member states of the European Union, new institutions 

for people with mental disabilities continue to be built despite the fact that some governments 

have stated their intent to close institutions. None of the new EU member states have concrete 

plans or financing mechanisms to develop networks of community based alternatives. 

• In the former Soviet Union, the transition from state dominated societies has created conditions 

that continue to spell untold human suffering. Pervasive fiscal crises and the consequential cuts to 

government health and social welfare budgets have resulted in the deterioration of the already 

unacceptable conditions for people in long term institutions and increased isolation of those kept 

at home. 

Challenges and moving forward 

There are significant legal and policy-related barriers to the full integration of people with mental 

disabilities into societies, and to date there has been little effort to identify these barriers and 

consider how to address them. Despite the fact that general human rights standards apply to all 

people, there are major obstacles to people with mental disabilities realizing and enforcing their 

fundamental rights. Furthermore, stigma, prejudice and discrimination in relation to people with 

mental disabilities are deeply rooted and stand in the way of positive change. 




The Mental Health Initiative has worked closely with grass roots mental disability organizations in the 

region to affect positive change for people with mental disabilities. There are some examples of 

significant progress: 

• In Hungary, government financing is now available for the provision of community based day 

services for people with mental health problems in some districts of Budapest. This allocation of 

funding is the direct result of years of lobbying by a Mental Health Initiative grantee. Prior to the 

availability of these services, clients were either isolated at home or spent long periods of time in 

the hospital because there was no alternative. 

• The Mental Health Initiative’s Croatian grantee has succeeded in shifting government policy that 

directed funding solely to long term institutions, to include deinstitutionalization and the financing 

of community based residential services for people with mental disabilities. 

There are similarly innovative and effective Mental Health Initiative supported projects in other 

countries of the region. As these examples illustrate, supporting models of best practice is key to 

policy change. Without such models, evidenced based policy development would not be possible. 

Accordingly, continued support for exemplary projects will be essential to the development of 

progressive social welfare and mental health policies across the region. 

The Mental Health Initiative is committed to supporting initiatives that are characterized by respect for 

individuals with mental disabilities, which means ensuring that consumers of services have a voice in 

the planning, implementation and review of new policies, and that such policies comply with 

international human rights standards. 

Although international human rights standards apply to all people, there are major challenges to 

people with mental disabilities in realizing and enforcing their fundamental rights. Furthermore, there 

has been little effort to identify and address the significant legal and policy-related barriers to the 

social inclusion of people with mental disabilities. The 

stigma, prejudice and discrimination faced by people 

with mental disabilities are deeply rooted and present a 

major obstacle to achieving positive change. Thus, in 

addition to supporting organizations that are providing 

high quality and innovative community based services 

The Mental Health Initiative is also working with them to 

influence the development of governmental policies 

which promote the social inclusion of people with 

mental disabilities. 

Key Goals 

Equal access 

In collaboration with OSI’s EU Accession Monitoring 

and Advocacy Program (EUMAP) and local NGOs, the 

Mental Health Initiative is undertaking a comprehensive 

review of the legal and policy barriers to access to 

education and employment for people with intellectual 

disabilities in EU accession candidate states and 

selected EU member states. The findings will be 

published in country monitoring reports together with 

recommendations for change which will then be used 

as a basis for follow up advocacy by NGOs. 

Core values of the Mental Health 

Initiative’s work* 

Respect 

“In the institution no one heard me. Now 

experts listen to what I have to say” 

Equality 

“In the institution my work was not 

appreciated. Now I work and receive a 

salary” 

Choice 

“In the institution, I couldn’t choose a 

partner. Today we are married.” 

The Mental Health Initiative is committed 

to ensuring that these core values are 

integral to all programme activities. 

“In the institution I didn’t belong to 

anyone. Now I have my family”. 




Social inclusion 

In collaboration with Inclusion Europe, Mental Health Europe, Autism Europe, the European Network 

for Independent Living and the Center for Policy Studies at the Central European University, the 

Mental Health Initiative has monitored conditions in institutions and the impact of community based 

alternatives in EU accession candidate states and EU member states. This research reviewed 

institutional care and surveyed de-institutionalization programs in the target countries and made 

recommendations on how the quality of life of people with disabilities can be improved through the 

provision of community-based services and support. 


In collaboration with OSI’s Network Media Program the Mental Health Initiative provides training and 

technical assistance for NGOs across the region to develop and launch public awareness campaigns 

about mental disability issues. Training is also provided to journalists on responsible reporting in this 

field. The purpose of this initiative is to challenge the stigma and prejudice faced by people with 

mental disabilities, and how to address the barriers to their full participation in society. 

Promoting best practice 

A number of well-established partner organizations which provide high quality community-based 

services and have successful partnerships with local/national government are Mental Health Initiative 

Model Sites. These Model Sites provide training to other organizations from across the region as well 

as country specific training to local NGOs. 

Building capacity 

The Mental Health Initiative’s grants program provides financial and technical support to advocacy 

NGOs which provide community based services and promote the social inclusion of people with 

mental disabilities. The goal of the grants program is to support initiatives that stimulate the reform of 

national health and social welfare policies. The focus of the grants program is on community based 

services which are responsive to the needs of individuals with mental disabilities and enable them to 

participate as equal citizens. Examples of services that the Mental Health Initiative supports include 

residential alternatives to institutionalization, specialized foster care, day services, respite care, 

inclusive education, early intervention, psychosocial rehabilitation, supported employment and 

community education. 

Strategies for change 

In collaboration with OSI’s International Policy Fellowship Program, 

the Mental Health Initiative has engaged three policy fellows to 

research and develop strategies for positive change. Fellows will 

focus on two major areas: (1) mental disability and the media; and 

(2) policy analysis. This work will address the opportunities and 

obstacles for mental disability advocates to become involved in the 

policy making process. 

References 

1. Mental Disability Advocacy Center. Cage Beds: Inhuman and 

Degrading Treatment in Four EU Accession Countries. p. 5. 

The Mental Health Initiative 

works in Albania, Armenia, 

Azerbaijan, Bosnia and 

Herzegovina, Bulgaria, 

Croatia, the Czech Republic, 

Estonia, Georgia, Hungary, 

Kazakhstan, Kosova, 

Kyrgyzstan, Latvia, Lithuania, 

Macedonia, Moldova, 

Romania, the Russian 

Federation, Serbia, the Slovak 

Republic, Tajikistan and 

Ukraine. 




2. Mental Disability Rights International. Not on the Agenda: Human Rights of People with Mental 

Disabilities in Kosovo. p. 9. 

3. Mental Disability Rights International "Not on the Agenda: Human Rights of People with Mental 

Disabilities in Kosovo", pp. 20–21. 

4. Mental Disability Advocacy Center. Mental Health Law of the Kyrgyz Republic and its 

Implementation. pp. 5, 14, 15, 24, 25, 29, 30, 33. 

5. 8th General Report on the CPT's activities covering the period 1 January to 31 December 1997 

6. Amnesty International. Memorandum to the government concerning inpatient psychiatric treatment, 

4 May, 2004. 

7. Telephone discussion with Romanian mental disability NGO, August 2004. 




Mental health as a human rights issue 

Ignacio Pérez Caldentey 

Introduction 

The Council of Europe has a long history in developing legal instruments and formulating policies for 

the improvement of the situation of persons with disabilities. 

Despite the achievements, however, the gap between the ideals and the reality is still far too deep. 

Quite often, persons with disabilities find themselves pushed to the margins of society, faced with 

prejudice and discrimination. 

The Council of Europe and the protection of human rights of persons with disabilities 

The European Convention on Human Rights Convention requires that a State secures these rights to 

everyone within their jurisdiction without discrimination on any ground such as sex, race, colour, 

language, religion, political or other opinion, national or social origin, association with a national 

minority, property, birth or other status. Although disability is not explicitly mentioned as a ground of 

prohibited discrimination, the words “any ground” and “other status” extend the prohibition of 

discrimination to one based on disability. 

The Convention has subsequently been complemented by a number of Protocols of which perhaps 

the most significant in the context of human rights and disabilities is Protocol No. 12 relating to nondiscrimination. 

The European Social Charter (Revised) 

The Revised European Social Charter guarantees a wide range of rights, such as rights relating to 

housing, health, education, social protection and movement of persons. The equal enjoyment by all 

individuals of the rights contained in the Charter is secured by a non-discrimination clause contained 

in Article E of the Charter. The Charter also includes, in its Article 15, specific provisions relating to 

persons with disabilities. 

The implementation of the Charter is monitored by the European Committee for Social Rights, 

through a reporting mechanism and a collective complaints mechanism. 

The European Convention on the Prevention of Torture and Inhuman or Degrading Treatment or 

Punishment 

The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment of 

Punishment (the ‘CPT’), established in 1989, carries out visits to places where persons are deprived 

of their liberty (including psychiatric hospitals, social care homes for persons with mental and/or 

behavioural disorders, children’s homes, etc.) and draws up reports with recommendations to prevent 

torture and inhuman or degrading treatment. 

The 1997 Convention on Human Rights and Biomedicine and the 1959 Partial Agreement in the 

Social and Public Health Field should also be mentioned in this context as important instruments in 

the fight against discrimination of persons with mental disabilities. 




The Recommendations by the Committee of Ministers and the Parliamentary Assembly of the 

Council of Europe 

In 1999, the Committee of Ministers adopted a Recommendation on principles concerning the legal 

protection of incapable adults and last September, Recommendation 10 (2004) on the protection of 

the human rights and dignity of persons with mental disorders in which it sets out a series of general 

provisions among which the principle of non-discrimination, the full enjoyment and exercise of civil 

and political rights by persons with mental disorders, the promotion of mental health, information and 

assistance on patients’ rights and protection of vulnerable persons with mental disorders deserve to 

be highlighted. A substantial part of the Recommendation is devoted to the criteria, principles and 

procedures for involuntary placement and involuntary treatment as well to the rights of persons 

subject to these measures. 

For its part, the Parliamentary Assembly of the Council of Europe adopted a Recommendation 

Towards full social inclusion of persons with disabilities and Recommendation 1601 (2003) on 

Improving the lot of abandoned children in institutions is also relevant in this context. 

The Commissioner for Human Rights 

In the course of his visits, the Commissioner for Human Rights has the occasion to examine the 

situation regarding the respect of the rights of persons with mental disabilities. He has visited 

institutions for persons with disabilities and discussed the respect for their rights with NGOs and 

national authorities. All too often the conclusions have been worrying. 

Noting that the situation of persons with disabilities is often disturbingly low on the list of priorities of 

member States, the Commissioner decided to initiate specific activities in this field. To mark the 

European Year of Persons with Disabilities, the Commissioner organized a seminar in Copenhagen 

in February 2003 to raise awareness and work towards finding solutions to the many problems that 

remain in guaranteeing the respect for the fundamental rights of persons with mental disabilities. The 

Conclusions of this Seminar addressed a number of critical questions relating to the enjoyment of 

human rights by persons with mental disabilities, some of which I will touch upon later in more detail. 

The Commissioner has also raised these issues in international fora, such as the European Disability 

Congress in Madrid in March 2002 and the Second European Conference of Ministers responsible 

for integration policies for people with disabilities which took place in Malaga, Spain in May 2003. 

Particular issues relating to the enjoyment of human rights by persons with disabilities 

Non-discrimination 

Persons with disabilities often face obstacles in enjoying and exercising their human rights. 

Intolerance, ignorance and the still prevailing stigma surrounding disabilities often lead to 

discrimination, jeopardizing the enjoyment of rights essential for integration into society. 

In his statement given in the Malaga Conference, the Commissioner particularly emphasized the 

need to improve the situation of those persons with disabilities who suffer from multiple forms of 

discrimination, in particular women, immigrants and the Roma. 

Right to independence, social integration and participation in the life of the community 

The Revised Social Charter guarantees, in Article 15, “the right of persons with disabilities to 

independence, social integration and participation in the life of the community.” The strength and 

potential of this Article lie in the fact that it explicitly enshrined the objectives of equal opportunities, 

personal independence and participation into a legally binding obligation for the State parties. 




In the Conclusions of the Seminar held in Copenhagen, it was noted that integration represents the 

greatest challenge of all. In order to enable persons with disabilities to exercise the right to social 

integration, barriers to communication and mobility must be removed in order to enable access to 

transport, housing, cultural activities and leisure. 

Human rights in the institutional context 

Ill-treatment: Particular efforts have to be taken to ensure that persons living in institutions are not 

deliberately ill-treated. The Commissioner has witnessed situations of serious concern, especially in 

large remote institutions such as the use of excessive force, straps or cage beds. 

Conditions in institutions: The Commissioner has noted that the most immediate problems in the 

countries he has visited, arise in respect of the rights of residents of psychiatric institutions. 

Dilapidated material surroundings, remote locations, inadequate care and insufficient or poorly 

trained staff often give rise to serious violations of fundamental rights. Similar concerns arise when 

there is lack of appropriate food or heating. 

Placement in an institution: Every effort should be made to ensure that placement in an institution is 

based on the informed consent of the individual concerned. 

Safeguarding autonomy and legal capacity 

Retaining, as far as possible, personal determination, independence and autonomy are key 

objectives of modern disability policies. Existing freedoms and capacities should be preserved as 

much as possible. 




Supporting governments to adopt mental health policies 

Rachel Jenkins 

Background 

It is important to support governments to adopt mental health policies and to integrate mental health 

policy into public health policy and general social policy [1] because mental disorder causes a heavy 

burden for societies [2] impedes the development of other health and development targets, 

contributes to poverty and differentially affects the poor;[3,4] and last but not least, because mental 

health itself is of intrinsic value as is physical health. 

In developing mental health policy, it is important to include consideration of stigma about mental 

health issues and mental illness. A previous issue of this journal discussed the impact of stigma on 

people with mental illness.[5] As well as the impact on the individual with mental illness, stigma 

results in a lack of attention from ministers and the public, which then results in a lack of resource 

and morale, decaying institutions, lack of leadership, inadequate information systems, inadequate 

legislation, and inadequate attention to key public health committees. By resulting in social exclusion 

of people with mental illness, stigma is detrimental not just to people with mental illness, but also to 

the health of society as a whole. All too often our services are departure points for exclusion when 

they should be stepping stones for social inclusion. 

In 2001, WHO devoted both its annual health day and its annual health report to mental health, 

which called on countries to develop mental health policies.[6,7,8] In the same year, the Institute of 

Medicine, in Washington, launched a scientific report on Neurological, Psychiatric and developmental 

disorders in low-income countries which called for immediate strategic action to reduce the burden of 

brain disorders.[3] The EC plays an important role both in Europe and elsewhere and has recently 

produced a public health framework for mental health.[9] At national level, various governments, 

national NGOs, professional bodies and the media have played important roles in prioritising mental 

health in their countries.[10,11,12] 

The need for locally tailored solutions 

Epidemiology is fundamental to the overall goals of mental health policy.[13] Mental Health policy will 

need to take account of contextual factors, the epidemiology (range, severity, frequency and 

duration) of disorders, their accompanying social disability, their mortality and relationship to 

sociodemographic variables including geographic variation. A few countries are embarking on a 

specific rolling programme of detailed national mental health surveys [14] and WHO is coordinating a 

world mental health survey programme in a variety of participating countries.[15] 

Cultural and religious issues are very important. They influence the value placed by society on 

mental health, the presentation of symptoms, illness behaviour, access to services, pathways through 

care, the way individuals and families manage illness, the way the community responds to illness, 

the degree of acceptance and support experienced on the one hand, and the degree of stigma and 

discrimination on the other hand experienced by the person with mental illness. Thus, each country 

is very different, with different context, culture, resources and type of existing service structures, and 

each will require its own mental health strategy containing locally tailored solutions for addressing 

both the general and specific challenges and issues.[16,17,18] 




The policy process 

Health policy at national level will identify the range of health, morbidity, disability and mortality issues 

it intends to tackle, the relevant settings covered by the policy, the overall framework for 

implementing policy in the relevant settings including, for example, health services, social services, 

the education sector, the workplace and the criminal justice sector. The policy may set our desired 

goals and will set a framework for planning at local level. 

In order to get mental health into national policy, it is important firstly to identify and engage key 

agencies and stakeholders in the overall process so that there is shared ownership of the vision and 

its implementation; secondly to obtain a good understanding of the current situation (the context, 

needs, demands, current policy, service inputs, processes and outcomes); thirdly to develop an 

overall mission statement, set goals and targets to aim for; fourthly to identify and engage key 

agencies, and develop strategic plans and implementation frameworks with those agencies which 

take the local situation into account, and which specifically tackle local issues, constraints and 

disincentives; fourthly to regularly review progress using a variety of outcome measures, and to fine 

tune the strategy accordingly.[16] 

The views of service users and carers will be particularly important, as they will be directly affected 

by the strategy and will have personal experience of the problems in the current system. They will 

also be able to comment on those aspects of the current mental health system that are working well. 

Some common policy aims 

Some common aims for mental health policy include the promotion of mental health, reduction of 

incidence and prevalence of mental disorder (prevention and treatment), reduction of the extent and 

severity of associated disability (rehabilitation), development of services for people with mental illness 

and reduction of stigma, the promotion of human rights and dignity of people with mental illness, the 

promotion of psychological aspects of general health care, and reduction of mortality associated with 

mental illness, both from suicide [19,20,21] and from premature physical mortality.[22] 

Some common policy components 

Some of the components within mental health policy, which need to be addressed, include the 

following. 

The national components including the construction of a national strategy to promote mental health, 

reduce morbidity and reduce mortality; the establishment of policy links with other government 

departments including home affairs, criminal justice, education, housing, finance etc; the enaction of 

specific mental health legislation (to set the overall philosophy of approach to the care of people with 

mental disorders together with precise provision for assessment and treatment without consent under 

certain defined conditions in the interests of the individual, the public and with regard to safeguarding 

human rights); financing ( to remove perverse incentives, to ensure sustainable local financing, and 

develop funding streams for disseminating good practice models); implementation plans and overall 

system of accountability and governance. 

The supportive infrastructure components include a human resources strategy, a consumer 

involvement strategy, a research and development strategy, and a mental health information strategy 

(which should include context, needs, inputs, processes and outcomes. Information systems provide 

an essential resource for clinicians, managers, planners and policy makers, it allows the audit cycle 

to proceed, users and carers also require relevant information, and the general public require 

information for public accountability). 




The service components include primary care, specialist care, the links between the two, good 

practice guidelines, liaison with NGOs, police, prisons, social sector, dialogue with traditional healers, 

mental health promotion in schools, workplaces and the community. 

Important policy partnerships within the health arena 

The mental health policy needs to be linked in with generic health policy. It is particularly important 

that any general public health strategy addresses mental as well as physical health so that national 

mortality indicators include death from suicide - with attention to enhancing the accuracy of recording 

of suicides;[23] so that national morbidity indicators plan to include relevant measures of morbidity 

due to mental illness; and so that any health impact assessments explicitly include mental health.[24] 

Some of the generic health policy issues that will impact on mental health include primary care 

funding, training and incentive arrangements, and government generic health targets. 

It can be helpful to ensure mental health is included in generic health reforms that are occurring such 

as development of health information systems, (It is important to develop the facilities and 

instruments for routine monitoring of needs, inputs, processes, and outcomes, so that the information 

can be used for planning purposes); hospital optimisation programmes, quality standards, basic 

training standards, accreditation procedures. 

Governments need to ensure that all relevant agencies are aware of the importance of mental health 

for the population; that they are aware of the influence that their activities can have on mental health; 

and that appropriate co-ordination between relevant agencies tales place. This coordination is often 

in place for action on alcohol and drugs, and for AIDS programmes but is as yet rarely in place for 

mental health programmes despite mental illness forming the greater burden across the population. 

There is a need for a partnership rather than a competition for resources between those working on 

non-communicable diseases and infectious diseases. For example, mental health promotion is 

essential in schools if we are to reduce the risk of AIDS from unprotected sex and drugs, support 

girls to be assertive and confident in ensuring their sexual health and safety, if we are to address lack 

of acceptance of condoms in the male culture, and if we are to encourage abstention from drugs and 

concomitant harm reduction, treating maternal depression improves compliance with vaccination, 

nutrition, oral rehydration and hygiene regimes to reduce infection diseases in children. 

Primary care - a key service component for policy consideration. 

Out of the several issues identified above, primary care is selected here for more detailed 

consideration because it is a particularly important service issue.[25] Logistical consideration is 

required of the availability of primary care services, and of the specialist services relative to the 

population epidemiology of disorders. Specialist capacity is important. The precise framework for 

primary-secondary care integration depends on a country's specialist capacity. In low income 

countries there is often only 1 psychiatrist per million population, and in a few countries this is as low 

as 1 psychiatrist per 5 or 6 million. By comparison, in the UK there is 1 adult psychiatrist per 50,000, 

and in much of the former Soviet Union there is 1 psychiatrist per 10,000–20,000. 

Severe disorders including the psychoses, in richer countries, people with severe mental illness may 

be cared for by specialist services, with some shared care with primary care for long term support. In 

poorer countries, on the other hand, there may often only be capacity for a small number of people 

with psychosis to be cared for in specialist care, and most will need to be assessed, diagnosed and 

treated in primary care, with support from specialist services where available. Thus in poor countries, 

where there is often much less than one psychiatrist per million population, most people with 

psychosis will need to be cared for much of the time in primary care. 




Common mental disorders, we know from epidemiological studies that there is a high prevalence of 

mental disorders in the general population and in primary care.[3] Contrary to popular view, the 

common disorders seen in the general population and in primary care are not only frequent, but may 

also be severe, disabling and of high duration.[26,27,28,29,30,31] This high prevalence in all 

countries of the world means that not even rich countries can afford sufficient specialists to look after 

everyone with a mental disorder. 

Because of their high socioeconomic costs, it is not tenable to argue that the burden of common 

mental disorders should be ignored. These costs arise from the repeated primary care consultations 

if they remain untreated, sickness absence, labour turnover, reduced productivity, impact on families 

and children, and the difficult to quantify but nonetheless important concept of the emotional wellbeing 

of a country and nation. Primary care therefore needs to play a central role in overall mental 

health care in rich countries as well as in poor countries. 

Besides these logistical reasons why primary care is crucial, it also has particular advantages in that 

it allows attention to physical health care needs and accompanying social needs, it allows continuity 

of care, it is often preferred by consumers, is often more accessible than specialist care, and studies 

have shown it is possible to achieve good clinical and social outcomes in primary care. 

The importance of primary care for mental health has a number of implications for the training of the 

primary care team. In developing policy on training, it is helpful to understand the current situation in 

relation to the basic training for each tier of primary care and for each of the professional cadres. 

How much mental health if any is included? For example, in Iran and Pakistan, the village health 

workers receive a few months training in selected priority topics so that they can screen, assess, 

diagnose and treat.[32,33] In Zanzibar, there is a four year basic training for all nurses and the fourth 

year is devoted to mental health. Since primary care in Zanzibar, as in a number of other countries, 

is largely run by nurses, this results in the systematic availability of mental health expertise in primary 

care. 

What continuing training is available in primary care? It is important that mental health policy pays 

appropriate attention to the continuing professional development of primary care nurses.[34,35] In 

Zanzibar, the education coordinators organise and deliver continuing training for all staff in primary 

health care units which is regular (on several weekends a year), is accompanied by transport 

allowances and incentive payments, and affords an opportunity for mental health to be included in 

the programme. In low income countries, it is important to give mental health education to midwives 

and traditional birth attendants who have the opportunity to detect and refer post-natal psychosis and 

severe depression. The physical, cognitive and emotional development of children is influenced by 

parental mental health, and so ensuring prompt treatment of maternal depression is one of the most 

important preventive activities we can do. 

In low income countries where there are few medical practitioners in primary or even in secondary 

care, nurses are likely to be given responsibility for prescribing and managing medicine, and it is 

important that their basic training and continuing education programme support them in this role. 

What quality monitoring exists in primary care? In Iran, health psychologists perform a quality 

monitoring role for the village health workers, and visit every month to support, supervise and check 

on the quality of the work. Who is in the front line? Are the primary care doctor and nurse in the front 

line for initial assessment or are there other tiers? For example health workers with a few months 

training in Iran are responsible for 2,000 population and primary care doctors are in the second tier 

responsible for 10,000 population. In Tanzania, first aid workers are responsible for 50 people, 

dispensaries for 2,000 and primary health care units (nurses and medical assistants) for 10,000 or 

more. . 




Systems for information collection in primary care are needed for adequate planning. This can be 

effective without involving expensive technology. For example, in Iran, health workers routinely collect 

and display annual data on prevalence and outcome of priority disorders: infectious diseases, 

epilepsy, schizophrenia, depression and anxiety. 

Policy should address how proactive primary care should be. Should it mostly concentrate on active 

consulters or should it take a more population perspective and seek to find and treat common 

disabling conditions. 

Primary care capacity for outreach is important. Transport is necessary for outreach from secondary 

care to primary care, and from primary care to the community. It may need to be subsidised, be 

appropriate to the terrain and preferably not shared with other specialties with different working 

patterns. 

Integration of mental health into primary care is enhanced by training, by strengthening basic 

training, and continuing education in assessment, diagnosis, management and criteria for referral 

(criteria for referral of course need to be locally agreed in the light of specialist capacity); and by use 

of guidelines such as the WHO primary care guidelines.[36,37] 

It is important to train specialists for the job they will need to do. i.e. not just individual patient care 

but also in delivering a service to the whole catchment area population. If that population is around 1 

million, as is often the case, it is easy to see that the specialist must work to support primary care in 

assessment and management of all but the most severe cases, and to support what is often a largely 

nurse run hospital, outpatient and community outreach specialist service for the most severe cases. 

Thus, the specialist needs to spend a major proportion of his or her time as a supportive consultant 

advisor (e.g. supervision, teaching. local planning, service development, researching key local 

issues) for the service as a whole rather than purely as a hands on clinician if he or she is to able to 

have maximum impact on the population for which he or she is responsible, and if the specialist 

nurses and primary care teams are to be adequately supported for the tasks they have to do. 

Integration is assisted by communication, including regular meetings, between primary and 

secondary care, to discuss criteria for referral, discharge letters, shared care procedures, need for 

medicines, information transfer, training, good practice guidelines and research, by agreeing 

prescribing policies and by ensuring supply of essential medicines. 

Traditional healers are very common across the world (1 per 50 population in sub-Saharan Africa) 

and will remain a key deliverer of health care for large proportions of the population for many 

decades if not centuries. Their practice is variable, and there is no doubt that some traditional 

practice is very harmful; but it is also likely that some of the herbal medicines used have helpful 

psychoactive properties and that some of the interventions give important psychosocial support to 

individuals, families and communities. Rather that seek to destroy all traditional healing, it would be 

more productive to research their provision and outcomes,[38] seek dialogue with the aim of 

eliminating frankly harmful practices, and engage in joint training using diagnostic algorithms to 

encourage referral of difficult or chronic cases, including psychosis.[39] 

Important policy partnerships outside the health arena 

Social policy 

Some of the generic social policy issues which impact on mental health are policies on education, 

employment, housing, prisons, police, social welfare, environment and urban regeneration, rural 

issues, and transport. Effective interagency working at national, local and individual level is 




fundamental to the delivery of good mental health care, and needs to be firmly addressed at policy 

level. There may need to be a pan government working group on mental health, as well as regional 

and local groups to monitor and facilitate joint working. There may need to be policy action to 

address co-terminosity of geographic boundaries, synchronisation and communication of planning 

cycles, lines of accountability for joint working, joint financial and information systems, shared good 

practice guidelines and removal of perverse incentives against cooperation between agencies. 

Schools 

Children are a nation's most precious resource, and yet receive too little policy attention. Specific 

learning difficulties including dyslexia in schools lead to educational failure, school drop out, and 

unemployment and over -representation in prisons. It is therefore important for policy to address 

specific learning difficulties in schools. The WHO clear vision project has had a dramatic effect on 

reducing educational failure in poor countries.[39] 

Children in care 

Large numbers of children across the world are looked after in orphanages and children's homes 

which often contain children who have been abused and neglected, children whose home life has 

broken down, children with developmental delay and retardation, speech delay, fits, severe overactivity 

and aggression, chronic physical illness, disability and handicap. It should be an important 

policy imperative to ensure adequate mental and physical health promotion and care for ‘looked 

after’ children and to prevent their subsequent over-representation in the prisons. 

Prisons 

Prisons are another key setting of concern for mental health policy. Mental illness is very common in 

the prisons, and in some countries suicide is very high in prisoners. Guidelines for health care staff in 

prisons may be useful.[40] We need systems to prevent and treat anxiety and depression in prison, 

ensure people with psychosis are treated in hospital rather than prison, prevent suicide and suicidal 

attempts, and tackle dyslexia and educational failure in prisoners. 

Preparedness for disasters. 

No country can afford to ignore the possibility of disasters, whether man made or natural. More than 

50 countries have experienced conflict in the last 20 years. Conflicts are much more common in poor 

countries, and 15 of the 20 poorest countries of the world have had a major conflict in the last 15 

years. Nearly all low income countries are next to a country that has experienced war and are 

therefore frequently carrying burden of caring for refugees. Women and children are particularly 

vulnerable to war, frequently being witness or forced participants in murder, victims of rape, infection 

with AIDS, rejection, abduction of child soldiers, and the subsequent difficulty rehabilitating child 

soldiers. Psychosocial issues are often neglected in post conflict situations despite the fact that the 

presence of psychosocial disorders contributes to low compliance with vaccination, nutrition, oral 

rehydration, antibiotics and risky sexual behaviour; and hence to the high morbidity and mortality 

from preventable and treatable infectious disease. Sometimes the sheer volume of refugees and 

their movements make practical arrangements very difficult. For example, in Macedonia during the 

Kosovo crisis, there were over 250,000 refugees and large transfers at short notice between camps 

as new refugees arrived, making psychosocial work very difficult during the initial phase.[41] In 

Georgia, with a population of around 5 million, and an economic crisis which has reduced 

government health expenditure from 200 USD to 7 USD per year, there are more than a quarter of a 

million internally displaced people with largely unmet needs for psychological support, and a further 

7,000 refugees from Chechnya for whom the government does not accept responsibility so they have 




no access to medical care other than that supplied by the Red Cross.[17] The central importance of 

involving primary care teams in the management of the medium and long term psychological 

consequences of a disaster has long been argued.[42] 

Some implementation issues 

Implementation is even more challenging than strategy formulation, and particular attention needs to 

be paid to: 

Communications (public relations about the strategy, cascading information within organisations, 

organising feedback, alliance building between key partners); 

Resources (accessing key budgets, securing capital, ensuring revenue flows, maximising the use of 

generic budgets, sponsorship and aid), 

Staff (planning the development of the human resource, re-skilling for changing service 

configurations, basic and continuing education for mental health staff, skilling generic staff such as 

primary care and teachers, communicating with staff, engaging professional bodies and educational 

institutions; and 

Embedding the strategy (engaging generic organisations, managers, politicians), disseminating good 

practice, implementing and R and D strategy, including evaluation, learning from mistakes and 

successes and fine tuning the strategy, quality assurance, accreditation and inspection. 

There is a need to address high level stigma within government surrounding mental health so that 

mental health policy is well integrated with general health policy, and so that de-institutionalisation is 

seen as an important step towards achieving better health and social outcomes for people with 

mental illness, but not as an opportunity to save money on the costs of health care. 

An important component of the way forward includes building capacity for policy development, health 

monitoring, research architecture, for innovation, development and for empowering leadership. This 

means creative use of attachments and secondments during training and career development. We 

also need to know much more about national and local epidemiology, and so need to build capacity 

in local epidemiology. 

The Commission on Health research for Development drew attention to the importance of health 

research as the essential link to equity in development.[43] The research funding agencies have a 

key role to play in adopting a multi country approach, investing in young researchers, in research 

centres, and in acknowledging the complexity of health services research and evaluating preventive 

interventions. Long term commitment from governments, international bodies, donors and ourselves 

is needed. It is important to monitor research funding.[44] Access to the internet, the Cochrane 

Collaboration, and international journals are all essential if countries are to avail themselves of the 

international evidence base. There is a pressing need for costeffectiveness studies in low income 

countries.[45] 

Political will 

We need political will at national level to support mental health in public policy (including a high 

profile for mental health within the Ministry of Health, liaison with other ministries and a cabinet 

committee for mental health as in Iran); political will at international level (including mental health on 

the agenda of key international political meetings, for example, the EU Presidencies), debate in the 

international media and international cooperation.[6] 




Conclusions 

All countries are a mixture of developed and developing, and we can learn from each other. Largescale 

applications are dangerous and we need locally tailored solutions. We need to build capacity 

for strategic policy work, tackle stigma, enhance human rights, consumer involvement, individual 

assessment of needs and individually tailored care plans, evidence of interventions, public relations 

and evaluation of outcomes. Psychiatrists have a key role to play in influencing their governments to 

increase the priority afforded to mental health, to develop well tailored mental health policies and to 

support their implementation and fine tuning. 

References 

1. Jenkins R, McCulloch A, Parker C. Supporting Governments and Policy Makers on Mental Health 

Policy, Geneva: WHO, 1988. 

2. Murray C, Lopez AD. The Global Burden of Disease – A comprehensive Assessment of Mortality 

and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Boston: 

Harvard University Press, 1996. 

3. Institute of Medicine. Neurological, Psychiatric and Developmental Disorders. Meeting the 

Challenge in the Developing World. Washington DC: National Academy Press, 2001. 

4. Fryers T, Melzer D, Shah A, Jenkins R. Inequalities in Mental Health. London: Maudsley 

Monograph, 2002 

5. Corrigan PW and Watson AW. Understanding the impact of stigma on people with mental illness. 

World Psychiatry 2002;1,6–19. 

6. Jenkins R. World Health Day 2001 – Minding the world's mental health. Social Psychiatry and 

Epidemiology 2001;36,165–68. 

7. WHO. The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: 

World Health Organisation, 2001. 

8. WHO. Mental Health Policy Project – Policy and Service Guidance Package – Executive 

Summary. Geneva: World Health Organisation, 2001. 

9. Lavikainen J, Lahtinen E, Lehtinen V. Public Health Approach on Mental Health in Europe. 

Helsinki: STAKES, 2001. 

10. Department of Health. Health of the Nation: Key Area Handbook 2nd edition. London: The 

Stationery Office, 1994 

11. Department of Health. Saving Lives: Our Healthier Nation: a Contract for Health. London: The 

Stationery Office, 1999, CM 4386. 

12. Commonwealth of Australia. Better Health Outcomes for Australians: National Goals, Targets and 

Strategies for Better Health Outcomes into the Next Century. Canberra: Commonwealth of Australia, 

1994 

13. Jenkins R. Making psychiatric epidemiology useful: the contribution of epidemiology to mental 

health policy. Acta Psych Scand 2001;103,2–14. 




14. Melzer H, Jenkins R. The British Psychiatric Morbidity Survey Programme 1993–2003 

International Review of Psychiatry 2002. 

15. Ustun and Kessler. The World Mental Health Survey Programme, 2002. 

16. Jenkins R, McCulloch A, Friedli L, Parker C. Developing a National Mental Health Policy, 2002. 

17. Jenkins R, Tomov T, Puras D, Nanishvili G, Kornetov N, Sherardze M, Surguladze S, Rutz W. 

Mental health reform in Eastern Europe. Eurohealth 2001;7,15–21. 

18. WHO.Atlas. Mental Health Resources in the World. WHO, Geneva: WHO, 2001. 

19. United Nations. Prevention of Suicide: Guidelines for the Formulation and Implementation of 

National Strategies. New York: United Nations, 1996. 

20. Jenkins R,Singh B. General population strategies of suicide prevention. In: K Hawton and K van 

Heeringen (eds). The International Handbook of Suicide and Attempted Suicide. Chichester: Wiley, 

pp. 597–615. 

21. Taylor SJ, Kingdon D, Jenkins R. How are nations trying to prevent suicide? An analysis of 

national suicide prevention strategies. Acta Psychiatrica Scand 1997;95:457–63. 

22. Harris EC,Barraclough B. Excess mortality of mental disorder. British Journal of Psychiatry 

1998;173:11–53. 

23. Jenkins R. Addressing suicide as a public health problem. Lancet 2002;359:813–14. 

24. Health Impact Assessment. 

25. Jenkins R, Strathdee G. The integration of mental health care with primary care. International 

Journal of Law and Mental Health 2000;238:277–91. 

26. Shepherd M, Cooper B, Brown AC, Katon G et al. Psychiatric Illness in General Practice. 

London: Oxford University Press, 1996. 

27. Harding TW, de Arango MV, Baltazar J et al. Mental disorders in primary health care: a study of 

their frequency in four developing countries, Psychological Medicine 1980;10:231–41. 

28. Goldberg and Huxley. Common Mental Disorders – A Biopsychosocial Model. London: Routledge 

and Kegan Paul, 1992. 

29. Ustun TB, Sartorius N. Mental Illness in General Health Care, 1995. 

30. Mann AH, Jenkins R, Belsey E. The twelve month outcome of patients with neurotic illness on 

general practice. Psychological Medicine 1981;11:535–50. 

31. Jenkins R, Bebbington P, Brugha T, Farrell M, Gill B, Lewis G, Meltzer H and Petticrew M. British 

Psychiatric Morbidity Survey. British Journal of Psychiatry 1998;173:4–7. 

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Mental health policy, human rights and the law 

Camilla Parker 

Summary 

This paper considers the development of mental health policy – and the legislation required to 

support such a policy – from a human rights perspective. The application of human rights principles 

not only enables Governments to comply with their obligations under international human rights 

treaties but also assists in the development of mental health policy and the identification of areas in 

which legislation will be required to support the policy. For example, such an approach reinforces the 

arguments for shifting the focus of mental health care from institutions to the provision of communitybased 

services. 

Introduction 

There is often a tendency when considering the relationship between mental health policy, human 

rights and the law, to focus on the use of compulsory powers and the role of mental health legislation 

in protecting the human rights of people who are detained in psychiatric hospitals or other 

institutions. Given the potential for unwarranted use of such powers and the violation of individuals’ 

rights, this is an area of crucial importance. In her paper on the work of the Open Society Mental 

Health Institute, Judith Klein refers to some of the numerous reports that have highlighted the wide 

ranging and serious human rights abuses within institutions across Central and Eastern Europe. 

Another example is Amnesty International’s report, Bulgaria, Far from the eyes of society: Systematic 

discrimination against people with mental disabilities (2003). More recently a report, supported by the 

European Commission, sets out the findings of a study of institutions for disabled people in Europe. 

This report, Included in Society: Results and Recommendations of the European Research Initiative 

on Community-Based Residential Alternatives for Disabled People (October 2004) [1] states: 

“The in-depth study of residential institutions in France, Hungary, Poland and Romania showed 

that, in many respects, large residential institutions in these four countries are similar to those 

that have been studied elsewhere. Residents often live lives characterised by hours of 

inactivity, boredom and isolation. Staff members are frequently too low to provide rehabilitation 

and therapy. The physical environment is relatively impersonal and does not provide the kind 

of privacy and homeliness that the general population expect. Contact with family, friends and 

the community is limited. In this situation practices develop that should be unacceptable, such 

as keeping people in bed all day or the use of caged beds to confine people.” 

Thus it is imperative that laws and practices are developed to protect the rights of those who are 

detained and subjected to compulsory powers. However, this paper seeks to demonstrate that this is 

not the only area in which a human rights perspective is relevant to mental health policy. If mental 

health policy is to make a real difference to the lives of people with mental health problems, then 

respect for human rights must be central to its development and implementation. In other words the 

direction and focus of mental health policy must be guided by a human rights perspective. 

This paper will cover the following areas: (1) an overview of human rights instruments; (2) suggested 

key goals and principles for mental health policy; (3) the potential impact of such goals and principles 

on mental health policy; and (4) identification of areas where legislation can play an important role in 

supporting mental health policy. 




An overview of human rights instruments 

Set out below are some examples of the range of human rights instruments that have emerged over 

the past fifty years or so: 

• Universal Declaration of Human Rights (1948) 

• European Convention on Human Rights (1950) 

• European Social Charter (1961, revised 1991) 

• International Covenant of Civil & Political Rights (1966) 

• International Covenant of Economic, Social & Cultural Rights (1966) 

• Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 

(1984) 

• Charter of Fundamental Rights of the European Union (2000) 

These human rights instruments cover two broad categories of human rights – civil and political 

rights (for example the right to liberty, the right to marry and found a family) and economic, social and 

cultural rights (for example, the right to the highest attainable standard of physical and mental 

health). Although the Universal Declaration of Human Rights is not a legally binding document, many 

of its provisions are thought to fall within customary international law because they are so widely 

accepted.[2] Similarly the Charter of Fundamental Rights of the European Union (2000) is not legally 

binding as yet but is likely to be influential. Furthermore, its status will change when the European 

Constitution comes into force.[3] 

The rights set out in these instruments apply to everyone. Although until relatively recently disabled 

people (including people with mental health problems) have not received the same respect for, and 

protection of, their rights, this is beginning to change, albeit slowly.[4] For example, Article 26 of the 

Charter of Fundamental Rights of the European Union (2000) states: 

“The Union recognises and respects the right of persons with disabilities to benefit from 

measures designed to ensure their independence, social and occupational integration and 

participation in the life of the community.” 

In addition, there are a range of human rights instruments that are not legally binding but are of 

major significance because they provide further guidance for States on what steps they need to take 

in order to comply with their obligations under the legally binding treaties. (Such documents are often 

referred to as “soft law”.) For example, the ‘Standard Rules on the Equalization of Opportunities for 

Persons with Disabilities’ (‘the Standard Rules’) were adopted by the United Nations in 1993. The 

purpose of the Standard Rules is to ensure that disabled people may exercise the same rights and 

obligations as others. They set out a range of measures that States should take in order to achieve 

equal opportunities for disabled people in a range of areas such as education and employment. 

The ‘Principles for the Protection of Persons with Mental Illness’ is another example of soft law. 

These principles set out a range of rights relevant to the care and treatment of people with mental 

health problems, such as the right to live and work, to the extent possible, in the community. 




Suggested key goals and principles for mental health policy 

Although there is a wide range of human rights instruments, it is possible to identify some key 

themes or goals. Two fundamental goals that emerge and should be central to mental health policy 

are as follows: 

• Equal Citizenship: for people with mental health problems to be able to exercise the same rights 

as everyone else 

• Social inclusion: people with mental health problems to have the same opportunities as everyone 

else, to have choice in their daily lives, to be independent and participate fully in their 

communities. 

Such goals reinforce the importance of shifting the provision of care from institutions to the 

community. Even if the standard of care and the environment within the institution are of high quality, 

residents remain segregated from society and will not be able to exercise their rights freely. 

Continuing with such a human rights approach and building on these two goals, some principles for 

mental health policy can be developed. For example, mental health policies must: 

• Ensure respect for the rights and freedoms of individuals 

• Protect against discrimination 

• Promote personal autonomy and independence 

• Provide care on the basis of individual need 

• Address barriers to social inclusion 

• Enable participation 

It is not suggested that these principles are new – many discussions and publications concerning 

mental health policy are likely to have included such principles or something similar. However, a 

human rights approach to the development and implementation of mental health policy emphasises 

the importance of including, and adhering to, such principles. 

The potential impact of such goals and principles on mental health policy 

This section considers how such principles would work in practice in relation to mental health 

services and support, protecting the rights of people with mental health problems and addressing 

stigma and discrimination. 

Services and support 

The provision of services and support available should be directed towards enabling people with 

mental health problems to exercise their rights and participate in the community. Thus when 

considering how to plan and develop mental health services it will be necessary to ensure the 

following: 

Individual Assessments: Where individuals are thought to have mental health problems and be in 

need of support, their needs for health, social care and other support requirements, such as 

accommodation, must be assessed on an individual basis. 




Services provided on the basis of individual need: The services provided to each individual must be 

on the basis of that particular individual’s assessed needs, taking the person’s views and preferences 

into account. 

Wherever possible, provide community-based services: The goal must be to ensure that a range of 

community-based services are available so individuals can receive care and treatment in the 

community in which they live. 

Service planning to involve service users and families: It is essential that those who are likely to 

receive mental health services and support can have an input into the type of services that are likely 

to be the most helpful to them. 

Monitoring and review: Mechanisms to monitor and review the mental health services provided need 

to be established and individuals using such services and their families should be involved in such 

monitoring and review. 

Protection of rights 

The following are examples of the issues that will need to be addressed when developing mental 

health policy: 

Personal autonomy: Individuals should be given the opportunity to make decisions for themselves 

and provided with the support to assist this where necessary. Furthermore, people with mental health 

problems should not be assumed to lack capacity to make their own decisions. Capacity to make 

decisions should be considered in relation to the particular decision that needs to be made at the 

particular time. 

Least restrictive alternative: Any intervention must be based on the principle of least restrictive 

alternative. Accordingly, individuals should only be detained in hospital as a matter of last resort. 

Establish robust safeguards: Mechanisms to safeguard individuals’ rights will be essential. For 

example clear complaints procedures should be put in place and individuals given information about 

how to complain, if they so wish. Where individuals are detained they must have a right to an 

independent review of their detention. 

Addressing stigma and discrimination 

Sadly, there is widespread stigma towards, and discrimination against, people with mental health 

problems. Accordingly work to address this will be crucial to the success of the implementation of 

mental health policy. Challenging negative attitudes and taking steps to ensure that the public are 

better informed will not only be important in the development of community-based services – to avoid 

campaigns against such reforms (NIMBYISM – ‘not in my back yard’) – but also to ensure that those 

who develop mental health problems are not afraid to seek help. It is also important to address the 

barriers which restrict the ability of people with mental health problems living an ‘ordinary life’, for 

example the discriminatory attitudes of employers and assumptions that people with mental health 

problems will not be able to undertake parenting responsibilities. 

Identification of areas where legislation can play an important role in supporting mental 

health policy 

Legislation has an important role to play in the areas discussed in the above section – mental health 

services and support, protecting the rights of people with mental health problems and addressing 

stigma and discrimination. For example: 




Services and support: Legislation can set out the circumstances for the assessment of a person’s 

health, social care and other support needs such as accommodation, and the provision of services to 

meet such assessed needs. It can also clarify the different agencies responsibilities for the planning 

and delivery of services. Legislation may also provide for the involvement of service users and their 

families in the planning, delivery, monitoring and review of mental health services. 

Protection of rights: Legislation can provide for the circumstances considered to justify compulsion 

and establish safeguards to protect individuals when such powers are used, for example, an 

independent review of detention. It can also provide a framework for decision-making on behalf of 

individuals who are deemed to lack capacity, including safeguards such as procedures for assessing 

capacity. Complaints procedures and powers of monitoring and inspection bodies to take action 

against poor care and/or abuse can also be provided for by legislation. 

Addressing stigma and discrimination: Anti-discrimination legislation can be introduced to protect 

people with mental health problems from unfair discrimination. All laws should be reviewed and any 

provisions which perpetrate discrimination against people with mental health problems should be 

removed. 

Conclusion: mental health policy and human Rights – a shared goal 

In their report Human Rights and Disability – The Current Use and Future Potential of United Nations 

Human Rights Instruments in the Context of Disability,[4] Quinn et al state: 

‘…the end goal of the human rights model is to build societies that are genuinely inclusive, 

societies that value difference and respect the dignity and equality of all human beings 

regardless of difference.’ 

This paper has sought to demonstrate that mental health policy should share this human rights 

model goal. A human rights perspective highlights the importance of enabling people with mental 

health problems to participate in society as equal citizens. Thus the introduction of anti-discrimination 

legislation, together with strategies to address the barriers to the social inclusion of people with 

mental health problems must be a key component of mental health policy. Furthermore, the 

principles of equality and social inclusion underpin best practice principles of placing those 

individuals receiving mental health services at the heart of the planning, development and 

implementation of mental health policy. 

References 

1. Available at: www.community-living.info 

2. United Nations. Basic Facts about the United Nations. New York: United Nations, 1998, p. 218. 

3. Included in Society: Results and Recommendations of the European Research Initiative on 

Community-Based Residential Alternatives for Disabled People (October 2004), p. 19. 

4. Quinn et al. Human Rights and Disability – The Current Use and Future Potential of United 

Nations Human Rights Instruments in the Context of Disability. United Nations, 2000, p. 1. 




Mental health reform in Bulgaria 

Hristo Hinkov 

Abstract 

The presentation focuses on main topics of the mental health care reform in Bulgaria. It starts with a 

brief description of the demographic situation and institutional capacity of the existing health care and 

mental health services. The basic incentives to start reforming the mental health sector are 

presented: going behind the general health care reform, systematic violation of the human rights and 

international pressure on the official institutions, lack of appropriate legislation, lack of standards and 

guidelines for good medical practice etc. A variety of answers to the challenges of the 21st century in 

Bulgaria are presented as well: National Mental Health Programme, National Mental Health Policy 

and Action plan, a separate chapter for mental health in the project law for public health, a number of 

projects related to mental health. 

The political changes in the last decade of the 20th century gave opportunity for profound changes in 

the overall health care sector. Reforms carried out aimed to improve the quality of the services by 

introducing market elements in the existing state financed and possessed system of health care. To a 

great extent these approaches proved to be hardly applicable in the field of mental health. As a result 

the reforms in this sector are behind the schedule. 

Institutional type of services provided in Bulgaria is a big challenge for the relatively small group of 

reformers. Apart from the old fashioned model of dispensary – hospital inherited from the totalitarian 

past and uneven distribution of the services in the territory, a serious obstacle for establishing 

continuity of care is the fact that two ministries (Ministry of Health and Ministry of Labour and Social 

Policy) are responsible for the vulnerable groups of mentally sick people and mentally retarded 

persons. A number of patients have been transferred from acute psychiatric hospitals to the nursing 

homes (under the jurisdiction of the Ministry of Social Affairs) as already hopeless cases. 

Since 2000 almost all of outpatient care has been privatized, but psychiatric hospitals remain fully 

budgeted by the Ministry of Health. 

In 2001, the Council of Ministers approved the National Mental Health Programme, which described 

the philosophy of the reform in that sector and provided an action plan for implementation over a 

five-year period. 

In 2002, the SEE mental health project under the Stability Pact initiative was started. The project 

objectives are to enhance the social cohesion in the region through introducing modern forms of 

mental health care. The project is in a phase of implementing a model of community-based 

psychiatric care since March 2004. Under another PHARE project four additional community mental 

health centres will be established in selected regions in the country. 

In 2004, a new draft law for public health is in the Parliament for adoption. A separate chapter for 

mental health is proposed which includes a patients rights description, involuntary treatment 

procedures and so on. 

A National Policy and Action Plan 2005–2012 on mental health reform was adopted by the Council of 

Ministries this year. 




Reforming mental health services in England 

Andy Porter 

The Policy context: The National Service Framework and the Local Development Plan 

Taken together the National Service Framework for Mental Health and the NHS Plan, propose a 

radical programme of development for the mental health services over a ten-year period (from 1999). 

It is not an exaggeration to say that this amounts to one of the most significant policy initiatives in 

mental health since the early days of the NHS. If the second half of the twentieth century was about 

the shift to community care, then the first decade of the 21st century is intended by government 

policy to be about learning from mistakes and from good practice – and about finally making 

community care work. Significantly it is also an opportunity for a historic shift towards primary care 

commissioning and delivery of mental health services. 

Local Development Plans 

The Department of Health has prioritised a limited number of key NSF targets which when 

implemented will bring about significant changes in the way mental health services are delivered. 

These targets are to be found in the Local Development Plans that are being implemented across 

the country. 

The key national mental health targets for the three years from April 2003 are as follows: 

• Early Intervention in psychosis 

• Crisis Resolution 

• Assertive Outreach 

• Breaks for carers and carers support 

• Improving mental health care in prison 

• Developing new primary care mental health services 

• Developing local strategies for black and minority ethnic mental health 

• Developing local strategies for specialist and secure services including services for personality 

disorder 

These services are best understood as part of an integrated set of reforms extending from health 

promotion initiatives for the whole population at one end of the spectrum through to secure provision 

at the other. 

What will the new services look like? 

• Early intervention services will operate at both primary and secondary care level to work with 

young people experiencing the first onset of a psychotic illness – ensuring prompt and effective 

treatment and in most cases a better prognosis. 

• Crisis Resolution services will be available 24 hours a day 7 days a week offering intensive 

intervention to people with mental illness in acute crisis and providing an alternative to hospital 

admission. 




• Assertive outreach teams will work in the community with people with severe mental illness who 

disengage with services – reducing emergency admissions and enabling planned programmes of 

treatment and care. 

• Carers will have access to support networks and respite care, and all carers of people with severe 

and enduring mental illness will have their own written care plan. 

• Mental health services in prisons will be provided at a level to ensure equivalence with the 

community – representing a significant increase in services available. 

• New Primary care mental health workers will work alongside GP practices – offering short-term 

interventions for common mental health problems such as depression and anxiety, and providing 

a link to specialist services for those who need them. 

• Community development workers will be employed to work with local black and ethnic minority 

communities and mental health services addressing mental health issues 

• Specialist and secure services – including for personality disorder – will be developed on a 

regional basis to reduce cost and ensure that high quality services are provided in a planned way. 

These developments will significantly and positively affect the experience of service users and the 

outcome of treatment for service users. The aim is that patients will be able to receive flexible and 

responsive community based services that respond with appropriate interventions at the time they 

are needed. We will be doing a significant number of things that we are not doing now – a greater 

number of interventions will be in the community rather than hospital, and a greater number of 

interventions will be at primary care level. 

The National Service Framework for Mental Health 

The NSF for mental health is a comprehensive policy providing a structure for looking at mental 

health and illness from a whole community perspective – covering everything from Health promotion 

and prevention to Secure provision. The five key themes in the NSF are: 

Mental health promotion – promoting mental health and reducing discrimination and social exclusion 

for people with mental health problems 

Primary care and access to services – ensuring access to treatment at primary care level 24 hours a 

day 

Effective services for severe mental illness – ensuring people with mental illness have access to the 

range of services they need including prompt and effective help in a crisis 

Caring about carers – ensuring that services meet the needs of carers of those with severe mental 

illness 

Preventing suicide – developing services to reduce the suicide rate by at least one fifth by 2010 

A large number of national targets have been derived from the NSF and the NHS Plan – in 2004/5 

there were 45. Whilst some of these are nationally determined targets in the high priority LDPs – 

many are not. Many important targets do not feature in the LDPs – for example the development of 

local mental health promotion strategies, women only services, dual diagnosis, improvements to 

acute inpatient services, user involvement – but are still intended to be implemented by 2006. 




Structures and context for implementation 

The key local agencies tasked with the implementation of the mental health reforms are the Primary 

Care Trusts. PCTs are a relatively new structure in the NHS – established from April 2002. Three 

hundred and four PCTs operate across the UK – and have the lead responsibility for local 

commissioning and strategic planning in relation to all NHS provision. New legislation has also 

encouraged the integration of NHS and Local Authority provision – and in many areas mental health 

services are integrated both in terms of commissioning and provision. 

The mental health reforms and targets do not stand alone but operate in the context of rapid and 

wide ranging policy changes in the NHS – the principles of which are outlined in the NHS Plan 

(2000) – and in policies that have developed from this. The whole system is managed by a complex 

array of targets and star rating assessments for PCTs and provider NHS Trusts. 

The NHS reforms are funded by an unprecedented level of new government funding – £25 billion 

new funding between 1999 and 2002, and a five-year programme from 2002 with projected annual 

increases of 7.5%. 

Progress and problems in implementation 

Mental health reforms have struggled to maintain a high profile in this climate of rapid change, tightly 

defined targets and rating systems. Few of the mental health targets have featured in the key 

national targets for the NHS – and new funding has not been ring fenced to ensure that the mental 

health targets are met. A study by the independent Sainsbury Centre for Mental Health suggested 

that new money promised by ministers is not getting through to the mental health trusts. Many of the 

trusts reported problems with debts, staff shortages, and rising medication bills. More than half of the 

Local Implementation teams said that financial pressures were delaying progress towards meeting 

key NHS Plan targets. The Sainsbury Centre warned that government plans might have to be scaled 

back significantly. 

Currently plans and targets for mental health remain in place – but it is clear that the original 

timescales for implementation will not now be met in some key areas. For example – in August of 

this year the Health Service Journal reported that only half of the Crisis Resolution teams required by 

the NHS Plan had been established. 

The Sainsbury Centre is also concerned that the emphasis on target areas will create gaps in 

services – predicting a trend in which fewer people – those who are higher risk – will get better care 

– whilst those with lower needs may lose out on traditional areas of support such as day care 

services. There is a danger that this will remove a layer of support without putting anything in place 

as an alternative. For people with common mental health problems – the provision of effective 

primary care services could be seen as a progressive alternative to older style secondary provision – 

such as day centres. However, progress in developing the new primary care services is patchy and 

in many areas is not keeping pace with the radical developments in secondary care. 

The answer may lie in a new policy initiative – addressing mental health and social exclusion - 

launched by the National Institute for Mental Health and the National Social Exclusion unit. The 

policy has the aim of addressing social exclusion and discrimination in the community and in the 

work place. The policy can be seen as complementing the specialist developments outlined above by 

encouraging a shift towards genuine community integration. The success of the National Service 

Framework in improving the lives of people with mental health problems may in the end rest as much 

on society wide initiatives such as the Social exclusion policy as it does on specific initiatives in 

relation to illness and treatment. 




Focusing on the solutions: what should governments consider in 

developing mental health policies 

John Bowis 

I was calling round my London Constituency a few years ago, when I met an elderly lady in tears 

watching television with the sound off. I asked her what was the problem and she said she was very 

deaf and could not hear the sound and her sight was not good enough to read the subtitles. Perhaps, 

I said, we could try to get a better hearing aid. Oh no, that was not the problem, she said. A very nice 

lady had called and arranged for her to have a hearing aid but the problem was she could not 

manipulate the volume control on it with her arthritic fingers. 

One person with two health problems, together leading to mental health deterioration. 

Another day, as Minister, visiting a psychiatric hospital. “Can I have a word with you?” a young man, 

a day-patient, asked. The staff tried to hustle him away but I said I should like to hear from him. 

“Well”, he said, “You know, I know when I am going to be ill but, if I go to my doctor, he says I am not 

ill enough to refer to hospital, so I have to wait until I am really ill and then it is bad for me and bad 

for the hospital staff and it takes me longer to get better”. 

Two examples from my own experience of services not talking to each other and the system not 

being flexible enough to provide the seamless care a person with health problems needs. 

Nobody seeing the wider picture – except perhaps the patient, who knew his needs but not how to 

coordinate all the different agencies that could meet them – and anyway nobody with the power to 

bring it all together was listening to him. 

For three years I was Health Minister responsible for mental health in the UK. I used to say that, 

when I went there, I thought I knew it all; after a year, I knew I didn’t; and, after two years, I knew 

nobody else did either. And that is when I relaxed and really enjoyed the hunt for solutions to our 

health challenges. 

I had also come to realise that the three flaws in our mental health system were: 

• the inadequacy of community services; 

• the failure to listen to service users and their carers; and 

• the inability or unwillingness of different agencies to work together. 

It persuaded me above all that someone with mental health problems needs a one-stop shop – the 

sort of care I had seen in the Threshold organisation in Chicago, where one organisation ensured 

contact, access to medical care, housing and other social care needs, income, legal services and 

rehabilitation. In other words a single purchasing agency or brokerage for all the person’s needs and 

a trusted friend who knew his or her way around the provider organisations. 

Of course that is not the whole solution. It must go hand in hand with the skills and dedication of our 

doctors, therapists and nurses, the work of our research scientists, the managers of our hospitals, 

clinics and community teams, the support of NGOs and the allocation of resources adequate to the 

task. 




But, if I am ill or recovering from illness, I need the security of a home, access to activities that will 

aid my recovery, support from my family and neighbours, just as much as I may need medication or 

therapy sessions and organising that support may be beyond me, at least for the time being. 

In London a couple of years ago nearly a third of rough sleepers were said in a survey to have been 

discharged from the armed forces and found themselves unable to cope with civilian life. The 

downside of failing to address the causes for someone in such a situation is lost income, lost family, 

lost home, lost self-respect and so on. The upside of preventing it, by promoting wellness, by 

providing that on-stop shop of care, is that you have someone leaving the army and being helped to 

cope with his new life. 

We have to look to, but also beyond, the health and social care professionals; to, but also beyond, 

the drugs and therapies; to, but also beyond, the hospitals and community health teams. 

We need to engage with new partners to prevent illness and to avoid relapse. Housing people, for 

example, not in the isolation of high-rise flats on run down estates, but in communities where the 

living environment will be part of the support and stability a person needs. And rehabilitation and 

training, so that he or she can regain self-confidence and self-respect and, in so doing, make 

readmission less likely or at least less frequent. 

In my lifetime we have seen tremendous advances in medical science and practice in Europe. 

Diseases that killed have been eradicated or controlled; children survive the risks of birth and 

infancy; and life expectancy moves up. 

Yet these advances have brought new challenges and new costs in health and social care. A 

healthier longer living population eventually means later years of high dependency, often with 

physical or mental frailty. Lifestyle, education and work pressures, changes in family structures, 

isolation, forced population movements, can all trigger mental health problems –psychoses, neuroses 

and often with an addiction link. New drugs, therapies and treatments have come at an escalating 

cost. New challenges and costs accompany new beds, new centres, new day care and new 

community teams. And policy changes on where and when to treat and care have often added 

uncertainty to the standard problems of lack of understanding and inadequate resources, together 

leading to prejudice and the breeding grounds of stigma. 

When I left government office, I accepted the invaluable opportunity to work with the World Health 

Organisation on two of their global campaigns: 

Nations for Mental Health and Out of the Shadows for epilepsy. That set me on a new learning path. 

I think every country I visited then and since has taught me something new – as well as opened my 

eyes to new dimensions of our global challenge. 

Then in 1999 I was elected to the European Parliament. And I looked around to see what we could 

do for health at the European level. Health is now firmly on the European agenda, has been given 

greater emphasis in recent years and is going to go on growing in scope. It has now ensured its 

share of the policy, if not yet the budget, cake. 

Its Treaty base is, however, to put it kindly, muddled. Article 152 states boldly: 

“A high level of human health protection shall be ensured in the definition and implementation 

of all community policies and activities. Community action, which shall complement national 

policies, shall be directed towards improving public health, preventing human illness and 

diseases and obviation of sources of danger to human health…” 




One might think that was a green light for Europe to forge ahead, working with member states to 

improve health and reduce the causes of illness, disorder and disability. But the Treaty proceeds with 

a caveat: 

“Community action in the field of public health shall fully respect the responsibilities of the 

member states for the organisation and delivery of health services and medical care.” 

In other worlds, the European Union has power – even a duty – under the treaty to protect human 

health, but not to ensure that across Europe we can count on basic standards of health provision. 

Despite that, the truth is that over the years, Europe has added competencies and standards from 

public health to health promotion, all of which apply to mental as well as physical health. And it 

needs to go on doing so. Europe needs to wake up to the realities of health and mental health in 

particular. Whether East, Central or West; whether Bismarck or Beveridge systems of finance or any 

combination of the two; our health systems are crumbling and failing to meet the continuing, much 

less the changing, needs of our citizens in the 21st Century. The pressures of demographic and 

social change and the pace of scientific advances in medicine and research bring exciting 

possibilities but also awesome challenges. Just as the individual service user needs new 

organisational structures, we can meet those national and continental challenges and benefit from 

the pace and depth of change, if, and perhaps only if, we develop new partnerships, methodologies 

and structures. 

We do now have the new European Health competence under the Treaty of Amsterdam, which both 

places Health Promotion firmly on our agenda and requires that a Health Impact Assessment be 

carried out on any major new policy from any area of Commission policy and, in due course, for any 

major new policy from any ministry or local authority in any member state. But it is being developed 

oh so slowly and noone seems to have a clear idea as to how the mental health impact of a policy is 

to be measured, much less incorporated. 

Essentially, leaving aside research, EU health policy is based on the three strands of its Action 

Programme – Health Indicators, Health Emergencies and Health Determinants. The first and third 

are very relevant to mental health. 

Health Indicators means we can map Europe’s health needs and we can map how they are being 

tackled, and then we can share information about best practice – and, indeed, worst practice. We 

shall be able to arm our citizens with the facts about how other countries are doing things, so that 

they can press for parity of treatment. In other words, we shall not prescribe European standards in 

mental health care, but we shall describe them. 

Determinants give us the opportunity to promote mental health and prevent mental illness and 

disability. 

And then there are the other collateral health policies that have grown from other treaty clauses. For 

example, following the various ECJ judgements, we are looking at how to manage the new patient 

mobility rights – good for patients, who will be able to bypass "undue delay" for treatment in their own 

country; but not so good for health service managers, who will have to cope with unplanned bills. 

There are innumerable questions as to how to manage the system and give guidance to doctors, 

managers and patients. But no-one to my knowledge has given more than a passing thought to how 

these rights might improve the options for people with mental health problems. 

Enlargement has brought other dimensions to our debates, but rarely has the mental health 

dimension of those dimensions been heard. For example, debates rage as to how to manage drug 




prices, when pharmaceutical companies may be reluctant to continue discounted pricing in the EU 

countries of Eastern and Central Europe, if they find their drugs being sent across the internal EU 

borders to be sold at a profit? 

And how do we manage the potential for a flow or seepage of doctors and nurses from East and 

Central Europe to other EU countries, where pay may be higher and health professionals in short 

supply? All these issues have a serious mental health aspect. 

Then of course there are specific policies crying out for reform. With the MDAC I have been involved 

in persuading the four new Member States of the former Austro-Hungarian Empire – where the policy 

is exclusively found in Europe – that caged beds are an inhumane anachronism and that the 

alternative is not bed straps but staff trained in humane but effective methods of restraint. 

One of my ambitions in the European Parliament has been to put mental health on a par with its 

physical counterpart. 

• We got it put into the Health Action Programme; 

• I included it in my report on Health and Poverty in Development Policies, and 

• most recently, I insisted it be referred to in my report on establishing the new European Disease 

Prevention and Control Centre. 

One of the good developments I have witnessed in my first five years in the Parliament, Commission 

and Council, has been their willingness to give new emphasis to mental health. Finland started it 

during their 1999 Presidency, with an initiative on Mental Health Promotion. This led to a Council 

resolution calling for action in the areas of children, the elderly and those at work. 

Other Presidencies have followed. For example, Belgium pushed forward with proposals on 

depression and stress; last year we had the excellent initiative by the Greek Presidency on tackling 

stigma; and the current Dutch Presidency has this week assured me they will support the 

Commission in its emphasis on mental health in the 2005 Work Programme. Next stop Luxembourg 

and then Great Britain and then Austria. I hope that each and every Presidency, including the 

upcoming British one next year, will help to move European mental health policy forward and push 

for more action in this field. 

We have also managed to get the EU and the WHO working more closely together – and this should 

be evident as the WHO Action Plan for Europe develops. 

The crucial question is how to divert more political attention and then financial resources to mental 

health promotion. Mental Health really only penetrates the political and public mind, when there is a 

crisis. 

As Health Minister in the UK we achieved more progress on mental health, in terms of cash, 

initiatives and reforms, when one man jumped into the lion’s den at London Zoo and another stabbed 

a stranger on the Underground, than at any other time, because colleagues across government saw 

the need to do something and the press, Parliament, public and NGOs clamoured for it. 

But it was at a price – the price of lowered public confidence and increased stigma. Mental Health 

promotion does not even benefit in that way from negative stories. 

There is little understanding by governments, politicians or even health service planners of mental 

health promotion. The main reason is they have no idea what it is about or why they should be 




interested. I think we have to do more to get across the facts. 

Fact People are living longer and, on the whole healthier, lives, but in their later years a growing 

number of them become frail of body and mind. 

Fact Carers, of a child, an adult or an elderly relative, have not been helped to adapt to the new 

community care of people with mental health problems. 

Fact Mental disorders are the fastest growing health burden and unipolar depression leads the 

pack. 

Fact Drug addiction and crime, drunkenness, accidents, absenteeism, vandalism, disruptive pupils, 

rough sleepers, and many others of society’s ‘problems’ in fact link to mental health problems. 

Fact 450 million people in our world live with a neurological or mental disorder. 

1 in 3 of us will be affected in our lifetime 

1 million people in our world commit suicide. 10 million try each year. 

121 million of us have Depression – 3 in every 100 of us every year. 

Fact Neuropsychiatric disorders are responsible for one third of disabilities, 15% of inpatient costs, 

Nearly a quarter of drugs costs, 

Half the caseload of our social workers; 

In this country alone over 90 million days lost at work a year. 

Fact If we do not invest in the right range of services – in-patient, acute, long-stay, secure, medium 

secure, day-care, domiciliary care and the trained staff for each – we shall not cure, care for or 

rehabilitate those who are ill now. 

If we do not invest in a mentally healthy life for our citizens, then the graph will continue rapidly 

to climb, in numbers and in cost 

If we do not invest in bringing understanding about mental health and mental disorders, then 

budgets will remain pitiful and stigma and prejudice will be rampant. 

We are but a short step from a return to an intolerant and inhumane society, even in Western 

Europe. How often we see caricatures of people living with a mental disorder, that we would never 

see of someone living with cancer. The Sun newspaper's appalling headline about the boxer, Frank 

Bruno's, illness, referring to "Bonkers Bruno" was so awful the public reaction forced that tabloid to 

apologise; but they are not alone in their unthinking tabloid headline cruelties. And too often lurid 

newspaper headlines give the impression that every unsolved murder or assault must be the result of 

a dangerous person being discharged from hospital. Is it any wonder the public are anxious. 

Stigma is rampant in all our countries and stigma is a human rights abuse; unintentional, born out of 

fear and ignorance, but just as damaging to the individual as any other form of abuse. It almost 

certainly means that we are labelled, patronised, despised, feared and, to a greater or lesser extent, 

segregated – in society, within our family, at work, at play and even within our health and social 

services. 

In recent years mental health policy and practice have been on the move, with more humane 

surroundings, treatments and therapies and patients have been on the move too – no longer locked 

away but in community housing or back in their own homes. But the public do not always like that. 

No longer ‘out of sight, out of mind’, it became ‘out of his or her mind and living next door to me and 

my children’. 




If you place people neatly into a hospital ward, politicians, press and public feel you have dealt with a 

health problem and will not enquire too closely what you are achieving behind the hospital gates. If 

people are visible, then so is the nature of their health problem, and questions are asked as to 

whether the policy is working, 

Communities are, on the whole, prepared to tolerate, if they know what the problem is, what to 

expect and when to go for help. If they know none of these things, they tend to react first against the 

policy and then against the individual. So services need to be as visible as the patients they serve; 

and the safety net needs to be accessible and confidence building for patient and community alike. 

Progressive mental health policy needs a convinced public and adequate government spending. 

They are interdependent. If the public believe, they will put pressure on the government to spend. If 

the government spends they will make public belief possible. 

We have a new Europe and we have a new mental health opportunity. I am an optimist. I believe we 

can meet the challenges and make the changes - change of attitudes, change of practices and 

change of philosophies, change of priorities. 

If I have one forecast to make it is that patients and service users will move centre-stage. They will 

be better informed, be more involved in decisions affecting them and will use their new rights to 

bypass sluggish services and effect change. 

I live with diabetes. When I am to be put on a new medication or dosage, my specialist explains the 

options, asks me what I think and then, together we decide. Of course, normally, I accept his 

professional advice. But when recently he suggested a new drug, which had the unfortunate side 

effect of sometimes resulting in slurred speech, it was I who said that I thought on balance that would 

be unwise for a politician! 

I just hope that if I develop a mental disorder, I shall be in the same sort of relationship with my 

specialist and that he will explain and consult before decisions are taken. I would then respect his 

professional judgement but I would also, perhaps, understand a little more what was wrong and be a 

little less apprehensive about what was being done to me. 




Financing mental health reforms – what does it cost? 

Martin Knapp 

Considerable changes have been made to or are planned for the mental health care systems of 

many European countries. Central to many of these reforms is the closure of specialist mental 

hospitals, many of them large, old, isolated, poorly maintained, regimented and dehumanising. In 

some countries – such as Italy and England – the policy of mental hospital closure was launched two 

or three decades ago. In some other countries – particularly in parts of central and eastern Europe – 

it has been the subject of some discussion but relatively little action. While hospital closure is likely to 

dominate the headlines, many other, but less dramatic aspects of reform or policy change are also 

receiving emphasis in various parts of Europe. These include the promotion of human rights, the 

wider introduction of evidence-based clinical guidelines, the extension of choice and independence 

for service users, concerted attempts to identify need and to widen access to treatment, the 

introduction of more ‘assertive’ models of community-based care, recognition of the needs of family 

members whose lives are affected by a relative’s mental health problems, efforts to remove barriers 

to proven new pharmacological or psychological therapies, an emphasis on employment, and 

adoption of ‘recovery’ models of care. 

Each of these reforms has cost implications, whether for the health care system or for other parts of 

society. Some of the changes being introduced or discussed will need additional funding if they are to 

succeed in improving the mental health status or general well being of the population. Some of the 

changes may be expected to lead to expenditure savings and/or cost-effectiveness improvements. 

The purpose of this paper is therefore to discuss the main economic questions raised by mental 

health reform. Of course, different health systems have different funding arrangements, with 

consequences for the funding of mental health services. I shall generally aim to abstract from those 

differences in what follows. 

The paper is organised around ten evidence-based statements concerning economic aspects of 

mental health. 

Mental health care gets only a small share of the ‘pie’ 

In many countries, both in Europe and elsewhere, mental health care is grossly under-funded. 

Despite the high rates of incidence and prevalence, the substantial contribution to the global burden 

of disability, the strong association between deprivation and mental illness, and the growing body of 

cost-effectiveness evidence, the proportion of total health system expenditure devoted to mental 

health care is often very small. As other presentations at this conference have made plain, there are 

still many countries without an explicit mental health policy, with acute shortages of specialist mental 

health staff and with very low political commitments to making improvements. The stigma of mental 

illness is an enormous barrier to action in some cultures. 

Mental health reforms will therefore often require the injection of additional resources. A system that 

has been starved of funding and skilled human resources for decades will be in no shape to support 

major changes to the locus, organisation or processing of care. 

The costs of mental health problems range widely 

Most mental health problems, particularly if they are enduring, have other consequences across 




many domains of an individual’s life, and therefore for many parts of society beyond the health 

system. The costs of mental health problems therefore fall not only to the health care system but 

also to bodies responsible for social care, housing, employment, criminal justice and income support. 

Indeed, the health care share of the total cost impact is often a very small part of the total. 

An immediate consequence of this funding plurality is the need for carefully coordinated action to 

ensure that all of the resource pieces are in place or are committed for the future before embarking 

on systemic or other changes. 

Mental health has many external impacts 

Not only are the people with mental health problems affected by their illness, but their families, 

employers and others in society could also be affected. The personal and economic impacts on 

family carers are well known, as are the huge national productivity losses attributable to mental 

illness. Both need to be factored into decision-making about reform. Some mental health problems 

are also associated with violent incidents, whether to oneself (deliberate self-harm, suicide) or to 

others (aggressive behaviour, homicide). These external ‘costs’ also need to be taken into account 

when discussing, planning and implementing mental health reforms, for the benefits of improved 

services could be experienced across many parts of society. 

The process of reform can itself be costly 

There have been some dramatic changes in the systems of mental health care over recent decades, 

with many countries moving from an era dominated by the old asylums to one that is much more 

actively focused on community-based arrangements for support. Such shifts require additional 

resources, at least in the short term. There is obviously a need to invest in new physical capital and 

human capital resources in the community prior to the closure of a hospital, to ensure the smooth 

and effective movement from one system to another. Second, community and hospital systems will 

need to run in parallel for some time, resulting in double running costs. Consequently, mental health 

reformers will almost certainly need to invest in order to save. Many countries will definitely need 

injections of additional resources in order to promote quality of life. Reforms that are introduced in a 

cost-neutral way – or, worse, are planned to save money – could result in many people being denied 

care, at least in the short term. 

Multiple costs, hidden dragons 

Multiple costs, not just to different agencies within the public or private sectors, but also to individual 

service users and their families, raise a number of challenges. In particular, unless the full cost 

implications of mental health problems, and of changes to mental health systems, are recognised, 

multiple costs raise the risk of the reform process being seriously under-funded. They also give rise 

to the potentially very constraining problem of silo budgets: resources held in one budget cannot be 

allocated to other uses, to the general detriment of the pursuit of effectiveness. There is also a risk 

that key opportunities to promote service user well-being will be missed, for example by denying 

individuals the opportunity to secure paid employment. 

Money talks 

Financial power can be enormously important: the flow of funds within a mental health system 

(interpreting the latter term broadly to include all relevant agencies, not just those within the health 

care sector as conventionally defined) creates incentives and disincentives to better action and 

performance. Making decision makers aware of the cost implications of their decisions can be quite 

illuminating; making them financially responsible in a direct way can be quite influential in changing 




behaviour. 

When the funding to pay for inpatient psychiatric treatment was rerouted in both England and 

Australia so that it was no longer passed as a block grant from a central authority to hospital 

managers but was instead transferred to local health agencies who then had to purchase inpatient 

care for those of their local residents accommodated there, it provided very clear signals of the real 

costs of treatment. Local decision makers began to ask whether it might not be possible to provide 

support more cost-effectively in other settings, such as in the community. 

There are both benefits and risks associated with such an approach, of course. The potential 

benefits are that there will be improvements to the quality of life of mental health service users 

without unaffordable increases in costs – indeed, perhaps with associated expenditure reductions. 

On the other hand, the potential risks are that local decision makers (who are now the budget 

holders) will spot an opportunity to cut expenditure without regard for the well-being of those people 

affected by the change in service arrangements. 

More generally, the funding that is already committed to provision in support of people with mental 

health problems, as well as any new funding earmarked to support reforms, should be raised, 

allocated and spent in ways that do not create the wrong incentives. There are many examples of 

well-meaning resource commitments that have exacerbated rather than alleviated the underlying 

problems. 

Some reforms to financing can promote user choice 

Empowering service users is an explicit objective for a number of mental health systems, and the 

promotion of greater consumer choice has widespread support. Some reforms to the financing of 

mental health services can themselves promote choice. For example, giving case managers (or 

equivalent professionals) devolved funding responsibilities can both improve the responsiveness of 

services to needs, and provide openings for service users to express their preferences. The 

encouragement of direct payments (consumer-directed care) is even more powerful in this regard. 

Individual people are given cash with which to purchase services. This promotes independence and 

inclusion, and offers opportunities for rehabilitation, education, leisure and employment. However, 

few care systems across the world have moved very far towards a direct payments system for 

mental health services, even if they have done so for people with disabilities or age-related needs. 

Mental health is different 

Mental health problems are, first and foremost, health problems and need attention from health 

systems. But, as we have seen, the personal, family and economic consequences go much further. 

Any discussion of mental health problems and the policies needed to address them therefore needs 

to take into account the highly complex combination of major externalities, pervasive stigma, 

widespread discrimination, associations with dangerous behaviour (very real but sometimes 

exaggerated in the public mind), restricted choice because of assumed or ascribed inability, 

correlation with social exclusion, strong links with suicide, compulsory treatment and denial of human 

rights. 

There is an economics evidence base 

Resource allocation decisions are notoriously difficult, and decision makers will generally look for 

evidence on the consequences of alternative courses of action for effectiveness and costeffectiveness. 

Although it is still limited, the economics evidence base in the mental health field is 

certainly accumulating. Some areas are relatively well provided with evidence; for example, many of 




the most frequently used treatments for schizophrenia and depression have been the subject of costeffectiveness 

evaluations. On the other hand, there have been relatively few economic evaluations of 

treatments or service arrangements for people with anxiety disorders, child and adolescent mental 

health problems, personality disorders or mental health problems in old age. Moreover, given the 

general finding that economic evidence – unlike most of the evidence coming from clinical studies – 

does not generalise well from one health system or country to another, it must be of considerable 

concern that there are so few mental health economic evaluations conducted in middle- and lowincome 

countries. 

One obvious consequence is that encouragement needs to be given to research endeavours that 

can generate robust cost-effectiveness and related evidence on the range of therapeutic and service 

options available within a mental health care system. But it is also important not to waste scarce 

research resources in repeating studies that have already provided solid evidence as a basis for 

clinical or system-level decisions, or in conducting research of such low quality that it cannot provide 

any kind of sound basis for policy or practice planning. 

Health systems are designed to promote health 

This final statement might seem startlingly obvious, but it often appears that health systems need to 

justify changes in service arrangements to their funding bodies or to government on the grounds that 

they save money. Sometimes improving a health system, in order to improve the health of the 

population, requires that additional funding be injected. Reformers should not have to be so 

defensive about innovations and developments that promote the mental health of the population just 

because some of them lead to higher levels of expenditure. This, of course, takes us back to the first 

of the ten statements in this cycle in recognising that in many countries the mental health system is 

grossly under funded. 




Developing mental health policy and legislation 

Toma Tomov 

Introduction 

This paper is concerned with mental health policy as a written document, which presents the position 

of a government on the mental health in a country. Such statements usually announce, describe, 

define or argue what activities in the mental health field are deemed necessary and why. The written 

policies are taken to mean that the governments commit themselves to the position expressed in 

them.[1] 

Mental health policies vary a lot across countries but certain ingredients seem to be common.[2] All 

policies make statements of missions and goals; put on the public agenda issues related to problems 

of mental health, mental illness, and mental disability; announce and argue the direction to be 

followed in the field of mental health care; provide a frame for planning of services at various levels; 

and outline the requirements that the government, the health insurers and the service providers 

should meet in the immediate future. 

What follows is an elaboration of these five major components of mental health policy. After that the 

recent experience with mental health policy in Bulgaria and its neighbors from southeast Europe is 

described. This part of the continent has attracted attention with intense activities on the national 

mental health arenas steered by the Stability Pact for southeast Europe, the Greek government in 

particular, and supervised by the World Health Organization. 

Ingredients of mental health policy 

In formulating the mission and goal of mental health policy it is essential to make a link to the 

country’s other preoccupations in the public domain, such as unemployment, crime, corruption and 

poverty. Unless this is done it would be difficult for the human rights of psychiatric patients and the 

concerns about the quality of their life to hold the stage. 

A second point here is that it is important to enlist for the policy the support that stakeholders 

command. In countries with little experience with democracy, however, important actors on the 

mental health scene like users and carers have little awareness or capacity to step into the 

stakeholder role. Bringing this fact into focus for the public to grasp is already making good policy. 

This would be an example of good governance, of which there are not many in the field. 

A third point is that the mission and goal need to be rooted in the national and regional zeitgeist if 

they are to contribute to the contextualization of the policy. The role of experts in adding this vital 

dimension to policy cannot be underestimated. 

Mental health policy has the important function to raise public awareness about mental health and 

mental ill health. These are topics only too often disavowed or misrepresented by the media and 

reduced to gossip that sells the news. Illness, disability and their prevalence in society are the 

domains that mental health policies attempt to put on the public agenda. Common messages in 

policy documents are: that the way people behave with one another affects their mental health, that 

severe mental disorders benefit from both proper treatment and humane context and that either one 

or the other is not enough; that the disability due to mental illness is reduced by the employment 




policy - not just by psychosocial rehabilitation; that coordinated programs make a difference and it 

can be shown in terms of change in prevalence, etc. 

Another component of any policy document is the choice of direction for mental health action. This 

concerns the sustainability of the policy and, by the same token, - of the mental health system. To 

that end visualizing policy as a spiraling sequence of planning, implementation, evaluation and 

planning again is important. The policy affirms a consensus on priorities. Most policies try to balance 

between a service and a prevention component. The disregard of the psychosocial needs of the 

people with severe disorders may result in serious imbalance in the service packages. Involvement 

with policy making usually reveals how inadequately supplied with data governments are to be in 

position to develop good policy. An important direction of development therefore usually is the setting 

up of information systems and the conduction of surveys and service evaluation. 

The planning frame is another essential ingredient of mental health policies. The usual tensions 

between central and local governments are addressed, as are the collaboration between sectors and 

the available resources - material and human - as well as their development. The finances - their 

sources and their distribution - are usually subject of much debate. 

And finally policies pose requirements to governments to translate them into action by involving the 

health administration, by opening avenues for contributions from stakeholders, by establishing 

steering committees, by introducing accountability rules, by reporting, evaluating, updating, etc. 

Mental health policies in southeast Europe 

Developing mental health policies in southeast Europe is a practice of little tradition if any. Two of the 

countries – Bulgaria and Romania – are expected the join the EU in 2007, whereas the rest – 

Albania, Bosnia and Herzegovina, Croatia, Macedonia (Former Republic of Yugoslavia), Moldova, 

and Serbia and Montenegro would like to do this some time in the near future. Good mental health 

policy is an important criterion for the acceptance of a country into EU and the attempts of these 

eight countries to fit psychiatric practice into their health and social policy as future democracies is 

exciting. 

These attempts will be reviewed here on the basis of the documents these countries prepared in the 

course of 2003 as part of the Southeast Europe Mental Health Project ‘Enhancing social cohesion 

through strengthening community mental health services in southeast Europe’. Special emphasis will 

be laid on the sociopolitical context [3] in the countries from the region as it differs markedly from the 

contexts in the old democracies at the time they embarked on mental health reforms by shifting to 

community care and closing psychiatric beds. In the second place a discussions of the priorities [4] in 

these national policy documents will be made as this topic highlights the risks of imposing solutions 

from outside. Finally the issue of governance will be picked up as it penetrates all the documents. An 

attempt will be made to capture what good governance actually implies in a context of 

sociodemographic upheaval. 

The context 

The eight countries from southeastern Europe went through the experience of developing nonperfunctionary 

mental health policies working in parallel and following similar steps, which was an 

agreement between the health ministers from the region signed in Dubrovnik. Most of the social 

context issues which the country teams had to accommodate in their policy documents were very 

different from those that developed democracies needed to grapple with in the mental health field. 

A good example is the human rights issue. In the policy documents from the region the human rights 




issue is expressed as a concern that in these countries people relate to each other without due 

respect for human dignity and that this is true of interpersonal interactions as well as of interactions 

arising from social roles. For instance, exploitation and victimization driven by envy, greed, and hate 

as illustrated by wars, unrest, displacement of people, crime and so on would not meet with public 

outcry as would be expected in any civil society and as historically had been the case in the region 

prior to the imposition of totalitarian regimes. 

The globalization of economy and of many other aspects of life, which became possible with the 

arrival of democracy, was mostly taken to be bad news for the region as it revealed painfully the 

inadequacies in industry, trade, organizational life and the precariousness of living arrangements. 

This caused gloom among most of the local people that contrasted with the enthusiasm for change 

expressed by visitors from the old democracies. The work ethos was yet another source of 

humiliation for the people from the region as it became clear that many attended work and applied 

themselves to the jobs with disinterest, boredom, cynicism and even subversiveness – an attitude 

carried over from totalitarian times. 

As health reforms were launched and health insurance faltered in many places the generations born 

before 1940 went through the bitter experience of finding themselves to be a burden to their sons 

and daughters with their ailments and lack of access to health care. In the mental health field the 

toleration of degrading conditions in the institutions by staff and patients alike became emblematic of 

a system wrongly conceived. 

People were so preoccupied with pertinent issues of day-to-day life in every field that they tended to 

turn a blind eye on mental health. They remained unresponsive even to the revelations of the 

desperate conditions under which the chronically mentally sick and disabled had been kept in many 

of the institutions from the region.[5] 

The priorities 

One of the biggest obstacles to policy development in southeast Europe was the lack of systematic 

evidence on which to argue choice of priorities. The report of the Stability Pact project for southeast 

Europe was impeded in illustrating many of its finding because of the lack of agreed standards (and 

evidence to the adherence to standards at all) by the countries’ administrations in collecting data. 

Annual returns of hospitals, for example, had been made to comply with the dominating ideology of 

totalitarian culture and were known to report with positive bias. No estimate of this bias was possible 

though because it had never been thought in any of those countries that the collection of data on the 

services independently of the data reported by the service providers was a meaningful exercise. The 

belief that the service utilization data, biased or not, were informative of all needs in the community, 

even of the unreported cases, was strong. 

The mental health policy documents developed under the project revealed that in most countries of 

southeast Europe psychosocial rehabilitation has been heavily under-delivered. Attempts to take 

action on that matter have resulted in channeling money in the past decade into the upgrading of the 

old institutional facilities but not in changing the culture of care in them. Most sponsors have 

dismissed requests to support the training of staff in therapeutic skills with the argument that there 

are more fundamental needs that have to be addressed first, for instance, that the patients should be 

fed and dressed. 

A recent expression of the belief that there is an east - west division in Europe on the matter of 

mental health priorities has been the setting up of the EE and Balkans program of the World 

Psychiatric Associations. It clearly admits that the training of mental health personnel in addressing 

local needs would differ in southeast European schools compared to schools in the rest of Europe. 




This seems to imply less preparation in how to meet the frustration and distress of the individuals 

with severe mental disorders who attempt to come to terms with their predicament, fewer skills in 

helping them to accept the limitations that their life careers are bound to suffer. And by the same 

token it suggests more emphasis in the training on supplying basic needs like medication, food and 

shelter for those who have fallen through the loops of social networks and have ended up destitute. 

Common mental illness is a case in point of particular poignancy in respect to policy priorities. 

Common mental illness had never been targeted care-wise or research-wise in the area, because 

emotional distress, which is its core manifestation, was never seen of significance worthy of 

engaging policy. A project on social inclusion was faced with a long-standing practice of governance, 

which disavowed the very assumption that social upheaval could impinge on mental health of 

individuals and on public health in general. The Bulgarian Government made a step in the right 

direction by prioritizing in the first five-year policy document community care of severe mental illness 

and the study of the prevalence and the natural history of common mental illness. This was done 

with a view of collecting evidence that would enable it to launch a more comprehensive mental health 

policy a few years later. 

The good example 

Central to the implementation side of policies in the Stability pact project is the setting up of 

demonstration projects that would show the way. Whether a demonstration project can instill a policy 

of genuine mental health reforms in a social context, which cultivates hostility to difference, is yet to 

be shown. There is a long experience with demonstration projects in underdeveloped areas being 

used as a front for perpetuating unenlightened practices in many fields of health care.[6] 

Demonstration projects have no alternative in the case of policies, which attempt to re-form existing 

practices, which is the case with the countries of southeast Europe. Having lived in parochial 

isolation for several generations local psychiatric ethos has come to regard seclusion as the way with 

severe mental disorders and it takes a paradigm shift with all its complexity to change over to 

community care. The figure below attempts to illustrate the sequence of steps in time that would 

need to be taken by a mental health system in its transition from institutional to community care. 

Mental health policy in southest Europe: the challenge to the profession 

Policy 

unavailable 

Wild guessing 

Service activity is 

not accountable 

Policy 

available 

Operational policy 

and protocols 

made possible 

Services adopt 

structured clinical 

practice 

TIME 

Standards 

available 

Quality assurance 

made possible 

Services adopt 

evidence-based 

management 

Research 

available 

Descriptive studies 

of services made 

possible 

Services transform 

into learning 

organisations 




Several ideas in-built in this figure deserve special mention. First among them is the idea that unless 

there is a clear policy driving at re-construing care as happening not in the isolated world of closed 

wards but in the stimulating social interaction with a well meaning human environment services 

cannot even begin to question their practice of wild-guessing what the needs of patients actually are. 

A second important idea is that policy is worth developing only if the crucial next step – the 

operationalization of it – is undertaken by the services in operation. This implies the introduction of 

structured clinical practice and a demonstration project can be indispensable in carrying this through. 

For the full impact of structured clinical practice to be capitalized computer assisted documentation 

and process statistics is essential. 

A third important idea is that evidence based management can step in if good practice is described 

in terms of standards and if indicators and ways of measuring them are developed and applied. Once 

management begins to proceed from criterion based service evaluation the issues of costs, utility and 

benefits can begin to be adequately addressed. 

And finally the figure suggests that as a result of these developments the mental health system will 

reestablish itself in the community as a learning organization, which comes ever closer to the 

expectations and needs of the populations it serves. 

Severe mental disorder: the big challenge to community care 

Severe mental disorder is 

epitomized by schizophrenia. 

As subject to policy it brings to 

light an amazing complexity of 

services that have to be put in 

place if the implementation of 

the policy would be taken 

seriously. They belong to 

several domains - the medical, 

the psychosocial and the 

social among them (see 

Table). 

Patients with severe mental illness: types of needs legimated 

by enlightened mental health policies 

Medical needs Pyschosocial needs Social needs 

Hospital treatment Daily living skills Supported housing 

Mobile/emergency 

care 

Maintenance 

treatment 

Patient skills Social life 

Social skills Paid work 

In addition needs vary on the 

time dimension. Good practice 

Work role skills 

distinguishes between three 

phases – breakdown, 

stabilization and stability. Each of them elicits a specific combination of needs. With recent 

developments yet another phase in the course of schizophrenia – remission – has been proposed for 

regular consideration . Enlightened policies ‘legitimate’ a number of these phase specific needs and 

introduce the service of case management (or coordination) to reduce inappropriate illness behavior 

such as poor adherence to treatment with its numerous negative consequences.[7] 

Facing as they are a multitude of needs, persons with severe mental disorders and numerous 

vulnerabilities can cope well in their role as patients if indeed seamless care is offered by the system. 

It can easily be grasped that unless the different services synchronize their interests, language and 

operations seamless care can hardly be achieved. It is at this juncture that the biggest risk for mental 

health reforms lay hidden in countries, as deregulated as those of southeast Europe. 




Good governance – a rare commodity 

The Final Report [8] on the Stability Project quoted above touches on the issue of governance when 

clarifying that the nature of the change involved in the implementation of a policy that has made 

mental health reforms its goal is transformational. This suggests that the work tasks under the new 

policy are planned to be so different as to require new competencies from the staff. Since this implies 

a shift in skills and attitudes individuals may feel affected very personally by the new developments. 

A host of different responses can be imagined at this point coming from the staff and facing them 

would require more than managerial skills; it would require leadership as every transformational task 

does. 

The capacity to carry through the reform and at the same time show sensitivity to the emotional 

needs of those whose lives it influences requires good governance. In takes a leader capable to give 

words to the anxieties related to change, able to provide support when words fail, and fit to offer 

interpretations when the social defense in the organization threatens the work task. The complexity 

of the service restructuring is such that the transformation cannot happen by itself, particularly if the 

environment is not supportive. 

The report concludes: "The countries of southeast Europe are emerging from a period of totalitarian 

regimes which varied in their level of harshness and aggression but generally disregarded the need 

for evidence-guided management in health as in every other sector." 

And further: "The lack of good governance following periods of totalitarian regimes has left the region 

with failed institutions, compromised rule of law, and confusion about what constitutes good 

leadership. This sets formidable challenges for achieving reform." 

References 

1. Jenkins R, Tomov T, Puras D, Nanishvili G, Kornetov N, Sherardze M, Surguladze S, Rutz W. 

Mental health reform in Eastern Europe. Eurohealth 2001;7,:15–21. 

2. Jenkins R, McCulloch A, Friedli L, Parker C. Developing a national mental health policy. Maudsley 

Monograph. Andover: Psychology Press, 2002. 

3. Jenkins R. et al. The mental health country profile. International Review of Psychiatry 

2004;16:1–2. 

4. Townsend C et al. The mental health policy template: domains and elements for mental health 

policy formulation. International Review of Psychiatry 2004;16,1–2. 

5. Kickbusch I. Mobilizing Citizens and Communities for Better Health: The Civil Society Context in 

Central and Eastern Europe. A background paper for USAID Conference, Washington,DC, 29–31 

July 2002: “Ten Years of Health Systems Transition in Central and Eastern Europe and Eurasia”. 

Washington DC, 2002. 

6. Walt G. Health Policy: An Introduction to Process and Power. London and New Jersey: Zed 

Books, 1994. 

7. Andreasen N et al. Remission in schizophrenia: proposed criteria and rationale for consensus, 

Submitted to American Journal of Psychiatry. 

8. WHO-Europe. Enhancing Social Cohesion Through Strengthening Community Mental Health 

Services in Southeast Europe. Southeast Europe Mental Health Project, Final Report, 2003. 




Exploring normality 

Stefan Bandol 

Good afternoon, my name is Stefan Bandol and I am here on behalf of The ‘Aripi’ Association. I have 

been a mental health services user for 22 years. I will start my presentation with a short story. 

It takes place during the summer, by the sea, on a beach beneath a high seashore. Four men, fully 

dressed, with woollen hats and winter-coats lay in the sun on two comforters, perspiring heavily. At 

one point, a young man in a bathing suit is getting down to the beach with nothing but a beach towel 

on his shoulder. Seeing the four heavy-dressed men, he starts laughing. Hearing the young man’s 

laughter, the four men raise their heads and look him into his eyes with surprise and contempt. They 

get up and walk menacing towards the young man. Scared, the young man runs away. One of the 

four men cuts in front of him while the other surround him. They fetch him and carry him towards the 

comforters. The young man struggles helplessly. They dress him heavily, put him down on one of the 

comforters, covering him with the other. They put a hat on his head and with great tenderness and 

satisfaction start caressing him fatherly. 

From this short story we can conclude that normality is a matter of majority, given by the numbers. 

I will try now to review sections of normality, of what normality represented in different cultures and 

times. 

Let’s remember the Biblical times, God erasing from the face of the Earth the cities of Sodom and 

Gomorra that were turning into perversity temples. About the same time, homosexuality in the 

Roman Empire and in Ancient Greece was regarded as a natural fact. But from that point on, 

Christianity condemned homosexuality for 1,500 years. Only recently, around the middle of the 20th 

century, homosexuality became accepted again, and starting around 1980 homosexual marriages 

became legally valid in some countries. At the same time, homosexual couples gained the right to 

adopt and raise children. In contrast with the Christian rules, the Japanese culture allows all sexual 

pleasures, ruling them as normal. 

Going back to biblical times, in Hebrew society the unfaithful wife was sentenced to death. 

Nowadays, around the world, efforts are being done to abolish the death penalty. This has been 

already achieved in Europe. 

Mihai Ralea, in ‘Lectures on Aesthetics’, a class he taught at the Lasi University during the 1930s, 

mentioned that during the XVIIth century, in France, at the Royal Court, spitting into a woman’s 

décolleté was considered an act of courtesy. Ioan Timis, a piano teacher during early 20th century, 

describes in his travel notes on Japan one interesting conflict. This highlights the Japanese attitude 

towards nudity, which at that time was regarded and accepted as natural and normal. The British 

ambassador in Japan filed a complaint with the Japanese government on behalf of the European 

community living there. He denounced the Japanese practice of bathing nude in the sea as 

unacceptable. The Japanese government assured the British ambassador that they would make sure 

this practice would stop right away. Clear signs, banning all nude sea bathing, were posted on every 

beach. Few days later, the British ambasador’s wife went by the beach and noticed that although all 

Japanese wore a bathing suit while bathing, they still sunbathed nude. Scandalized by this 

behaviour, she immediately called the police. The policemen however stated that they could do 

nothing about it, as the interdiction was only on bathing nude in the sea. Lying nude in the sun was 




not banned at all. On the same note, let’s remember that no more than 20 years ago, a topless 

woman on a beach would have been an outrage, whereas this is now very common, at least on 

European beaches. 

We judge and define normality based on context. For example, someone in a bathing suit would be 

considered normal by the swimming pool, but not so normal on a nudist beach where he would be 

too dressed up. The same person would also be considered as not normal in a restaurant or an 

office, but for different reasons: there he would be too lightly dressed.. 

A short excerpt from ‘The Citadel’(?) by Antoine de Saint Exupery says: “In that constellation you see 

a swan, whereas someone else could have seen a woman resting. But it is too late, we will never get 

out, we are the prisoners of the invented swan.” 

Normality is a concept, the result of tradition and our own imagination. 

I met a patient in the hospital. He was brought there, among other things, because he was drinking 

his own urine. But somewhere across the world, in Thailand and Malaysia, a good number of people 

are practising urinotherapy. There are special stores dedicated to this and they offer a wide variety of 

samples targeting various maladies. 

Let’s think for a while about the custom entertained by some cultures to offer the host’s wife to the 

guest of honour . We find this highly abnormal, a perversion, whereas they see it as a sign of 

courtesy. 

A woman, mother of three, had her body in continuous transformation for almost three years. This 

alone makes her more irritable, more nervous and prone to depression. Nobody around her will think 

to put her into a mental care facility though. They will try to comfort her by being tolerant and gentle. 

Take the same mood swings and apply them to someone with a history, however brief, of being 

hospitalized in a psychiatric facility, and you will see his family and doctors ready to recommend 

urgent hospitalization, in isolation rooms even, for rather minor reasons. 

There is this strong prejudice that a person with mental disorders is a violent person too. This has 

been disproved by international statistics showing that the percentage of violent behaviour among 

people with mental disorders is not at all higher than that in healthy individuals. 

The tolerance of the Romanian society in general, and of rural society in particular – remember the 

days when each community treated gently, helped morally and materially the village’s crazy ones – 

this tolerance has eroded lately. Mostly because of the high impact of tabloid media. Headlines like 

“Crazy man raped old lady”, “Schizophrenic kills six in cold blood” makes people generalize the 

behaviour of very few to the whole community of people with mental health problems. Equally 

confusing is the message sent out by reporters, some of them quite well known, who put out 

alarming titles like “Hundreds of mentally ill people out on the streets, why are they free?” 

According to these people, should the great painter Van Gogh live nowadays, we would have not 

been able to enjoy his paintings as he would, most likely, become a ‘vegetable’ in some hospital after 

being turned in for cutting his own ear – a gift to the woman he loved so much. Neither would have 

John Nash, Nobel Prize winner, been able to teach his classes at the University after being 

diagnosed with schizophrenia. 

There is too little talk about mental illness and society pays too little attention to these matters. 

Psychiatry is seen as the Cinderella of the medical science. This is even more stunning as about 

25% of the population need the help of psychiatrist at one moment in their life. This segment of the 

medical system is systematically granted the smallest budget and the patients of the psychiatric 




hospitals are treated as the pariah of society. On the other hand, the cure of AIDS , which affects 

only 0.1% of the global population, is widely advertised and granted big budgets. In time, those 

infected by HIV have gained some rights (the right to work, the right to be treated without 

discrimination) that those mentally ill have not, at least yet. In addition, those infected by HIV are not 

forced to take their medication, are not isolated, but are still perfectly able to hurt others by infecting 

them with a deadly virus. 

In many psychiatric hospitals, staff often forget that the patients are there to be treated and cured, 

not to be punished for their behaviour. The practice of applying electrical shocks or over-sedating a 

recalcitrant patient is wide spread, but this type of treatment results too often in transforming the 

patient into a vegetable, a person without a voice of its own. 

Most people regard mental illnesses as something that will always happen to others, never to 

themselves. But we should not forget that events could trigger psychological problems: the death of 

someone close, divorce, career setbacks. Some of these are bound to hit each of us someday. Why 

not prepare to deal with them? In most schools and high schools today there are classes on 

sexuality, on protection from sexually transmitted diseases, from unwanted pregnancies. Why not a 

class on mental health? 

My next example is about the general attitude of the society, of those people with an open mind, 

towards persons with mental health problems. 

Three years ago, on national television, there was a debate on the rights of the patients with mental 

health problems. Among those invited were psychiatrists, hospital directors, psychologists, heads of 

clinics, social workers from various non-governmental organizations working in the mental health 

area, local authorities. The debate was held in the Psychiatry Hospital Balaceanca, but no user or 

ex-user of mental health services was invited to participate. As the discussion went forward, they 

forgot that the topic was patients’ rights and the whole debate became centred on the problems 

doctors need to overcome, the problems social assistants, psychologists and social workers have, 

the implications of a law on mental health. 

In the Romanian Encyclopedic Dictionary, edited by the Romanian Academy in 1966, the definition 

for schizophrenia is: chronic mental disease, characterized by the progressive weakness and 

deterioration of psychic functions through which the patient loses contact with reality, is nonresponding, 

acts bizarre, incoherent, is aggressive, presents affectivity changes, delirium etc; it 

appears mostly in young people, during teenage years, with a continuous-progressive or intermittent 

evolution; schizophrenia is also known as early dementia. At the time of this definition, neurolepticals 

had just been discovered. Their discovery revolutionized the treatment of schizophrenia and other 

psychoses 

The number of mental health services users that get back to living a normal life increased 

significantly after the apparition of the latest generation of neurolepticals. The problem now is no 

longer to cure these patients, but to get over the stigma that society puts on them. 

This change is reflected in the new definition dictionaries give to schizophrenia. In 1997, the DEX 

(the Romanian dictionary edited by the Romanian Academy) defined schizophrenia as a chronic 

mental disease, characterized by the weakness and progressive deterioration of psychic functions 

and by losing contact with reality. Notice that a schizophrenic is no longer called an aggressive 

person and that schizophrenia is no longer associated with early dementia. 

In the end of my lecture I would like to cite Mr Robert Hayword of the Hamlet Trust: “We are in 

hospital to be treated, not to be punished.” 




Promoting social inclusion in an enlarged Europe – international 

cooperation and involving stakeholders in the mental health reform 

process 

Michelle Funk 

It is hard to disagree with the statement that: International cooperation doesn't work well a lot of the 

time. We have seen this in many places of the world. The causes or difficulties are well known. Noone, 

for example, would disagree that often: 

1. There is a lack of cooperation amongst agencies involved. 

2. Funding dictates the nature and type of reform 

3, There is a lack of strategic planning and a long term vision 

4. Reform is not based on the needs of the population but instead narrow mandates and a priori 

assumptions about the needs of the countries concerned. 

I will use the example of international cooperation in the mental health reform of post conflict Bosnia 

Herzegovina (after 1995) to highlight some of these difficulties. The situation was one of great 

physical, psychological and social devastation. All the major international organisations were active 

as well as over 50 NGOs either working directly or indirectly on mental health issues. 

One could argue that as a result of the presence of international organisations some progress was 

made in: 

• Putting mental health on the agenda of health reform and in carrying out some technical 

cooperation activities such as training 

• Increasing the awareness of mental health problems amongst policy makers and professionals 

and the community 

• Providing technical support and training for professionals 

However, it would be wrong to minimise some of the negative consequences of the actions or lack of 

actions resulting from international cooperation 

International agencies became the most powerful agents driving reform because they were funding 

reform. As a result local actors perceived it as a reform from abroad and as a consequence some 

actively or passively resisted reform. 

Those agencies with the most funding were able to drive aspects of the reform even if not 

appropriate to the needs of the population, for example, training conducted by some organisations 

was out of touch with the needs of the professionals in the country. 

Some of the international donors and organisations created temporary parallel mental health care 

services like trauma programmes. Running these programmes to meet the very narrowly defined 

objectives of the organisation concerned, assumed more importance than the successful long term 




implementation of mental health reform. 

Finally, and importantly, international cooperation failed to unite the different professionals in the 

country, and instead, led to considerable resistance. 

In this situation, WHO took important steps to coordinate reform efforts in order to reduce the 

fragmentation, however, the above mentioned influences were difficult to overcome. We can 

conclude that international cooperation for mental health in Bosnia, was successful in identifying 

mental health as an important reform issue, and in stimulating some progressive services, but was 

not successful in terms of uniting reform efforts amongst all stakeholders towards common reform 

goals. The end result was that the reform was limited to what the external donors funded, with no 

realistic national plan to take the reform ahead, and consequently human and financial resources 

were not used optimally for the benefit of the Bosnian population. 

Having said all of this…what can be done? 

International cooperation in mental health should mean developing shared objectives and a common 

agenda across agencies/stakeholders based on the needs and priorities of countries. Simply said, it 

requires forming partnerships with governments, other national stakeholders, and international 

agencies active within the country. It also means developing policy and a strategic plan, to coordinate 

actions of all international and national stakeholders. The plan needs to be driven by the needs of 

the population, evidence and human rights principles. 

We believe that the mental health reform initiated after the ethnic conflict in Kosovo, (from 1999) was 

an example of better international cooperation. Alliances were formed with the local professionals 

and a steering committee for the reform was established very early in the reform process. This 

resulted in the development of a strategic plan which helped to coordinate technical actions, identify 

gaps, and guide donors on where the needs where and how funds could be best utilised. 

All of what I said is simple and logical so the question to answer is why is it so difficult to establish a 

common reform agenda for mental health? Apart from the fact that everyone thinks that they can do 

the job better than anyone else, there are many additional problems which I would like to highlight in 

relation to some important stakeholder groups. 

Starting with Donors: As already mentioned, donor priorities are not necessarily country priorities and 

this can lead to further fragmentation of services and division within the country. Also problematic is 

the sometimes sudden withdrawal of funds from mental health programmes before sustainability has 

been achieved. In these scenarios, many programmes of work collapse. Sometimes more wastage 

and damage can be produced by funding a program and withdrawing prematurely, than not funding it 

at all. Donors need to work within the reform framework established by countries and involve or be 

guided by the range of professionals already working in the country. The common belief that 'I know 

better' does not hold or work 

In relation to Governments: Governments are clearly needed to take the leadership in mental health 

reform. However, it is true but not original to say that there is a lack of commitment from many 

governments in this area of work. Even when commitment exists, it is often from the department 

responsible for mental health and does not have the higher level endorsement required, nor the 

support and involvement of other key ministries in the Government. Consequently, mental health 

policies are not integrated into general health or social policy reform. 

It is not uncommon to find that over a period of years, some national actors have made repeated 

attempts to develop a policy or update a failed policy without success because of the lack of higher 




level commitment. This, over time adds up to a significant waste of valuable human and financial 

resources . 

In relation to professional associations: what we see is that professional interests are sometimes 

more oriented towards ‘conservative solutions’ rather than change to more innovative communityoriented 

systems, particularly when it is perceived as losing power, funds, a working environment or 

a familiar way of working. What is more, power struggles often exist between different professional 

groups. These divisions become more pronounced during periods of reform. What are the 

consequences? Simply stated, many reforms are resisted and actively sabotaged when these 

professional issues are not debated and resolved. Active involvement of all professional groups in 

the reform process is therefore essential 

Mental health users and family groups should be one of the most important stakeholders in mental 

health reform, however, the consumer, and family movement in many countries remains weak; 

sometimes groups push a very narrow agenda, not representative of the needs of the wider group 

they are meant to represent; and sometimes groups, by collaborating with governments, lose their 

independence and hence their voice and influence. The consequences are that: reform will not be 

responsive to the needs of consumers and families and the required shifts to develop client centred 

services, which uphold the human rights and autonomy of people with mental disorders will not be 

respected. 

NGOs: While it is true to say that NGOs fulfill important gaps in service provision in many countries, 

where governments have failed, it is also true to say that many NGOs, fail to respond to the needs of 

the population in the services that they provide . When this happens, the consequences are 

fragmentation, duplication, and detraction from the main mental health issues and needs of the 

countries. 

I have outlined some of the difficulties in establishing alliances and a common agenda for reform, but 

have by no means mentioned all the stakeholders or all problems. However, this is not entirely 

necessary to make some concluding remarks. 

Donors – should be more committed to offering funds based on population needs and evidence for 

interventions and more committed to involving the other important stakeholders 

Governments – Governments should not be tempted by the mere seeking of funds but should 

exercise authority in assessing and accepting what donors are offering 

Professional associations – need to overcome the conflict between their own interests and real 

innovation in treatment, care and service delivery. 

Consumer and family groups – need to represent all rather than some consumers and families and 

maintain their independence and voice 

NGOs – must feed into rather than detract from the agenda based on population needs and 

stakeholder agreement. 

International cooperation is important but needs to be improved, with the active involvement and 

engagement of all stakeholders. 




Vicious circles of social exclusion – attempts to diagnose and cure 

mental health systems in Eastern Europe 

Dainius Puras 

There is a growing concern about the poor state of public mental health in former communist 

countries of Eastern and Central Europe and lack of adequate and effective response from 

governmental agencies in this field. Analysis of mental health scene in some of these countries 

(Azerbaijan, Bulgaria, Georgia, Lithuania, Ukraine) was performed (Tomov T. et al) with the help of 

Country profile – a new instrument (Jenkins R. et al) which has been designed to gather and 

enhance the use of qualitative and quantitative data from relevant country expertise about mental 

health issues. Special emphasis was made on assessment of context, resources, processes and 

outcomes. Analysis revealed several basic obstacles for development and implementation of 

effective mental health policies: 

1. Poor governance and low level of cooperation and trust between: (a) different government 

agencies; and (b) between governments and citizens. 

2. Further medicalisation (after several decades of ideologically based biomedical reductionism in 

soviet psychiatry) of societal aspects of public mental health problems, as a result of transition of 

mental health services to new health insurance schemes based on narrow biomedical paradigm; 

lack of traditions of teamwork, effective psychosocial interventions and modern public health 

approaches. 

3. High level of stigmatisation of vulnerable groups (including mentally ill people, families with social 

problems and troubled youth) among general population. 

4. Lack of modern culture of evaluation (processes are usually emphasized as if they were 

outcomes) and absence of evidence-based mental health policies. 

One of typical examples of attempts to develop modern model of mental health services in Lithuania 

will be now presented, as an example of challenges in the field of mental health in the countries in 

transition. 

At the end of year 2003 an interesting debate was vividly reflected in Lithuanian mass media. The 

Ministry of Health declared that they decided to concentrate all psychiatric beds in Vilnius county 

(capital city and neighbouring territory with around one million inhabitants) in one hospital – a large 

traditional psychiatric hospital (built in 1903) in the suburb in Vilnius. The leadership of Vilnius 

municipality reacted with the statement that this is an outdated approach, and that the municipality 

will support, as it was during several last years, development of community based services, including 

restructuring of services in a small municipal mental hospital in the centre of Vilnius and gradual 

integration of psychiatry into community services and general hospitals. For the first time in the 

official document an idea of closing the largest psychiatric hospital (the fortress of traditional power of 

psychiatry) was presented – just as introduction for political debate. 

This debate reflects a painful process of implementation of new approaches in post-communist 

psychiatry. Some of us – those who had no sympathy and nostalgia for ideology, culture and practice 

of Soviet psychiatry – have been very optimistic in early 1990s. We just thought that with the 

disappearance of iron curtain and with political changes in new democracies traditional custodial 




institutions will lose their power and will be gradually replaced by community based mental health 

services, oriented to the needs of clients. We also thought that it will take just several years to 

change prevailing culture of mental health services – from a culture of dependency and paternalism 

to culture of participation, autonomy and partnership. In Lithuania, for example, the first years of 

changes (1990–1996) resulted in the development of what we call Vilnius model – a network of new 

model services implementing new kinds of services and approaches in different fields – general 

mental health, child and adolescent mental health, psychotherapy, addiction psychiatry, etc. The 

feeling was in the middle of the 1990s that new approaches are already in successful process of 

implementation and that it will take just a few years to replicate innovative models throughout the 

country. But slowly, by the end of last century, another feeling was appearing and becoming stronger 

– that something has gone wrong with reform of mental health services. 

It appeared that new services – those alternative to large segregated institutions – are just surviving 

with the support of international organizations, and they are like exotic exceptions tolerated by the 

official system; while traditional system of psychiatric institutions (hospitals and social care homes) – 

managed not only to survive, but also to strengthen their positions in competition for limited financial 

resources. 

The first reaction of reformers to the unexpected turn of events was emotional – to look for ‘enemies’ 

who are blocking reforms and to find them among bureaucrats in the ministries or powerful directors 

of psychiatric institutions. Later, more mature ways of reaction followed – including attempts to 

analyse the system in a scientific way and to identify main obstacles for mental health reforms in our 

countries, and in the region in general. 

There have been many interesting projects internationally and nationally – supported by the Geneva 

Initiative on Psychiatry, the Open Society Foundation and other organizations – which shed more 

light on the processes going on in post-communist countries. Projects like ANAP (Attitudes and 

Needs in Psychiatry), Assessment of mental health policies and services with the help of Country 

profile instruments – they accumulated a lot of new evidence about context, resources, processes 

and outcomes in the field of mental health services in the countries of Eastern and Central Europe 

and even Central Asia. 

The context in most of these countries appears to be extremely unfavourable for implementation of 

new quality of policy based on ideas of social inclusion, participation and autonomy. Just to become 

for a country a new member of EU – is not enough for basic change in mentality and views of their 

populations – the prevailing attitudes are still very far from those based on modern European values. 

The population of Eastern Europe tend to be very survivalistic (‘the stronger should survive’) and 

intolerant to most vulnerable groups and minorities which are perceived as scapegoats to be blamed 

for difficulties. And, of course, among these scapegoats we find people with mental disabilities and 

addictions – most of the population in Eastern Europe is supporting policy of social exclusion and 

discrimination of those people. We should then better understand in this context – how many 

different groups of ‘hostages’ we find in such situation. Firstly, patients and their relatives are obvious 

hostages, most often being unaware of alternatives to psychiatric hospital and long term care 

institution. Politicians are also hostages because they will lose elections and power if they are too 

open in promoting ideas of tolerance and social inclusion. Psychiatrists are hostages of the traditional 

stigmatised image of psychiatry; they think they might lose power and support of population and 

government if they stop cultivating culture of stigmatising services and start to defend the rights of 

mentally ill people to live and get support in a least restrictive environment. 

And what about resources invested in our mental health systems? Why are governments reluctant to 

fund new community based services? Because – in the absence of evidence-based policies – they, 

under influence of interest groups, follow ‘historical’ principles and keep all existing stigmatised 




services and extremely medicalised approach dominant as earlier. In countries with obvious crisis in 

economy (Caucasus, Central Asia) psychiatric institutions are in very poor shape or even have 

collapsed; but in other countries – like Lithuania – economy has stabilized and started to grow; so we 

see that all traditional psychiatric institutions (including large psychiatric hospitals and social care 

homes) are enthusiastically improving their conditions. But is this an effective solution – to feed the 

system which is not effective and to reinforce vicious circle when services based on principles of 

social exclusion are still having monopoly of state funding, while no resources are left for 

development of community based alternatives? 

One of the new and powerful players in mental health scene in the region appeared to be 

representatives of international pharmaceutical industry. Unfortunately, a very strong influence of the 

international pharmaceutical industry in the region not always has been contributing to progressive 

and transparent development of the field. With all understanding of a need to introduce modern and 

evidence-based methods of biological treatment of mental disorders, two problems should be raised 

and analysed openly in this connection. The first question is whether ethically appropriate methods 

have been used to introduce and promote new psychiatric medications in the region of Eastern and 

Central Europe and what will be impact of this controversial process to the complicated development 

of ethical standards within medical profession in the region. Another problem is connected to a long 

tradition of lack of balance in biopsychosocial paradigm in East European psychiatry. Attempts to fill 

large gaps in the area of psychosocial interventions after many decades of ideologically based 

biological reductionism in soviet psychiatry were unexpectedly blocked at the end of 20th century by 

effective introduction of new generation of psychiatric medications and their reimbursement by new 

health insurance or state budget schemes. Needless to say, that it would be regarded as a big 

achievement – if we do not pay attention to existing context and the cost of this achievement to the 

future of the biopsychosocial paradigm. However, this also meant that once more in the history of 

these countries psychosocial interventions have no chance to be developed and funded, as they 

have lost a battle for limited resources to the supporters of biomedical interventions. To give an 

example of huge discrepancies in the failure to reach balance in biopsychosocial paradigm, in 

Lithuania health insurance spends more money to reimburse each of modern psychotropic 

medications (on average – 2 to 3 million Euro), than to cover all costs of secondary and tertiary level 

child and adolescent psychiatric services throughout the country (1 million Euro). 

Here we come to the question about outcomes. Each system has to have very clear idea – what 

outcomes does it want to reach. In the field of mental health in the region of Eastern Europe we need 

a paradigmatic change in policies and their implementation. Instead of serving as a state system to 

control ‘unpredictable’ people with mental health problems and to isolate them from society – and 

that was the role of psychiatry for many decades – psychiatry and all mental health fields should start 

working in other direction; so that people with mental health problems could be liberated from social 

‘chains’ and empowered to strive for autonomy and responsibility; so that a ‘healthy’ part of society 

(including mental health professionals) could be liberated from outdated prejudices and myths and 

start supporting modern approaches. Vicious circles and negative self-fulfilling prophecies are still 

very strong in our countries – blocking implementation of modern approaches the field of mental 

health. To change the general direction, a critical mass is needed in the slowly emerging civil society 

in the region of Central and Eastern Europe – so that the vicious circle of defending and supporting 

old ineffective approaches could be turned into circle of success – a circle which will support the 

mental health field as a cornerstone of a modern public health approach based on investments in 

social inclusion, participation and empowerment of each citizen of a new Europe. 

Coming back to the debate about the system of mental health services in Vilnius – this debate 

symbolized and reflected both bad news and good news. Bad news was that after 15 years of 

attempts of mental health reforms, even in a country which has become a EU member, the position 

of the Government is usually reflects and supporting powerful tradition of social exclusion, stigma 




and discrimination. This bad news should sound as an alarm bell, also because European Union is 

expected not to be involved in the structural changes of health care services of member countries. 

The good news is about the reaction of the municipal authorities of the city of Vilnius. It means that 

mental health is slowly appearing on political agenda, and that politicians are starting to understand 

that in this field – like in all other important fields – there is a painful choice between options, and that 

they – politicians – will have to make transparent and evidence-based decisions about the future. 

For different historical reasons the health care system has been for many years the most closed field 

for modern participatory decision making in the countries of Eastern Europe. Decisions about how to 

invest in health care (and especially – in mental health care) has always been a privilege and 

monopoly of several experts, closely related to governments and having their own interests to keep 

the system closed from transparency and prevented from all possible changes. There has been no 

tradition of analysing the system in an independent way and of demonstrating how ineffective and 

how wrong – both in economical and ethical understanding – it may become if deprived of public 

participation and critical analysis. 

General society is also changing in our countries. We have to make use of growing civil society – a 

critical mass of citizens who will be interested in growth of positive social capital and sense of 

citizenship, and independent mass media which will disclose and analyse a phenomenon of “double 

reality” in mental health care systems of the region – a situation in which reality of perfect laws and 

other documents cohabit with the grim reality of abuse of civil rights of mentally ill people, especially 

when they are staying in large institutions. 

Meanwhile most stakeholders (including professionals, politicians, general public, users and 

relatives) appear to stay heavily dependent on historical traditions of paternalism and social 

exclusion. Analysis of the mental health scene and surrounding contextual factors reveal that 

attitudes of the general population, politicians and professionals, based on stigma, learned 

helplessness, paternalism and lack of political will, are major obstacles for the development and 

implementation of modern mental health policies. Lack of funding for effective psychosocial 

technologies in the field of mental health appears to be just a negative outcome of prevailing 

attitudes and cynical environment in all levels of health care systems. This conclusion challenges the 

traditional view which emphasizes lack of financial resources in former communist countries as a 

basic obstacle for development of modern mental health services. 

EU enlargement and the fact of growing economies of some countries in the region create new 

opportunities and risks for the process of mental health reforms. The newest experience of some 

countries with growing economies and new opportunities after EU accession indicate that in the 

absence of political will new resources may be invested in a new cycle of the ‘modern social 

exclusion’. In this situation of vicious circle development of effective modern public mental health 

approaches and innovative alternatives to a traditional system of segregated psychiatric institutions is 

often ignored by authorities, and priority in allocation of limited resources may be given again to the 

traditional system based on the principles of dependence, social exclusion and institutionalisation. 

Creative and innovative approaches are needed to break powerful vicious circles with the help of 

reform-oriented internal (growing movement of users and relatives, NGO sector and other forms civil 

society, new generation of professionals, existence of demonstration services) and external 

(international organisations active in mental health and human rights, EU bodies, WHO) forces. 

Permanent open debate has to be introduced and strengthened about the urgent need to change the 

direction of priorities and investments in the field of mental health services in the countries of Eastern 

Europe. 




Is the incorporation of public hospitals the ‘silver bullet’ to address 

overcapacity, managerial bottlenecks and resource constraints in 

the EU? 

Examples from Austria and Estonia 

Armin H Fidler, Reinhard R Haslinger, Maria M Hofmarcher and Toomas Palu 

To generate more efficiency in hospital management, and to deal with an overextended service 

network are critical policy demands in all EU and OECD countries. Advances in medical technology, 

in particular less invasive surgical procedures and effective new drugs have dramatically reduced the 

need for long hospital stays. New incentives, both in management and in recourse allocation, such 

as prospective payment systems (diagnosis related groups, DRGs) have resulted in reduced length 

of stay and overall improved resource use, but have done little to address the problem of 

overcapacity or lingering debts. Pressure to contain costs in the face of limited resources and the 

ever-increasing demand for cutting-edge health care services is forcing countries to look for 

innovative ideas to right-size the hospital sector, which accounts for the lion’s share of health 

expenditures. This is even a bigger problem for the new EU countries of the former socialist bloc that 

have up to two times more hospital capacity, but less than a quarter of the resources than OECD 

countries to support it. Entry into the EU and the need to comply with Maastricht macroeconomic 

cohesion criteria is putting pressure on those new economies. EU accession has also been held 

responsible for increasing salaries of health care personnel to levels closer to the EU, and many 

inputs (medical technology and equipment, pharmaceuticals) have to be obtained at international 

market prices. But any intervention in the hospital sector is politically a very sensitive issue, as health 

is an important concern for consumers and voters. Furthermore, hospitals are typically large 

employers, and are particularly exposed to the lobbying power of the medical profession. This paper 

discusses two country examples, both, from the ‘old’ EU (Austria), and from the ‘new’ EU (Estonia). 

In both countries effective policies have been introduced to provide an improved facilitating 

environment to better manage hospital resources, and at the same time to address the political 

sensitivity of optimizing hospital capacity. Several common features emerge when comparing the two 

country cases which may provide viable lessons for other EU countries and beyond. 

Austria 

In Austria, a federal master plan prepared by the Austrian Health Institute (Österreichisches 

Bundesinstitut für Gesundheitswesen, ÖBIG) and imposed by ministerial decree of the Ministry of 

Health and Women’s Affairs sets the general framework for the provision of medical care in Austria: 

Regional governments are responsible for the provision of health care, including to plan for hospital 

capacities which meet regional needs and adapt to demographic and epidemiological changes. 

Starting in the early 1980s, in several of the nine Austrian states the idea of hospital holdings, 

(originally conceived but never implemented in Northern Germany [1]), was introduced to create a 

contractual relationship between regional governments and hospitals, to stop the further accrual of 

debt and to shield hospitals from political influence within local municipals. 

Most hospitals in ‘old’ EU countries where the health sector is tax-financed are managed by public 

authorities, while hospitals in Social Health Insurance countries like Germany, Belgium or Austria are 

owned by a mix of public, private, not-for-profit and private for-profit providers. By now, hospital 

holdings* have evolved in the majority of the nine Austrian states and are currently responsible for 




the administration of around 30 percent of hospitals and 50 percent of hospital beds.[2] Recent 

research shows that hospitals owned by municipalities and in particular hospitals owned by religious 

orders perform significantly better than state hospitals,[3] indicating that non-profit providers 

organized in holdings have been successful in this new arrangement. 

The first hospital holding (Krankenhaus- Betriebsgesellschaft m.b.H.) was founded in the Austrian 

State of Vorarlberg, in 1979. Hospitals owned and administered by state and municipal governments, 

as well as owned by private owners were integrated into a holding organization established under 

private corporate law. The establishment of the KHBG was facilitated by the fact that most municipal 

and private hospital owners were in deep debt, and were not keen to maintain ownership of their 

local hospital, which was seen more and more as a large liability for the municipality. The holding 

concept was also based on the idea of creating a harmonized decision making process, as well as 

an integrated approach for administrative regulations and hospital capacities. Furthermore, it was 

believed that the operation of regional hospitals as networks as opposed to individual entities would 

create efficiencies and economies of scale. In addition, it would permit over time the ‘right-sizing’ of 

needed infrastructure, specialties and equipment, based on the Austrian hospital master plan. The 

pilot project turned out to be politically and economically successful, as acknowledged by Austria’s 

supreme auditing authority, the Court of Accounts in 1992. Over the past decade this concept 

became a viable and successful model for transferring hospitals ownership from local governments 

and private operators (largely religious orders) into an independent holding organization. Since then, 

seven other Austrian states have established similar holding organizations for similar purposes.[1] 

The political goal of establishing holdings was to extract the hospitals from the local governments 

and public administrations and to create a contractual relationship between the hospitals as the 

provider of health care and municipal, state (regional) and the federal governments. This 

arrangement, created for the purpose of hospital networking is similar to private business practice, 

where resources, investments in personnel, operating costs, budget and goals are planned according 

to strategic business goals, as opposed to political ‘fiat’. Independence from local politics was 

ultimately necessary in order to react quickly and adequately to a fast changing environment. 

Reinforced by technical progress, labor demand has been growing vigorously in the 1990s.[4] 

Furthermore, we believe that the implementation of case-based hospital financing in 1997** 

(Leistungsorientierte Krankenanstaltenfinanzierung, LKF – Austrian DRGs) has advanced the need 

for more managerial flexibility, as specialization has been increasing over time.[5] Before the creation 

of hospital holdings, the decision-making process had to go through the local government, involving 

the local bureaucracy and politicians which at times lead to politically motivated, delayed or 

technically inferior decisions. With the creation of statewide hospital networks within a new ownership 

and management structure the basic framework for more operational flexibility, improved decisionmaking 

processes, clear accountability and transparent financial management has been achieved. 

The holdings are established according to Austrian corporate law and feature just like any other 

business corporation a board of directors, which oversees management and represents the owner(s). 

All assets of the hospitals such as medical equipment, facilities and infrastructure were transferred 

into this new corporation .[7] The creation of this model moves hospitals out of the domain of public 

* The creation of hospital holdings in Austria corresponds to formal privatization. As opposed to material 

privatization, formally privatized hospitals include organizations, which are still owned by public authorities but 

run by a private entities.[6] 

** Currently 874 DRGs are being reimbursed, including intensive care service delivery and psychiatric care. 45% 

of those are reimbursed on a fee-for-service basis (Medinische Einzelleistungen) and 55% on DRGs. 




administration and creates a contractual relationship between the former owners (local governments) 

and the regional provider of health care services, the regional hospital network holding.[8] The new 

arrangement introduced a new corporate culture calling for a dynamic and efficient service-based 

business. Yet the goal of the holdings is not to realize profits as they are founded as non-for-profit 

entities with a binding mandate to provide health care for the target population. If the holdings 

focused on maximizing profits, it would be seen as counter to the public mandate of providing 

comprehensive health care at a regional basis.[9] This original founding purpose is emphasized by 

the fact that in some Austrian States (such as Upper Austria) the Government assumes the residual 

liability for its regional hospital holding. 

The KHBG is the largest provider of health care in the Austrian State of Vorarlberg and has a market 

share of 84%, serving around 450,000 people in a geographical area of around 2,600 km 2 . The 

KHBG is legally owned by the Government of Vorarlberg (96%) and the towns (and former hospital 

owners) of Feldkirch, Bludenz, Bregenz and Hohenems (each of them 1%). It manages five public 

hospitals with around 1,700 hospital beds at eight different locations. With a total of about 3100 

employees, it is the largest employer in Vorarlberg.[10] The various centralized services such as IT 

services are based in the Landeskrankenhaus (state hospital) LKH Feldkirch, which is Vorarlberg’s 

largest hospital (677 hospital beds, 1,500 employees) and the state’s only tertiary facility. Focusing 

on its core competencies, the KHBG encourages the outsourcing of non-premium services such as 

facility management, laundry, and consumer services such as restaurants, banking, kiosks, 

maintenance services (medical equipment and general maintenance) and partly IT services. In 

addition, there are plans to convert central sterilization services into a public- private partnership 

project.[1] Three hospital sites were closed over a ten-year time period, their beds eliminated and 

their technical capacity merged into more specialized sites. Compared to stand-alone municipal 

hospitals, resources can be managed in a more efficient way, leading to synergies in terms of risksharing 

of large investments in medical equipments. In addition, individual hospitals in the same 

geographical area specialize in certain areas to avoid redundancy and overlap, resulting in reduced 

overall costs.[11] 

In Upper Austria with the size of around 12,000 km 2 and a population of around 1.4 million (2001) 

among Austria’s largest states, the newly established holding took over 12 public hospitals until then 

owned by the State Government. Established in 2002 as a holding corporation (Aktiengesellschaft) 

the GESPAG (Oberösterreichische Gesundheits- und Spitals-AG) has a market share of around 50% 

and is with around 8,500 employees Upper Austria’s largest health care provider. It now runs 12 

hospitals at 16 different locations; 9 of those are general public hospitals and three are mono-profile, 

specialized hospitals. 

The creation of the holding led to several changes in the structure and capacity of the Upper Austrian 

hospital landscape. Mirroring the experience in other states, some hospitals of the network will be 

closed and some beds transferred to more appropriate sites, resulting in improved efficiency and 

substantial cost reduction, especially of management costs. In 2005, two more hospitals, will merge 

into one single organization and contribute to the network specialized internal and psychosomatic 

medicine services.[9] 

The holding concept has shown to lead to more flexibility in staffing and human resources 

management. However, employment policies are some of the most sensitive concerns in the 

transformation from public to privately administered entities. Generally more than 60% of total 

hospital costs are labor costs. In the course of modernizing public employment, in many Austrian 

states the ancient civil servant status which included special rights with respects to flexible working 

hours and protection from lay-offs has been abolished and replaced by modern employment 

regulations. Newly hired hospital employees are contracted through new state laws whose 

employment laws are similar to those of the private law. The holdings are established by business 




law and have very few employees of their own, in most cases only its management board. The 

majority of employees in the network hospitals, such as nurses, doctors, administrative personnel 

(and all newly hired staff) are formally employed by the government but are contractually transferred 

to the holding by means of a special law. This arrangement gives the holding company the full rights 

of an employer (hiring, firing etc.) and assures that there is only one type of employment contract 

and compensation scheme based on the employment law of the respective Austrian state. Thus 

personnel issues are at arms length from the government. As a result, selection and hiring 

procedures are much shorter and more flexible, as they are processed directly by the holding and the 

time consuming selection procedures that had to be sanctioned by local government can now be 

avoided. Hospital directors can independently select doctors, nurses and other staff. Managerial 

selection needs to be cleared by the holding management.[7] 

In summary, the establishment of hospital holdings in Austria achieved over the past decade its 

original goals. Hospital networks in most states of Austria were largely successful in realizing 

economies of scale for purchasing and administration, for introducing more flexibility in human 

resources management, for introducing a contractual relationship between providers and the state as 

the ultimate steward of health care, and for rightsizing installed capacity in line with an established 

master plan. These benefits were achieved in a gradual manner, making it politically and socially 

acceptable in the Austrian cultural and political context, where rapid and aggressive privatizations, or 

massive hospital closings, including firing of staff would have been politically unpalatable. 

Estonia 

Entering the transitional period from socialist economy to market economy in 1991, Estonia had 

significant overcapacity of the hospital bed stock. For 1.4 million population, Estonia had 120 

hospitals with more than 17,000 beds. By 1996, the number of hospitals had declined to 78, mainly 

through administrative closures of small rural hospitals that failed the licensing requirements. To 

facilitate further efficiency and quality gains from economies of scale, the Government developed a 

more comprehensive and proactive approach that comprised the following components: (a) develop 

a long term hospital masterplan; (b) give hospitals appropriate financial incentives to reward 

efficiency; and, (c) give hospitals a legal status and organization that would be conducive for making 

cost-effective management decisions. 

In 1999, Estonia developed a masterplan for hospital services until 2015. The criteria used for 

planning hospital capacity were sufficient population pools to support necessary service volume for 

quality and efficiency; direction of development of medical technology; demographic and 

epidemiological projections; and a requirement that a hospital can not be further away than 60 

minutes travel time by car (70 km). This masterplanning exercise resulted in a proposed future 

hospital configuration of 13 

hospitals by 2015 (instead of 78 

in 1999) that would comprise 

two university-level teaching 

hospitals, four multi-profile subregional 

central hospitals and 

seven county hospitals (see 

Table 1). The Government 

endorsed the masterplan in 

2000. 

The Estonian Health Insurance 

Fund that is established under a 

separate law and governed by a 

Table 1 

Estonia hospital masterplan projections for hospital capacity 

Number of 

hospitals 

Number of 

hospital beds 

1993 1999 2001 2015 

115 78 67 13 

14,337 10,358 9,160 3,500 

ALOS 15.4 9.9 8.7 4.0 




15-member board representing stakeholders from Government, corporate business sector and civil 

society, is a monopsonistic public purchaser. It has four territorial branches, each managing a 

population based budget and purchasing services for their respective populations. Hospital services 

are financed through cost-and-volume contracts based on estimated number of cases in different 

hospital departments and estimated cost per case. In 2004, Estonia began a transition to DRG-based 

hospital contracts using the Nordic DRG-model. There is a clear separation of health care financing 

and health care provision. 

The 2001 Health Care Services Organization Act requires that all public hospitals in Estonia be 

incorporated under private law as foundations (trusts) or joint-stock companies. The transition period 

expired in 2003, and in 2004 all public hospitals are being run as companies. Supervisory boards 

govern the newly established public hospital companies with members appointed by the owners 

(joint-stock company model) or founders (foundation model). The owners or founders are central 

government, local governments or a combination thereof. The boards approve strategic development 

plans; decide about the size of the executive management team, appoint it’s members and decide 

their compensation; approve structure of organization; approve and monitor budgets; approve annual 

performance and audit reports; decide about any sale of immovable assets and about borrowing 

above pre-defined thresholds. The board member and executive team members have term contracts, 

typically for five years. Independent auditors audit accounts of these public hospital companies. One 

remarkable change in management practices that occurred early on in the newly incorporated public 

hospitals was the emphasis on financial management and business administration expertise: not only 

did the hospitals recruit high level chief financial officers from private sector, in several large hospitals 

also the chief executive officers were hired from private sector other than health care. This was quite 

a difference from the former practice where medical doctors ran the hospitals and financial matters 

were handled on the chief accountant level. 

The establishment of new companies has been the critical instrument for consolidation in the hospital 

sector. In many cases, the new companies were established by merging a number of freestanding 

hospitals. The first public hospital company, the Tartu University Hospital Trust* was established in 

1999 on the basis of nine hospitals. The founders of the trust were the central government, the 

university and the Tartu municipal government. Central government and the university both appoint 

three members and the municipality two members of the Board of Directors. In the course of the first 

two years of existence, the executive team developed a strategic vision, mission statement and a 

new corporate visual image for the hospital; defined clients, interest groups and partners; put in place 

new management instruments (financial planning and reporting, central procurement regulations, 

incentive regimes for staff, marketing) and management information systems; established public 

relations and inner communication systems; streamlined administration and support services. This 

was followed by the reorganization of clinical services that allowed the hospital management to 

vacate and sell four buildings. Employment terms were re-arranged so that all physicians have now 

term contracts. After the third year of existence, the hospital was already able to demonstrate results 

from improved management: savings from administration, streamlining of support services and 

optimizing infrastructure went to improve the pay of the clinical staff – minimum salary for nurses and 

physicians almost doubled, average pay increased by about 30%; the hospital was able to launch 

procurement of modern medical technology (MRI, CT, gamma scanner, ultrasound, etc.) and 

improvement of buildings. Improved financial management also allowed employing long term 

financing instruments that were not accessible before. In 2002, the Tartu University Hospital Trust 

employed about 2,900 staff and provided 489,000 outpatient visits; 37,000 inpatient admissions and 

about 9,000 day surgery procedures. 

* Tartu is the an university town of 100,000 people in south of Estonia with the country’s only medical school. 

The hospital is also a tertiary care provider for about 600,000 population. 




In 2001, the 17 public hospitals serving about 500,000 population in and around capital city of Tallinn 

were consolidated into 4 hospital organizations – two hospital trusts and two hospital joint-stock 

companies. For example, a North-Estonia Regional Hospital Trust (NERH) was established on the 

basis of: a tertiary level emergency care hospital, a cancer specialty hospital, a pulmonary specialty 

hospital, a dermatology specialty hospital, a psychiatric specialty hospital, center for occupational 

diseases, a general county hospital; and an ambulatory family counseling center. In 2003, the new 

hospital organization comprised almost 3,000 staff and 1,500 beds in seven sites. The NERH is 

going through similar reorganization process as the Tartu University Hospital Trust and by 2004 was 

able to vacate the pulmonary hospital site through re-organization of services. 

By the end of 2002, the number of hospitals had declined to 50 from 78 in 1999. The consolidation 

process continued in 2003 and although the official statistics are not available yet, the number of 

hospitals is likely to come out around 45 by the end of 2003. 

Discussion and summary 

Both, Austria and Estonia, can be considered success stories when it comes to putting the hospital 

sector on a more fiscally sustainable footing. Both countries developed hospital master plans that 

provide the framework for the organization of hospital services. Both countries have separated health 

services financing from provision, introduced contracting and put in place financial incentives for 

hospitals that reward efficient service provision, maximizing the potential of prospective payment 

systems. Both countries have essentially corporatized public hospitals by re-establishing them under 

private law, but preserving public ownership. This concept has provided a framework where public 

hospitals are run as business entities and management has responsibilities and decision rights to 

ensure good clinical practice and efficient financial performance. It has put hospital management 

issues at arms lengths from politics. Both countries have used hospital incorporation as an 

instrument to realize efficiency gains in line with the agreed master plan. Surprisingly, the 

management processes inside the newly established hospital organizations that step-by-step have 

led to optimization of staffing and infrastructure, have received relatively little public (or international) 

attention. 

As an organizational form, Austria has opted for a ‘holding company’ type where certain functions of 

administration and purchasing are pooled in the organization, but the individual hospitals belonging 

to the organization still enjoy some level of independence. Estonia opted for a more hierarchical type 

of company model where decisions are more centralized. One of the reasons why, for example, the 

“holding company” model has not been used in Estonia, has been a lack of experience with this type 

of organizations. Estonia’s more hierarchical structure has allowed for the management not only to 

realize efficiency gains from centralized administration, purchasing and outsourcing support services, 

but also savings from closing down entire hospital sites which were previously independent. One of 

the most important issues that has emerged through the hospital management reforms in Estonia, is 

the need to ensure effective oversight of the independent public hospitals in a country that is only 

beginning to accumulate experience in corporate governance in a market economy. 

Nevertheless, a number of other countries in Central and Eastern Europe (the new EU) and some 

countries of the former Soviet Union (FSU) are considering introducing hospital autonomy, networks 

and hospital mergers as a policy measure to optimize performance in the hospital sector. In 2004, 

Armenia began to implement a hospital services masterplan in the capital city of Yerevan where a 

population of 1.2 million has been historically served by 43 hospitals. The basic elements of the 

reform are similar to the one featured in Austria and Estonia: A rational masterplan was developed; 

financing and provision of care were separated; and public hospitals have been incorporated under 

corporate law. The first step was to merge 37 public hospitals and policlinics into ten newly 

incorporated public hospital joint-stock companies. Armenia would be the first country where the 




successful concept of hospital corporatization would be put to a test in a poor, non-EU country with 

an extremely resource constrained health sector. 

References 

1. Maikisch H. Personal Communication, June 8, 2004 

2. Hofmarcher MM, Riedel M. Health expenditure in the EU: no public sector without the private one. 

Focus: the Austrian hospital sector – one system or nine? Health System Watch 2001;1. 

http://www.ihs.ac.at/departments/fin/HealthEcon/watch/hsw01_1e.pdf: [acessed June 20, 2004]. 

3. Hofmarcher MM, Weichselbaumer M. The impact of Austria’s EU-accession on the health sector 

labor market. Wirtschaftspolitische Blätter 1/2004;1. 

4. Hofmarcher MM, Kraus M, Riedel M. Finanzierungsmodus der Fondskrankenanstalten nach 

Bundesländern. Vienna: Institute for Advanced Studies, IHS HealthEcon, 2004 (mimeo). 

5. Hofmarcher MM, Lietz Ch, Schnabl A, Weichselbauer M. Effizienzanalyse im intramuralen Bereich, 

Study commissioned by the Federal Ministry of Social Affairs and Generation, Vienna, July 2003. 

6. Strehl R. Privatisierungswelle im deutschen Krankenhauswesen? In: Arnold M, Klauber J, 

Schnellschmidt H. (Hrsg.): Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im Wettbewerb, 

2003, S. 113–29) 

7. Öchsner S. Personal Communication, June 15, 2004. 

8. Theurl E. Personal Communication, June 15, 2004. 

9. Geck H, Koblmüller M. Personal Communication, June 8, 2004. 

10. KHBG Geschäftsbericht. Annual Report, 2002. 

11. Kastl J. Personal Communication, June 14, 2004. 

References not indicated in text 

Birner H. Personal Communication, June 8, 2004. 

Busse R, Wörz M. Marktorientierung von Krankenhaeusern: Ein Überblick über Reformen im 

europischen Vergleich, in: Arnold M, Klauber J, H. (Hrsg.): Krankenhaus-Report 2002, Schwerpunkt: 

Krankenhaus im Wettbewerb, 2003, S. 21–30. 

Gespag Geschäftsbericht. Annual Report, 2002. 

Klauber J, Schnellschmidt H. (Hrsg.): Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im 

Wettbewerb, 2003, S. 113–129. 

Palu T, Kadakmaa R. Estonian Hospital Sector in Transition. Eurohealth 2000;7(3)special issue. 

Rechnungshofbericht (Report of Central Auditing Authority), Vienna, 1992. 

Ministry of Social Affairs of Estonia. Estonia Hospital Masterplan 2015. Technical Report. Ministry of 

Social Affairs of Estonia web page: http://www.sm.ee/est/HtmlPages/HMP2015/$file/HMP2015.pdf 




Ministry of Social Affairs. Estonian Health Statistics 2000–2002. Ministry of Social Affairs, 2003. 

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World Bank consultant report. 2003. 




Summary 

David McDaid 

The latest estimates of the burden of disease from the World Health Organization indicate that all 

mental health problems account for more than 20% of the total burden of disease in Europe. (World 

Health Organization 2004) Globally mental health disorders account for five of the top 10 contributors 

to disease burden. These estimates are however conservative, they do not take account of the 

higher level of physical co-morbidity in people with mental health problems compared to the general 

population. There can also be significant health impacts on other family members, especially if they 

having to act as caregivers. 

What makes mental health almost unique compared to other health problems is the need to 

encompass so many other different issues and outcomes. Poor mental health can impact on all 

aspects of life: limiting education and employment opportunities, causing problems within families, 

leading to difficulties with housing and increasing contacts with the criminal justice system. There 

may also be inter-generational adverse consequences, with the children of people with mental health 

problems potentially suffering from neglect, while disrupted schooling could curtail their long term 

opportunities. The many consequences of mental health disorders mean that that the economic 

burden is also substantial, conservatively estimated to be at least 4% of GNP in Europe. The majority 

of these costs are incurred outside the health care system, with the greatest costs being due to lost 

employment. 

Legislation and human rights 

Of paramount importance however is the continuing need to address the human rights violations, 

stigma and discrimination and consequent social exclusion that set mental health apart from most 

other health concerns. In some parts of central and eastern Europe fundamental human rights 

abuses continue to be seen in the psychiatric institutions and social care homes (internats) that 

remain the mainstay of mental health systems. Individuals may still be kept in ‘caged beds’ in some 

institutions while electro convulsive therapy might be administered to individuals without anaesthesia 

or muscle relaxants. Individuals in internats historically are rarely discharged back to the community, 

they remain there for life. 

A fundamental challenge faced all over Europe, but most acutely in parts of central and eastern 

Europe, is to ensure that the overarching ethos becomes one of providing a community rather than a 

institutionally orientated approach to the provision of services and support, clearing empowering 

service users to play an active role. Yet in nearly all European countries, even where community care 

facilities are available, people with mental disorders continue to be excluded from many aspects of 

community life. Furthermore while the very small (and usually wildly exaggerated) risk of violence by 

people with mental health problems is often mentioned, it is often overlooked that people with mental 

health problems are themselves more vulnerable to violent assault compared with the general 

population. 

Legislation here more than in any other area of health has a crucial role. Human rights instruments 

from the UN, the Council of Europe, the EU and others are intended to protect people with mental 

health problems. The principles elaborated in these instruments need to underpin the development of 

national legislation. Legislation, however, can only protect the human rights of people with mental 

disorders, and promote social inclusion if effectively monitored with adequate sanctions to effect 




change. 

Legislation can also be a key tool for implementing mental health policy and addressing service 

reform issues, setting the framework for the assessment and provision of mental health services, and 

in particular, the integration of mental health into general health and community services. Within this 

context the principle of the least restrictive alternative for admission and treatment should be applied. 

Compulsory treatment or detention should be a last resort. The need to have independent periodic 

reviews of all people admitted or treated involuntarily should also be clearly specified in legislation. 

Legislation can also be used to encourage the development of new approaches to involving users, 

for instance promoting the use of direct payments where feasible, empowering individuals to 

purchase appropriate services of their own choice. Legislation must also move beyond health and 

social care, and protect against discrimination and encourage implementation of mental health 

promoting interventions in other sectors. 

Promoting social inclusion through tackling stigma is recognised to be a long-term task, but it is 

important to begin this early through interventions in schools to raise awareness of mental health, 

and further augmented across the lifecycle including through constructive engagement with the 

media. While it is perhaps too much to hope that the media will not sensationalise stories, 

engagement can make a difference. This can best be highlighted by recent headlines in a leading UK 

tabloid concerning the mental health of the former boxer Frank Bruno. Public outrage and complaints 

about the derogatory headline used, led the newspaper to replace the headline in later editions with 

one that was much more sympathetic and understanding. Empowering service users in the process 

of developing and delivering services is critical, this requires real input not only through participation 

in high level committees but also on the ground holding local services to account. Again legislation 

might be one approach to ensuring that service users have such a role. 

Developing and strengthening mental health policy 

Developing and strengthening policy for mental health across Europe remains a key concern, with a 

number of countries continuing to have no policy and action plan in place, and who may continue to 

regard mental health as a low priority. A pre-requisite to policy development should be to undertake a 

systematic appraisal of existing structures, funding mechanisms, entitlements and access to 

services. Consultation with all stakeholders should be integral part of this process, with final 

recommendations and plans tailored to take account of culture, resources and structures. This is vital 

to the development of approaches and solutions that can actually be implemented within a local 

context. In some countries for instance the rapid economic transition in society has led to the 

disintegration of general social supports and structures. Another challenge may be that the primary 

care sector may be underdeveloped and have had little to do with the recognition and management 

of mental health problems. There may also be little experience, and indeed distrust of inter-sectoral 

working. Moreover the very concept of the civil society taken for granted in many countries may be 

virtually non existent, with limited local NGO development in the field of mental health. Initiatives 

such as the Open Society Mental Health Initiative in central and eastern Europe are though working 

to build capacity, provide technical assistance and training in order to help attain a goal of 

sustainable community based alternatives to institutions. It is also important to recognise that policy 

can not develop in a vacuum, there have to be concrete examples of community based services and 

policies to help facilitate systematic change. NGOs can help build up from the ‘grass roots’ examples 

of such services, involving both people with mental health disorders and local communities more 

generally. 

Fair resourcing for mental health 

Resources across most of Europe for mental health are much lower than are justified on grounds of 




disability burden, fairness or efficiency. While the contribution to total disease burden is 

approximately 20%, evidence from the Mental Health Economics European Network indicates that 

only four countries in Europe report spending more than 10% of their health budget on mental health, 

with the lowest reported levels of under 2% in many newly independent states in the east of the 

region. (MHEEN 2004) The reasons for the low level of funding are numerous and include an overall 

low level of GDP attributed to health in some countries, coupled with financial crises in health 

systems. Governments may be unwilling to prioritise mental health while the levels of utilisation in 

existing services may actually be low because of the high level of stigma associated with being 

identified as having a mental health problem. 

The returns from investment in mental health can be very high compared to many other health issues 

because of the many negative external impacts of mental health that may be avoided. There is much 

evidence indicating that not only are effective interventions available but that these are also highly 

cost effective. While money is not everything, it is important in setting up cost effective health 

promotion, treatment and rehabilitation strategies. Major reforms are likely to need protected funding. 

It is important that as services shift from institutions to the community that safeguards are put in 

place to ensure that funds are also fully transferred, otherwise there may be a temptation to use 

system reform as a vehicle for cost reduction, especially when the economic climate is tough. It 

should also be recognised that during this transitional period funding will be required both for the new 

community services as well as the institutions that are being phased out. 

A focus on mental health promotion and innovation in service delivery 

When thinking of services there is a need also to move away from focusing solely on mental illness 

towards promoting good mental health and well-being. There is a small but growing evidence base 

on the effectiveness and cost effectiveness of mental health promoting interventions, especially in 

school and the workplace. This again also emphasises the need to work with a range of stakeholders 

including teachers, social workers, employers associations and trade unions. Coordination of access 

to services across sectors can be improved in all parts of Europe and one approach may be the 

further development of the ‘one stop shop’ model where one agency is responsible for working with 

service users to help them to purchase services or gain access to entitlements not just in the health 

and social care sectors, but elsewhere e.g. providing help with housing and obtaining social security 

benefits. ‘Direct payments’ to service users, allowing individuals to purchase services directly that 

best meet their perceived needs may be another possibility, although it should be stressed that this 

still requires careful evaluation. 

Workforce challenges 

The needs of the mental health workforce should not be overlooked when considering services, as a 

well trained workforce is a prerequisite for quality services. This should not be restricted to training in 

mental health related skills alone, there is also evidence of a deficit in managerial skills and 

organisational behaviours in systems, which left unchecked, will continue to hamper reform and the 

coordination of multi agency, multi sector services. In former totalitarian countries governance 

structures may be poor and there may be little culture of using evidence to support the decision 

making process. To put it bluntly administrators in some systems, particularly those when innovation 

and change were frowned upon, may be extremely reluctant to countenance radical change. They 

may also be worried about losing their status and authority if for instance institutions are shut down 

and replaced by community services. Employees in institutions will also be worried about their own 

future job prospects should an institution close. 

International cooperation 




Much can be done at the international level to build on existing cooperation between agencies, 

donors and civil society, and think more about how to ensure the long-term sustainability of initiatives 

to promote social inclusion beyond initial funding streams. This means concentrating efforts not on 

highly visible but ultimately low priority projects, but instead on those projects that seek to engage 

with the most vulnerable groups in society, who may be well out of sight and the public conscience. 

Early on projects should be helped develop a long term strategy for sustainability. 

International cooperation in these efforts needs to be promoted not just across agencies but also 

within agencies, including the different directorates of the Commission such as employment and 

social affairs. This builds on Commissioner David Byrne’s recent observation that ‘every 

commissioner should be a commissioner for health.’Social exclusion can manifest itself in the 

workplace while poor mental health can have substantial adverse macroeconomic consequences. 

This is of particular importance given the role of the EU in both promoting a single market and also 

ensuring a high level of health for all. Another issue at EU level that thus received little attention has 

been the issue of the cross border mobility of European citizens with mental health problems. Given 

that many mental health problems are characterised by acute episodes that can occur in any location 

and at any time, this is clearly something that needs to be addressed more fully. There have though 

been many positive developments at the international level in recent years, which have helped raise 

awareness of the importance of addressing the challenge of mental health, culminating in the 

intergovernmental conference on mental health to be held in Helsinki in January 2005, under the 

auspices of the WHO, EU, Council of Europe and the Government of Finland. Nevertheless more 

can be done to raise the profile of mental health within public health, while always recognising that 

solutions may have to be different because of the multi-faceted nature of mental health. 

There is no public health without public mental health 

More can be done to encourage greater cooperation between different public health NGOs and 

agencies in Europe. Health promoting strategies to promote physical health also help to promote 

good mental wellbeing. Similarly those working in the area of mental health promotion can do more 

to emphasise the benefits for physical health. The burden associated with mental health disorders is 

substantial but in terms of health and socioeconomic impact, but effective interventions are available 

not only to treat but also to prevent the onset of many problems. Never has the case been stronger 

for stating that there is no health without mental health, and therefore no public health without public 

mental health. 

References 

World Health Organization. The World Health Report 2004. Geneva: World Health Organization, 

2004. 

Mental Health Economics European Network. Final report to the European Commission. November 

2004. 



Forum AIII 

Pharmaceutical policy in 

the enlarged Europe 




Part I: Pricing, reimbursement and innovation 

��Hugo Hurts Priority medicines and pharmaceutical 213 

policy under the Dutch EU Presidency 

��Paul Weissneberg Text not available 

��Imre Holló Text not available 

��Brian Ager Text not available 

��Kees de Joncheere Affordability of pharmaceuticals in the 218 

enlarged Europe (abstract) 


��Ingrid Rosian-Schikuta Introduction and overview 219 

��Paul Bundgaard The pharmacists’ perspective 220 

��Rui Santos Ivo The public health perspective 223 

��Greg Perry The availability of generic medicines in 226 

the European Union 

��Angelika Kiewel The insurance perspective 229 

Part II: Health technology assessment (HTA) 

��Finn Børlum Kristensen Overview on HTA under a global dimension 230 

impact on policy and practice and scope for 

transnational cooperation 

��Iain Gillespie HTA – does it encourage or hinder innovation? (abstract) 

233 

��Chris Henshall HTA from a political and ethical perspective 233 

Page 





��László Gulácsi National HTA strategies: the case of Hungary 234 

(abstract) 

��Alric Rüther HTA in Germany (abstract) 236 

��Antoinette Wenk Lang Text not available 

��Clare McGrath Pharmaceutical industry 237 

��Monica Burchell Patient involvement in NICE technology appraisals 239 

��Josef Probst Social insurance 241 

��Sabine Vogler Summary 243 




Priority medicines and pharmaceutical policy under the Dutch EU 

Presidency 

Hugo Hurts 

The motto of our conference is indeed well-chosen: global health challenges for the 21st century. 

These very challenges play a role in our pharmaceutical policy. 

Dutch Presidency 

The challenges are two-fold: public health challenges and cost containment challenges. I will go into 

both, but my emphasis in this forum will be on public health. 

I put G10 at the bottom of the page, because in a way this IS the bottom line: a serious set of 

proposals to get both public health and competitiveness on the agenda. I am aware of the fact that 

competitiveness is not the same as cost containment. Yet, that IS an important item for us. 

Research policy is another important item, I will come back to that. I noted the intense interest from 

the new commissioners in this topic. 

Public health challenges 

Let me first look at the public health challenges. We view pharmaceutical innovation in the first place 

from a public health perspective. That is indeed challenging! We note that there are two 

‘pharmaceutical gaps’: 

• No pharmaceutical treatment exists 

• No adequate treatment exists 

No treatment 

Sometimes there is no treatment available because it is just too difficult to find the right remedy. I 

label that ‘lack of scientific knowledge’. I give you Alzheimers disease as an example, but there are 

more: ostheoarthritis, certain cancers, depression in the elderly and children, and acute stroke. 

In other cases, there is what could be labelled a ‘market failure’. There are apparently not sufficient 

incentives for industry to produce a certain drug. Malaria and TB are cases in point. 

Sometimes both factors play a role: orphan diseases and so-called ‘neglected diseases’, a term that 

refers to certain diseases in tropical countries. But some lung diseases, caused by smoking and liver 

diseases caused by alcohol are in this category. 

No adequate treatment 

Sometimes there is a lack of efficacy: in plain English: the medicine does not work well enough or 

has important side effects. For example, some lung diseases (in medical language: COPD, Chronic 

Obstructive Pulmonary Disease). 




Sometimes there seem to be safety problems. For example, medicines for depression in children. 

Delivery mechanisms are also an important category. To give you an example of this: pills that are 

too large to swallow for a baby or an elderly person. Or the situation that in serious illnesses some 

pills have to be taken three times daily, others twice daily and others four times. Try to manage that! 

Key areas 

Briefly our attention is focused on three areas: 

Not only diseases have our attention. Also the patient groups that are most concerned when it comes 

to availability of medicines. I mention children, and we welcome last week’s Commission initiative to 

launch a new proposal for paediatrics. 

We think the elderly deserve more attention as well. They are an ever increasing group in our society 

and their pharmaceutical problems are not always well understood or well taken care of. We also 

include pregnant and lactating women – in the context of pharmaceutical clinical trials and the R&D 

of pharmaceuticals this is a group that needs special attention. 

We all know the patient information leaflet when your doctor prescribes you medication: if you are a 

child, consult your doctor. If you are pregnant, consult your doctor. In other words, we do not know, 

or at least have not tested, whether this medication is really good for you. 

That is one of the reasons that we need a more public health driven R&D agenda. 

And finally, I have mentioned delivery mechanisms already. 

What does the Dutch presidency want? 

Now given this situation, what does the Dutch presidency want to establish? 

We would like a public health based R&D agenda. That is an agenda that takes principles of equity, 

evidence and efficiency into consideration. 

We would like all major stakeholders to support such an agenda: political stakeholders, stakeholders 

from civil society, and also industry stakeholders and academic research centres. 

When I put ‘attention for barriers to innovation’ on the slide, this is to stress the fact that we have not 

forgotten the economic and regulatory sides of the problem. 

Europe is involved, including the ten new member states where the health and social security 

situation can be quite a challenge! But not only Europe, also the world as a whole is important in this 

project. We gladly admit the commonality of many disease patterns. We have diseases in common, 

more so than one would think. Therefore: what is good for Europe is also good for the world as a 

whole. 

A win-win situation for all stakeholders 

We are after a clear win-win situation for all stakeholders. First, we have been concentrating our 

efforts on the European Commission. We will continue to do so. We are happy that the 

Commissioner for Research, Mr Potocnik, has accepted our invitation to be a keynote speaker at our 

Conference. We are counting on the commissioners for Enterprise, Mr Verheugen, and for Health, Mr 

Kyprianou as well. 




We have convened preparatory meetings in Brussels to which we invited DG Research, DG 

Enterprise and DG SANCO. The European Investment Bank was there as well as we consider them 

an important player in this field. 

Stakeholders 

I am pleased to say here that the interest in our project is high. Last Monday in Brussels, WHO 

organized a large meeting involving all major stakeholders to discuss the latest version of their report 

and the turnout was quite good. They got some very encouraging comments. 

We are also pleased to see that industry is following this project with a keen eye. They remain in 

overall terms positive towards initiatives such as this. I hope that, at our Conference, industry will be 

able to zoom in both on the public health context and on the barriers to innovation. The one not 

without the other. Mr Brian Ager and Kees de Joncheere will speak after me, and they will 

undoubtedly address these topics. 

NGOs are organizing their own stakeholder conferences around our conference. I consider that to be 

very positive. Patients’ groups have let us know their views as well. 

But let me return to my main topic: How do we want to reach our goal? 

First, we asked a renowned international organization, WHO, to conduct a study for us, and come up 

with a rigorously researched study. They are in the final stages now, and their report will be 

presented during the Conference. 

Then we asked our Medical Research Council to make an inventory of research programmes in 

Europe where in a subsequent phase a major research effort priority medicines might be in place. 

The High Level Conference on the 18th of November will then not be the end-point but the starting 

point of new developments. 

Let me tell you something about the follow-up as we see it. 

WHO Study 

I expect the WHO study to be available soon. What we expect – I am not betraying secrets here, I 

am sure – is that the report will recommend as priority areas for research: 

• Antibacterial resistance 

• Pandemic influenza 

We can expect a research agenda on: 

• Regulatory reforms 

And finally: 

• A list of diseases and conditions requiring priority medicines 

I hope many of you will take time to read at least the Executive Summary and the conclusions and 

recommendations and let us know your opinions about it. 




Follow-up 

One of the outcomes of this study and project should be funnelled into the preparatory work for the 

Seventh Framework Programme. There are interesting discussions going on at this very moment in 

Brussels whether there will be a technology platform whose topic would be pharmaceuticals. 

We will have to see how best to approach this. It is clear that Council will have to take important 

decisions next year when the contents of the Seventh Framework Programme are discussed. 

One can think of other EU research programmes, such as those initiated by DG SANCO. 

One further approach is via other policy programmes. Vaccines and influenza and AIDS come to 

mind. We are confident that the WHO report will have advice on this. 

Regulatory approaches are another option which should be further explored. The Commission has 

just launched their proposal for a paediatrics regulation and incentives. Orphan drugs have their own 

regulatory framework and incentives. We should be exploring further options for Priority Medicines. 

We could make full use of the possibilities of the new European pharmaceuticals legislation, or it 

might be worthwhile to explore even further options. 

My Minister has suggested that the Open Coordination Method might be a feasible approach for 

tackling some barriers to innovation. 

We will certainly report the outcome of the conference to the Council of Ministers, Health Council, 

and possibly also the Competitiveness Council. The British health minister, Lord Norman Warner, will 

speak at our conference so we are confident that future presidencies will carry the work further. They 

could envisage formal Council conclusions. 

EU has many options to take an initiative like this further. But the field is vast and complex! The 

challenge will be to use all the options, and the challenge will be to keep working together. We have 

seen that it CAN work in the framework of the G10 process. We should try to keep the momentum 

and even make it broader now that the research is such an important part of the whole endeavour. 

I need not remind you of the fact that the initiative often is the exclusive domain of the Commission. 

But Member States in their sphere of competence can greatly contribute as well. 

Europe should have a leading role in this process. I need not remind you here of the Lisbon targets. 

Cost containment challenges 

Let me finish by addressing briefly the issue of cost containment. 

As I said, one of the biggest challenges will be the sustainabilty of our health care systems in light of 

an ageing population and the availability of new, better but also more expensive medicines. We want 

the best of both worlds: controllable costs and access to innovative medicines ! 

It is important that innovations ahould be real innovations wherever possible. Of course, the process 

of innovation is often a matter of adding up different smaller innovative steps. But then, it becomes 

very important that pricing is reasonable. In no way it can be explained why small improvement in 

certain pharmaceuticals should justify prices 5, 6 or 7 times a high as the variants that were on the 

market before. 

I am convinced that there is a clear long term interest for the pharmaceutical industry – not only for 




governments or social health insurance systems – in prices that can be regarded as reasonable. 

But it is not easy to find out what is reasonable. There is a very serious lack of transparency on 

where the flows of money really go. As long as there are no figures that can be trusted on what flows 

into real production costs, marketing, R&D and profits, there is no good argument for high prices of 

new pharmaceuticals. 

I am convinced that European governments will be prepared to improve the possibilities for access to 

and reimbursement of new innovative products once they can be sure that prices are reasonable. 

There is still a lot of work to be done. I suppose the EU can play an important role here. 

The other thing the EU could do, is boosting non-competitive and transnational research. I believe 

there is a bigger difference between Europe on the one hand and the US on the other hand in this 

respect than there is within Europe. Closing the gap with the US is a real challenge for Europe, if we 

want to be serious about Lisbon… 



Skigebiet ....................................................bis 2.685 m 

Blaue Pisten ..........................................................60 km 

Rote Pisten .........................................................117 km 

Schwarze Pisten.................................................24 km 

Seilbahnen und Liftanlagen...............................47 

Schneetelefon +43 (0)6432 6455 50 

TV Wetterbericht live jeweils einige 

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Uhr, im 3 SAT von 8.00 - 9.00 Uhr. 

www.skigastein.com/schneeinfo 

6 Tage Skipass in Hochsaison 

für Erwachsene ..............................................€ 165,– 

für Kinder...........................................................€ 82,50 

live dabei in Ski amadé, mit nur einem Skipass 

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6-day ski pass in the main season 

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Snow Phone +43 (0)6432 6455 50 

Live TV weather report: on ORF 2 daily from 

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a.m. always a few minutes after every full 

hour and half hour. 

www.skigastein.com/schneeinfo 

Skiing region .......................................up to 2,658 m 

Blue runs ..................................................................60 km 

Red runs.................................................................117 km 

Black runs ................................................................24 km 

Cable railways and lifts............................................47 

Family Bonus 

Mittlerweile hat es sich ja bereits herumgesprochen, dass Familien beim 

Winterurlaub in Gastein viele Vorteile genießen. Die preislichen Vorteile 

reichen von einem günstigen Familienskipass über Vergünstigungen in 

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Osterfamily Aktion 

Ab 19.3.2005 kommt der Osterhase nach Gastein. Eigene Kinder 

bis 15 Jahre (Jahrgang 1989-1998) erhalten beim gemeinsamen 

Skipass-Kauf der Eltern einen Gratis-Skipass mit der gleichen 

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Saison- und Skiwertkarte) Familienzugehörigkeit ist für alle 

Mitglieder der Familien nachzuweisen (Lichtbildausweise). 

Family Bonus 

In the meantime word has got around that families profit from 

many advantages on a winter holiday in Gastein. Price advantages 

range from an inexpensive family ski pass to special prices at ski 

schools, for ski rentals and also of course at the family-friendly ski 

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the Family Events, in the 300m2 Fun Center or in the 8,000m2 Kids 

Park. 

Easter Family Offer 

The Easter Bunny is coming to Gastein as of 19.03.2005. Children aged 

up to 15 years (born 1989-1998) get a free ski pass when both parents 

buy a ski pass and this pass is valid for the same length of time as that 

of the parents (from 6 -18 days, with the exception of season tickets 

and Ski-Cards) All members of the family must prove their identity 

(identity card with photo). 

Gasteiner Bergbahnen AG 

5630 Bad Hofgastein · Tel.: +43 (0)6432 6455 

e-mail:info@skigastein.com 

Dorfgasteiner Bergbahnen AG 

5632 Dorfgastein · Tel.: +43 (0)6433 7223 

e-mail:office@dorfgastein-bb.at 

Ski, Berge & Thermen. 

Erlebnisgastronomie · Aprés Ski Bar 

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Ski-swing Dorfgastein - 

Großarltal 

Off to skiing pleasures with the Fulseck 

Summit Lift. An attractive and varied offer 

with guaranteed snow and fantastic downhill 

opportunities, the Wengeralm FIS race stretch, 

family runs and the rustic atmosphere of the 

ski huts. The challenge: the longest downhill 

run in Gastein, from Fulseck to Dorfgastein, an 

8 km run! 

Ski-swing Schlossalm - 

Angertal - Stubnerkogel 

Experience the 100 kms of ski and snowboard 

fun on slopes ranging from gentle and 

easy to Black runs. A special tip: the Hohe 

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in altitude, the downhill with the greatest 

altitude difference in the Eastern Alps. 

Graukogel 

A skiing region for all weathers with challenging 

downhill runs for skiing individualists 

who want to have fun skiing and snowboarding 

away from the crowd. FIS race stretch 

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Experience nature from the end of November 

until late spring in the midst of the main ridge 

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route. Please pay attention to warning signs 

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PISTENSPASS | GASTEIN FUN ON-PISTE | GASTEIN


Affordability of pharmaceuticals in the enlarged Europe 

Kees de Joncheere 

Abstract 

Europe has never stood still. However, rarely have the social, industrial and political changes been 

as rapid as they are now. It is also happening at a time when we are witnessing the swift 

development of challenges from new centres of economic growth such as China and India. The 

recent enlargement of the EU has the potential to strengthen its ability to compete and innovate in 

this rapidly evolving world. 

The Commission’s long-held objective is to establish a genuine single market in pharmaceuticals. 

This has only been partly achieved with a single European legislative framework governing the 

safety, quality and efficacy of medicines. However, there is a substantial fault line running throughout 

the single market. This fault line runs along the border between a single regulatory structure under 

which marketing authorisations are awarded and using these authorisations to place products on the 

market when a company can face up to 25 separate negotiations on pricing and relative 

effectiveness. 

We must find a way to meet the legitimate concerns of Member States to protect increasingly 

stretched public health budgets in a way that still allows us to create an environment where industry 

feels confident to invest in the high-tech and new frontier technologies that Europe will need in the 

21st Century. The G10 Medicines initiative has begun this process. It has also been able to build on 

the recently adopted Pharmaceutical Review which will provide the EU, with a modern, well balanced 

and robust legal framework. Our goal is to support the development of a world-beating, dynamic and 

innovative pharmaceutical sector that will lead our drive to achieve the Lisbon Agenda. 

The recent enlargement of Europe provides us with many opportunities. It provides industry with a 

significant increase in the single market and a well-educated work force. However, we will only be 

able to reap these benefits if we can ensure an effective implementation of the new pharmaceutical 

legislation throughout Europe. In parallel, we must also work on the less tangible, but equally 

important, issue of building partnerships between industry and national authorities. We must replace 

the, sometimes, adversarial nature of these relations with a partnership based on mutual respect, 

transparency and trust. 

Just as industry needs to recognise the legitimate concerns of governments to ensure equitable and 

affordable access to medicines we need to recognise that, without providing a stable and transparent 

European and national regulatory environment, we will not attract the investment in our science base 

to develop the next generation of medicines for all Europe’s citizens 




Panel discussion: Introduction and overview 

Ingrid Rosian-Schikuta 

The pharmaceutical market is characterized by numerous stakeholders (national health services, 

social insurances, research-based and generics industry, wholesale, pharmacists, physicians, 

patients) with conflicting interests, and by a strong degree of regulation. 

The European Pharmaceutical Legislation, dating back to 1965, focused on market authorisation of 

pharmaceuticals based on safety, quality and efficacy. Though market authorisation being 

harmonized within the EU, there is still a great variety in the availability of pharmaceuticals between 

the Member States, even between the ‘old’ ones. 

In contrast to authorisation, pricing and reimbursement issues fall, in general, under the national 

legislation of the Member States. However, the EU Transparency Directive, aiming at harmonizing 

national procedures, has also shown impact on national pricing and reim-bursement policies and has 

contributed to changes in pharmaceutical pricing and reimbursement in the Member States. 

Within the EU, there are different approaches concerning the regulation of manufacturer prices, 

different wholesale and pharmacist’s margins, different pricing strategies applied by the industry, and 

different agreements between states and actors. We see maximum prices, price negotiations, profit 

controls, reference price systems, price freezes, and the increased use of price comparisons. By 

now, pharmaceutical prices in the EU are far from being harmonized. 

Reimbursement also reflects the different national pharmaceutical policies aiming at keeping costs 

down, while encouraging innovation by rewarding new drugs. In addition to common instruments 

such as positive and negative lists, co-payment schemes, and pharmaceutical budgets used in 

several Member States, economic evaluation is gaining importance. 




Panel discussion: The pharmacists’ perspective 

Paul Bundgaard 

First of all, I would like to introduce you to the Pharmaceutical Group of the European Union (PGEU), 

the European Association representing Community Pharmacists in 29 European countries including 

EU Member States, EU candidate countries and EEA members. 

Community Pharmacy 

The Community pharmacy sector in the EU employs over 500,000 people [1], around the same as 

employed by the pharmaceutical industry [2], and is made up primarily of micro and small 

enterprises. Community pharmacies are recognised as undertaking a special type of activity in 

providing a service of general interest and being required to observe public service obligations, which 

include but are not limited to: 

• Providing any medicine on the national market to a patient within the shortest possible time; 

• Guaranteeing that any citizen visiting a community pharmacy has access to the qualified advice of 

a community pharmacist; 

• Cooperating with other community pharmacies to ensure out of hours pharmacy services. 

The pharmaceutical market 

In the pharmaceutical sector, services provided are paid for either by the state directly thorough 

social security systems or by third parties (social and private insurers) and the price for the services 

provided is incorporated into the price of the product, albeit in many different ways. This is the case 

for the pharmaceutical industry, pharmaceutical wholesalers, and the entities undertaking distribution 

to the public, i.e. the community pharmacies. 

Pricing and reimbursement and innovation 

The pricing and reimbursement of medicines is a complex process and one that PGEU recognises 

should reward innovation in order that progress in medical research continues. Pricing and 

reimbursement are however and should remain national responsibilities. Decisions taken reflect the 

structure of national health care provision and the resources available at national level. 

There is however a role for the EU to play and indeed it already has. The transparency directive 

(Council directive 89/105) does not remove any decision making power from Member States, but 

instead requires them to reach their pricing and reimbursement decisions in a transparent manner 

and within a given time period (normally 180 days). The transparency directive has been 

implemented by Member States, but there is evidence that it is not always respected. Perhaps there 

is an avenue for further EU action here? 

PGEU considers that a further role for the EU is to provide leadership and encourage the 

dissemination of best practices in tackling issues that could greatly contribute to optimising 

pharmaceutical resources within national medicines budgets so that “liberated” resources can 

indirectly also fund innovative medicines. Any action in this area must naturally be undertaken 

without jeopardising the safety, quality and efficacy of pharmaceuticals. 




Optimising pharmaceutical resources 

One way of optimising resources is through health technology assessment procedures, which some 

of our colleagues have spoken about today; therefore I will not go into further detail. PGEU strongly 

believes that there is also much scope to optimise resources in the following two areas: 

• Improving patient adherence; 

• Enhancing patient safety. 

Improving adherence 

In its 2003 report on adherence [3], the WHO pointed out the high incidence of non-adherence (up to 

50% in developed countries) and its cost both in economic and health terms. Adherence, as defined 

by the WHO report is: “The extent to which a person’s behaviour – taking medication, following a diet 

and/or executing lifestyle changes, corresponds with agreed recommendations from a health care 

provider”. The cost of non-adherence includes wasted or un-used medicines, additional medical 

consultations, additional medication, and in some cases even hospitalisation. The WHO report 

referenced many studies that were able to show not only the health benefit to patients of increased 

compliance but also the cost benefit to the health care system, for example a review of an asthma 

management programme in Germany revealed that for every 1DM spent, 5DM was saved.[4] 

PGEU considers that addressing this issue in a coordinated and structured manner with the proactive 

and committed support of relevant stakeholders and institutions is indeed a priority. After all, if 

Member States fund innovative medicines, recognising that their therapeutic benefit is proportional to 

their cost to the health care system, it seems extremely sensible to make sure those medicines are 

being correctly used so that the desired therapeutic outcome is achieved. Given that Community 

Pharmacists in collaboration with other health care professionals have been shown to provide an 

important contribution to improving adherence, PGEU is naturally committed to supporting actions in 

this area. 

Enhancing patient safety 

PGEU considers that information, adherence and patient safety are intrinsically linked. A recent 

study [5] revealed that lack of adherence for patients with chronic diseases is often a conscious 

action connected to problems encountered with medication and lack of information. Informed patients 

who understand their medical treatment including its benefits, possible side-effects and contraindications 

are less likely to take actions that might jeopardise the safety of the medicine, for 

example not respecting necessary precautions such avoiding alcohol. Informed patients also 

understand how to follow their medication regime and the consequences of not doing so. 

Improving adherence and promoting patient safety also helps to link the somewhat commercial 

question of pricing to what is really the core activities of community pharmacy and the mission of the 

community pharmacist: delivering the most appropriate treatment in a safe, efficient and cost 

effective manner to the public. 

In conclusion, we are convinced that in the debate on pricing, reimbursement and innovation it is vital 

to remember the important contribution both to better use of resources and to patient safety that can 

be made by improving patient compliance. 

References 

1. PGEU database, 2003. 




2. The Pharmaceutical industry in figures, EFPIA, Key data, 2003. 

3. WHO. Adherence to Long-term Therapies – Evidence for Action. WHO, April 2003. 

4. Trautner C, Richter B, Berger M. Cost-effectiveness of a structured treatment and teaching 

programme on asthma. European Respiratory Journal 1993,6:1485–91. 

5. N Barber, Clifford S, Darracott, R, Home R. Patients’ problems with new medication for chronic 

conditions. Quality and Safety in health care 2004;13(June). 




The public health perspective 

Rui Santos Ivo 

General 

Health systems in the EU and worldwide currently face a cost-containment era. Portugal is no 

exception in this regard. 

“Health care is vital to all of us some of the time, but public health is vital to all of us all of the time”. 

To that end we should bear in mind the main objectives of public health are: to assess and monitor 

the health of communities and populations at risk to identify health problems and priorities; to 

formulate public policies designed to solve local and national health problems and priorities, and to 

assure that all populations have access to appropriate and cost-effective care including health 

promotion and disease prevention services; and to evaluate the effectiveness of that care. 

A specific set of factors has a direct impact on the management of resources in health systems 

globally. Factors such as demographic changes, i.e. the ageing of population, the increasing number 

of chronic diseases, expensive health technologies and the accessibility of medicines to patients. 

There being public health policies should attain a balance in results: health gains, reinforced access, 

contribute to the sustainability of the financing of health systems and the opportunity of costs. 

In this context, the European Medicines Regulatory System has some interest in contributing to 

reinforce public health and competitiveness of the pharmaceutical industry by ensuring quality, safety 

and efficacy of all medicines, a rapid access to new medicines and increasing patients involvement in 

early stages of the evaluation process. These objectives are all fully in line with the new mechanisms 

stemming from the review of the pharmaceutical legislation, the G10 recommendations (14) and the 

EU Council conclusions and resolution (2003). 

In practice, the new mechanisms include a number of recommendations that may assist countries 

with their sustainability difficulties. This comprises measures like the promotion of generic medicines 

and cost-effective new drugs thus promoting health gains, the development of mechanisms to 

promote better information tools to patients and consumers, new mechanisms to improve access in 

accordance with specific patient needs and improving prescribing and dispensing mechanisms. 

Actually cost-containment is becoming an objective of a wide majority of countries willing to curb 

pharmaceutical spending as the use of medicines and the number of chronic diseases is on the rise. 

Simultaneously, there is a permanent need to ensure quality and efficiency in health systems, a need 

to stimulate the development of research and innovation, and pricing regulations and reimbursement 

trends are continually changing in response to ever increasing cost containment pressures. 

In this context, there is a need for more information in order to have an appropriate evaluation of the 

system. Pricing and reimbursement strategies need for accurate budgetary impact analysis, an 

increasing need for health economic data, outlining prescription restriction and clinical guidelines and 

give clear signals for national decentralization like the issuance of local drug formularies. 

Portugal 

In Portugal overall health conditions have significantly improve over the last two decades where life 




expectancy increased from 73 years in 1980 to 75 in 1995 and where mortality at birth decreased 

from 25 in 1000 in 1980 to 7.5 in 1995. 

However, among the EU countries Portugal remains at the top in terms of public expenditure with 

medicines on GDP (2.2% GDP in 1999). As for the indicator showing the weight of public 

expenditure in the total of health expenditure Portugal is also the one with more spending (23%) 

followed by Spain with 22%. 

To face all these challenges the Government decided to implement a new medicines policy in late 

2002 and in 2003. This policy encompasses a set of measures. 

The promotion of generic medicines through the INN prescribing and the implementation of a new 

model of medical prescription have given place to a trend of rationalisation of resources in the 

national health system and promoting a rational use of medicinal products among health care 

professionals country-wide thus giving place for innovation and increasing access to affordable 

medicines. 

This medicines policy implemented by INFARMED envisages as ultimate goals to guarantee the 

safety, efficacy and quality of medicines, to ensure the sustainability of the health system and its 

development, the promotion of the rational use of medicines and to conciliate social and industrial 

strategies. To achieve these objectives it is therefore vital to improve the quality of health services 

while maintaining costs, to reduce public health expenditure on a long-term perspective, to 

implement legislation on the regulation, financing and provision of health care, introducing new 

financing mechanisms, introducing incentives for productivity and quality in health care centres and 

hospitals. 

As mentioned in a 2004 OEDC survey on Portugal “The ongoing reform in the health sector is a 

good example of the strategy to improve the quality of public services and meet the population 

needs, while seeking to limit pressures on public expenditure over the medium-term”. (OECD/OCDE, 

2004) 

Some of the measures currently under implementation phase: 

• Promoting the use of generic medicines – information campaign 

• Reinforcement of information tools to health care professionals, pharmaceutical industry and the 

general public – publications and www.infarmed.pt 

• Increasing transparency through the publication in the website of medicines evaluation reports 

• Developing a reference pricing system based on generic availability 

• Promote prescription by INN 

• Introduce a standardised prescription form, introducing renewable prescription for chronic 

diseases 

• Development of electronic prescribing 

• Reinforce role of patient in the decision process, namely in choosing generics 

• Reinforce the role of health professionals 




• Excessive cost mechanism: de-listing products/lower prices 

• De-listing based on: non-presence on the market; violation of advertising principles 

• Reorganisation of hospital pharmacy 

• Development of information tools for patients and health care professionals 

The national medicines reimbursement system provides special attention to the access of innovative 

medicinal products after careful evaluation of their added therapeutic value. Generic products these 

are automatically reimbursed through the reference pricing mechanism, which is based on the higher 

generic price and is quarterly updated. The reimbursement mechanism is automatic for medicines 

below reference price and new medicines included on reference price system have retail price equal 

to reference price for reimbursement. The level of co-payment of medicines depends on: the 

essentiality to life maintenance, the level of disease chronicity or seriousness and economic and 

social situation of specific group of consumers. For example: insulins and anti-epileptics are fully 

reimbursed, while anti-hypertensives and antibiotics are co-paid at 70% and corticosteroids and 

analgesics at 40%. Levels of co-payment are: 100%, 70%, 40% and 20%. Retired pensioners have a 

special reimbursement regime providing extra 15% co-payment and generics have extra 10% while 

compared to brand products. The reimbursement system is only applied to prescription only 

medicines. As for dispensing substitution for a generic medicine is possible when authorised by 

doctors and doctors and pharmacists should inform patients about generics and their prices. 

INFARMED develops national information campaigns on the quality of medicines, on the promotion 

of generics and on the rational use of medicines. It edits a large variety of publications on medicines 

specially delivered to the different publics. INFARMED has implemented a pro-active information 

strategic delivering accessible and on-time information to all its partners (patients, health care 

professionals, pharmacies, pharmaceutical industry and the general public) through its website 

(www.infarmed.pt). Additionally, INFARMED has been awarded in 2003 with the European Generics 

Association annual prize for the work carried out in promoting generic medicines. 

All these measures are now producing their first results. The most obvious one is the steady growth 

of the generics market share from 0.3% (value) in 2001 to nearly 8% in the period from January to 

August 2004 (in line with G10 recommendation 4: To secure the development of a competitive 

generic market in Europe). The generic medicines market share allowed for significant savings in the 

national health system in 2003 and 2004. 

On the other hand, over the last three years INFARMED has witnessed internal reforms on the 

structure of the organisation, which have paved the way for a new dynamic in the institute’s 

performance near its public. In this context, average time periods for approvals (authorisations and 

reimbursements) have significantly decreased for all types of processes/marketing authorisation. 




The availability of generic medicines in the European Union 

Greg Perry 

Generic medicines and sustainable health care in Europe 

As a result of an ageing population in Europe, EU policy makers are increasingly concerned with the 

social and financial sustainability of health care. The alarming situation of increased pension costs 

and rising medicines bills, calls for a focus of the EU on accessibility, sustainability and quality of 

care. A solution to manage the problem of rising health care costs is partly found in increasing the 

use of affordable generic medicines. 

Generic medicines are price competitive therapeutic equivalents to patent expired brand 

pharmaceuticals. They go through the same regulatory procedures and have the same safety, 

efficacy and quality as original brands. 

Europe's ageing population: how do we sustain affordable medicinal care? 

250 

225 

200 

175 

150 

125 

100 

75 

50 

Source: EU Economic Policy Committee 

Note: Working age population refers to persons aged 15 to 64. 

Elderly population refers to person’s aged 65 and above 

The use of generic medicines in Europe 

Working age 

Employment 

Elderly 

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 

European citizens are most familiar with generic medicines in the self-medication area where 

payment is made directly by them, i.e. preferring to choose low priced generic paracetamol as 

opposed to branded Panadol for pain relief or generic loratadine as opposed to Claritin for treating 

hay fever or allergies. 




However, it is in the area of critical illness – where costs are mostly paid for indirectly by health 

insurance and tax contributions, that generic medicines play a crucial role. 

Examples of critical illnesses treated by generic medicines: 

• Cancer 

• Depression 

• Hypertension 

• Diabetes 

• Hyperlipidaemia (cholesterol) 

• Serious bacterial infections 

• Asthma 

Generic medicines, which sell at a 20–80% price differential to the patent expired brand, are currently 

creating 13 billion euros savings each year for the former EU-15 health care systems. If generic 

medicines were taken out of the health economics equation the EU's health care systems would 

become financially unsustainable. 

The generic medicines market in the European Union 

Over the next few years, there will be a major opportunity for increasing the availability of generic 

medicines both in the community prescription and hospital sectors, as 35% of top selling 

pharmaceuticals will be patent expired by end of 2004. 

Although most EU governments have started to promote generic medicines, the potential for more 

cost-effective medicinal provision in the off patent market is staggering. Many EU Members states 

have not yet maximised their generic medicines use potential. 

Generic availability and the new EU legislation 

The new EU legislation for pharmaceuticals, expected to come into force between 2005–2006, will 

have a major impact on generic medicines since it: 

• Encourages generic R&D before patent expiry 

• Allows marketing of generics where branded pharmaceuticals have been withdrawn for 

commercial reasons 

• Provides clear scientific and legal definitions of generic and bio-similar medicines 

Whilst this may simplify the registration of generics and promote more manufacturing of generics in 

the EU, the new law will also result in certain delays in the availability of generic alternatives both for 

hospital purchasers and pharmacists. This is because it has increased the overall period of time that 

generic manufacturers must wait until they can register their products. 

Government mechanisms for promoting generic availability 

At national level, governments need to give greater attention to generic prescribing, generic 

dispensing, consumer awareness and competitive pricing structures to promote generics. 

At the European Workshop on Generic Medicines held in Lisbon in February 2003 jointly organised 




by the Portuguese medicine agency (INFARMED) and the EGA, the following ten key measures for 

stimulating generic availability were recommended for implementation at national level. 

Ten key measures at national level for increasing generic availability: 

1. Educating doctors to use INN names 

2. Assisting doctors in understanding the economic implications of prescription decisions 

3. Increasing the use of electronic prescribing 

4. Creating substitution lists 

5. Increasing incentives for generic dispensing and substitution (regarded as particularly important 

in systems where doctors are not economically sensitive) 

6. Improving consumer awareness of generic quality and availability 

7. Increasing pharmaco-economic evaluation of new products in comparison with existing products 

8. Establishing generic-oriented reimbursement and health insurance systems 

9. Adopting reference pricing and free pricing systems instead of controlled price systems 

10. Reducing the time delay between receiving market authorisation for a generic product and 

gaining pricing, reimbursement and/or substitution status 

A successful EU policy for increasing access to generic medicines will require a greater commitment 

from European governments to introduce active generic policies and for the European Commission 

to ensure that any new EU legislation is not only directed towards the interest of the alleged “new” 

products but also directed to increase availability and to access to affordable medicines. 




The insurance perspective 

Angelika Kiewel 

Health insurers are the representatives and spokepersons of patients and have to insure the 

accessibility, quality and affordability of pharmaceuticals. Patients expect effective and not maximum 

treatments. 

Competition requires competitors. For an innovation, the manufacturer is a monopolist. The balance 

of industrial interests and health care needs requires regulation. In Germany, the government has 

introduced in 2003 a discount on manufacturing prices of 6% and raised it – limited on 2004 – up to 

16% to get under control the constant rising prices for new drugs. Due to the free prices in the USmarket 

drug expenditures there are three times higher than in most of the EU countries. The 

American health care system is near to collapse. 

Novelty alone is no proof of quality. A product must be both new and better to stand out from crowd. 

If the properties of a new medicine hardly differ from the drugs already available, then there is no 

reason for paying a higher price. Mutually replaceable drugs should be placed together in a single 

group for a unique reimbursement limit. Germany has such a system, the so called ‘Festbeträge’; 

until now it was only for off patent products. Since the beginning of this year, it covers also ‘pseudoinnovations’, 

new substances that show no relevant therapeutic advance. By this way, savings for the 

health funds about EUR one billion a year are expected. 

A therapeutic definition of innovation constitutes an incentive for pharmaceutical manufacturers to 

focus their research capacities on needs and to offer pharmaceuticals in areas where drug therapy is 

currently inadequate or where existing expensive therapies could be replaced by more cost-effective 

drugs. Independent information on the value of a product compared to alternative treatment would 

promote innovation. 

We need studies concerning the long-term utility of a new drug. The full therapeutic value of a new 

medicine cannot be determined unless the product has been used in a wide population of patients. 

But who pays a compensation, if the expectations are not fulfilled? When studies are paid by 

taxpayers, this has to be taken into consideration concerning the price. 

Industry is quick to request free prices in order to promote innovation. But there is no clear relation 

between free price and innovation. There a countries where prices are regulated by the state that 

have active research industry – for example Sweden – and others, such as Germany, have (until 

now) free pricing for all patented medicines, but a lack of supply of new preparations. 

25–30% of the costs for a new drug is spent on marketing and sales. It is a waste of resources that a 

lot of new medicines whose R&D costs are enormous, offer only marginal progress. Free prices 

prevent companies to make use of internal potential for efficiency. 




Overview on HTA under a global dimension – impact on policy and 

practice and scope for transnational cooperation 

Finn Børlum Kristensen 

Health Technology Assessment (HTA), which is a sort of research-based policy analysis, was 

introduced in USA in the mid-seventies and has experienced an exponential growth in terms of 

numbers of agencies, reports and impact, not least in EU member countries (12 of the 25 EU 

member countries have at least one HTA agency). This may be seen as a response to demands for 

broadly scoped and more rigorous bases for decision-making in health care and health policy in 

relation to increasing diagnostic and therapeutic potentials and limited resources. 

HTA synthesises clinical, organisational, economic, and societal/ethical analysis into policy input, 

which can help clinicians, economists, managers, and decision makers to find well-substantiated 

solutions. Technology is broadly defined to include medical devices, surgical procedures, 

pharmaceuticals, rehabilitation, and disease prevention measures. 

Properly done and meeting rigorous quality standards HTA reports in various countries have been 

shown to be helping rapid and wide introductions of effective technologies as well as diminish the 

spread of technologies that are proven ineffective or have a relatively low or unproven (cost-) 

effectiveness. 

Most of the ‘old’ EU-15 member countries have one or more agencies, which are linked to national or 

regional government. In addition, three EU-funded projects have been reported within the last ten 

years (EUR-ASSESS, HTA Europe, ECHTA), the reports being available in the Journal mentioned 

below. The projects have contributed to the basis for establishing sustainable networks for 

collaboration in terms of a theoretical framework and clarity on tools and methods, and improvement 

of transnational coordination and division of work. 

The growth demand for and impact of HTA has paralleled and been influenced by the establishment 

of an international Network of HTA Agencies (INAHTA, www.inahta.org), which has 42 member 

institutions in 21 nations, and an international society (HTAi, www.htai.org) with a scientific journal, 

International Journal of Technology Assessment in Health Care (www.journals.cambridge.org). The 

New and Emerging Health related Technologies (NEHRT) Project within the OECD Health Project 

(www.oecd.org) and the WHO Health Evidence Network (HEN, www.euro.who.int) contribute to 

promising international developments. 

INAHTA is a network with a mission to provide a forum for the identification and pursuit of interests 

common to health technology assessment agencies. The Network aims to accelerate exchange and 

collaboration among agencies, promote information sharing and comparison, and prevent 

unnecessary duplication of activities. The HTA Database of INAHTA, which is accessible through 

www.inahta.org and other channels, now comprises more than 3,300 reports and 800 ongoing 

projects. INAHTA Briefs on individual HTA reports are regularly compiled and published on 

www.inahta.org, and INAHTA developed the HTA Checklist – a Summary for HTA Reports, which 

increasingly is being applied to HTA reports and made available when reports are entered into the 

HTA Database. 

The conditions now seem developed for closer international collaboration on HTA. This could 




increase the policy impact of well-substantiated reports, and avoid duplication of work, and the 

international HTA community is ready to respond to new challenged. 




HTA – does it encourage or hinder innovation? 

Iain Gillespie 

Abstract 

HTA is a set of evaluative tools used in both public and private sectors though generally at different 

stages of the innovation cycle. There are contending views about whether HTA as applied in the 

public sector encourages or hinders innovation and about what the elements of practice that 

influence innovation are. The evidence for HTA impacting on innovation, including recent OECD work 

on new and emerging health related technologies (NEHRT), will be considered and conclusions 

drawn about elements of current and future best practices that are likely to provide a win-win 

outcome for health policy makers and innovators. 




HTA from a political and ethical perspective 

Chris Henshall 

Much of the HTA work presently conducted comprises clinical trials and/or meta-analysis, 

supplemented by economic modelling to derive incremental cost-effective ratios for comparisons of 

particular treatments. 

This can provide a helpful input to some decisions concerned with optimising allocative efficiency 

within a given health care budget. It is less helpful to decisions about how best to balance allocative 

efficiency with equity and ethical issues, or to decisions about how best to balance allocative 

efficiency in the short term with the need to promote and sustain the innovation in the health care 

system being sought by patients and the economies of the European Union and other regions 

around the world. 

If HTA is to address these wider needs of society, it must pay more attention to the technologies 

being assessed and to the extent of their contribution to innovation (incremental or disruptive), and to 

the legal, social and ethical implications of technologies and their uptake in the health care system. 

Health Technology Assessment International is a new professional society for all those interested in 

HTA, whether as doers or users, medical or social scientists or lay people, or from the public or 

private sectors. It seeks to support the development of the science and practice of HTA to promote 

innovation and improve health care. It holds annual scientific meetings for all its members and is 

convening an HTAi Policy Forum for in-depth discussions between senior figures from industry and 

health care systems about the use and development of HTA in decisions about health care provision. 




National HTA strategies: the case of Hungary 

László Gulácsi 

Abstract 

The process of the European Union enlargement reached an important step on 1 May 2004, when 

ten countries including Hungary became member states of the Union. 

Policy issues where HTA might be very useful 

Basic benefit packages have 

not been defined yet, and 

decisions on coverage related 

issues (drugs, medical 

devices, procedures) are 

made on ad hoc basis and in 

a non-transparent manner. 

There is a huge budget deficit 

of drugs even though most of 

the innovative drugs launched 

in the EU-15 market in the 

past 5–10 years are not 

available for Hungarian 

patients due to the lack of 

National Insurance coverage. 

Problems are not likely to be 

solved by the wide 

privatisation or the 

introduction of managed care 

operation. What is necessary 

is the development of a better 

health policy applying the 

results of EBM and HTA 

(Table 1) to a greater extent. 

Financing of health care 

Table 1: Chronology of the HTA development of Hungary 

1993 Hungarian Coordinating Office for Health Technology 

Assessment 

1996 Hungarian Society for Health Technology Assessment 

1997 Journal of the Hungarian Society for Health Technology 

Assessment 

2000 Unit of Health Economics and Technology Assessment in 

Health Care, Budapest University of Economic Sciences 

(undergraduate and postgraduate education) HunHTA 

2001 HunHTA – INAHTA membership 

2002 HTA section of the Hungarian Medical Journal 

2002 Guidelines for the economic evaluation of health services 

(for coverage decision purposes) by the Ministry of 

Health 

2004 Healthcare Strategic and Research Institute (ESKI) – 

Ministry of Health and Social Affairs 

In Hungary, the health care system is based on a compulsory national insurance model. Universal 

coverage is assured through a combination of mandatory social insurance for the working population 

and guaranteed coverage for the retired and the people under the poverty level. A DRG-type 

financing mechanism was introduced in 1993, capitation payment exists in the primary care setting 

and doctors are paid according to the German point system in the out-patient care setting. Relating 

to pharmaceuticals and medical devices, regulation, patent protection and registration has already 

been harmonised to the EU-15 countries. There are several reimbursement categories for drugs in 

Hungary and a significant percentage of co-payment. Since 1992, the share of private expenditure 

has consistently increased due to the modification in the reimbursement system to increase patient 

co-payment levels. On average, co-payments in 2001 account for approximately 35% of the retail 

prices of subsidized medications.[1] However, the health insurance budget will face an increasing 




pressure due to the fact that a number of new innovative technologies, which are widely used in the 

EU-15 countries – drugs/medications in diabetes, cancer, rheumatoid arthritis, gastroenterology, 

mental health etc. treatment – have not received coverage yet due to the limited health care budget 

and even more due to the un-transparent coverage policy decisions. These are expensive but costeffective 

technologies. Not only their direct costs are significant but their use requires various 

registries and databases to be created and operated to document effectiveness and patient safety. 

Transparency criteria 

Transparency criteria were implemented and institutionalised in Hungary on 1 May 2004. A new 

governmental institution, named Healthcare Strategic and Research Institute (ESKI), was created. 

According to these criteria, pharmaceutical firms have to submit a dossier (data on efficacy, 

effectiveness and cost-effectiveness of the new product) to the National Health Insurance Fund 

(NHIF) and they are free to submit this dossier in any given time of the year – pharmaceuticals have 

to pay HUF 1.5 million per submitted dossier. (This amount is supposed to cover the cost of HTA 

appraisal.) NIHF has to finish the coverage decision process within 180 days. NHIF can send 

dossiers to this new institute ESKI for health technology appraisal. Previously, price/coverage 

negotiations took place between NHIFA and each manufacturer to determine price increases for the 

following year once in a year or even less frequently. The government often used its political 

influence not to set a date for the negotiations or to delay the process – this was the major tool for 

cost-containment. Now manufacturers have the right to receive a HTA based coverage decision 

within 180 days and they have the right to appeal against the decision – regarding both the results 

and the methodology used. Pharmaceutical firms are supported by experts in creating their dossier, 

but in the NHIF (and government) side no (EVB, HTA, health economics) trained experts are 

available to do appraisal and make coverage decisions. Providers, professionals and patients also 

have the legal right to appeal against the coverage decisions. 

Main questions related to reimbursement (and HTA) policy [2] are as follows: 

1. Should evidence be requested for all new drugs, or just some? 

2. How should drugs be prioritised for assessment? 

3. Does it make sense to assess several drugs in the same class together? 

4. How prescriptive or flexible should data requirements be? 

5. Should data from other countries be accepted? If so, which? 

6. Should commercial-in-confidence data submitted by companies be accepted? 

7. Should an independent assessment be made of the evidence, including company submissions? 

8. Should the reasons for reimbursement decisions be made public? 

9. Should there be an appeals process? If so, what should this consist of? 

10. Should a two-stage appraisal process be considered? 

References 

1. Gulácsi L, David T, Dózsa Cs. Pricing and reimbursement of drugs and medical devices in 

Hungary, European Journal of Health Economics 2002;3:271–78. 

2. Gulácsi L, Boncz I, Drummond M. Issues for countries considering introducing the ‘fourth hurdle’; 

The case of Hungary, International Journal of Technology Assessment in Health Care 2004;20:2:1–5. 




HTA in Germany 

Alric Rüther 

Abstract 

Facing an exploding number of methods and research in prevention, diagnostics and therapy 

decision-making in health care requires an effective scientific tool to provide assessment of medical 

procedures in a transparent and objective way. Regarding this Germany was in need to implement a 

legal base to help decision makers in their duties within the legal national framework. 

Germany provides an insurance based health care system. The mandatory health insurance scheme 

covers approximately 90% of the population. The system is decentrally organised. Details are 

negotiated by self-administered bodies and the federal states. The Government sets the legal 

framework of health care including eligibility, definition of services, responsibilities and financing and 

has the task to control the self-administered bodies. 

The development of health technology assessment (HTA), especially in the European countries, 

convinced Germany in 1995 to set up a scientific programme for evaluation of HTA for the German 

health care system. The results led to integration of HTA into the legislation by the Health Care 

Structure Reform Act 2000. It demands scientific assessments for decision making in health care. 

Committees for the different health care sectors of the regulation framework, like ambulatory care, 

had been founded. Moreover, the Act made way for the founding of the German agency for HTA at 

the German Institute for Medical Documentation and Information (DAHTA@DIMDI), an institute under 

the German Ministry of Health and Social Security (BMGS). DAHTA@DIMDI built up a free, 

accessible information system for HTA and developed the quality assured pathway for preparing HTA 

reports relating to the German health care system. Following the Act the importance of HTA grew 

strongly in Germany. In 2004, the Health Care System Modernisation Act combined the different selfadministered 

decision-making committees into the ‘Federal Joint Committee’ (GBA) and, in addition 

to DAHTA@DIMDI as governmental agency, formed the ‘Institute for Quality and Economic Efficacy’ 

which also will provide HTA and evidence-based guidelines for decision maker and consumer. 

Very important input for the fast and rigorous development of HTA in Germany came from 

international collaboration. Especially the participation in the three EU-founded projects on HTA: 

EUR-ASSESS, HTA-Europe and ECHTA, had been very helpful for the development of methodology 

and theoretical structures. They prepared the way for establishing transnational networks in order to 

stay up-to-date and to use resources effectively. The next step, the building up of an European 

network for HTA, will be based on these results. Parallel the International Network of HTA Agencies 

(INAHTA), a supranational network of public funded HTA agencies where DAHTA@DIMDI is a 

member since 1999 provides the necessary support for a quality based HTA process in Germany. 

Additionally the scientific methodological development and the exchange of these data within the 

international HTA society (HTAi) form a very useful pool of methods and results in the field of HTA. 

HTA has been established in Germany as a highly reliable basis for decision making in health care. 

Since 2000, there has been an increasing acceptance of the HTA methods in the political area. The 

international collaboration in HTA, especially with EU member countries, provides the backbone for 

methodological quality and actuality. The progress regarding networking by the EU member states 

improves the development and implementation of quality assessed medical procedures . This is 

underlined by worldwide support and collaboration based on the international scientific HTA society 

(HTAi) and the network of public HTA agencies (INAHTA). 




Pharmaceutical industry 

Clare McGrath 

First, let me introduce myself. I have been working in the pharmaceutical industry for 20 years, in 

clinical research and outcomes research. For the past six years at Pfizer, I have been responsible for 

establishing an OR capability in Europe. The perspective I present here therefore is based on 

Pfizer’s experience of HTA in Europe and not necessarily representative of the whole industry. 

Pfizer has made a strong commitment to heath technology assessment in Europe. Our experience in 

Europe though is that it is being inappropriately applied as a means of controlling pharmaceutical 

expenditure rather than a means of allocating total health care resources for the best outcome. 

As it is not an exact science and still evolving, we would question the value of basing substantive 

decisions about which medicines are made available to patients and which ones are not. We have 

built up a strong HTA expertise in Europe and Canada with somewhere in the region of 60 specialists 

working in the country organisations alone. We use HTA criteria as part of the decision as to which 

medicines we take forward into development and which ones we don’t. We also believe that this 

resource would be best used in quantifying the value of medicines in real life use after several years 

experience with the medicine. 

I have the following points to make: 

Point 1 

More and more countries are developing HTA boards at national and regional level each with their 

own specific information needs and processes. The resulting diversity of technical requirements is 

becoming an issue for the limited HTA expertise we have in Europe both in the industry and in 

governments. In the UK for example next year there will be 4 separate HTA boards for Scotland, 

England, Ireland and Wales each with different technical requirements and decision criteria. For 

Pfizer this means that over the nest two years, we will submit approximately 60 separate HTA reports 

just for the UK alone. We then need to satisfy the needs of the remaining ten or so countries. 

Point 2 

We therefore need to ask the question “Are we using the limited HTA resource appropriately?” Surely, 

a more appropriate use of HTA by governments would be to answer questions such as “how do we 

know whether we are spending too much on Pharmaceuticals given the health needs in the coming 

years? Or “How should we best organise and fund health care in order to serve patients needs?” To 

focus government HTA resource one assessing new medicines without answering these two 

questions seems to be “putting the cart before the horse”. It also forces the industry to divert research 

resources away from areas where we can add value to clinical decision making as stated above. 

We therefore conducted an in house survey of the use of HTA in reimbursement decisions over the 

past five years. We found that with the possible exception of the UK, in a significant number of 

cases, the HTA of pharmaco economic analysis was not read, not understood or not taken into 

account in the final decision. These findings are similar to those of the OECD study and other 

published studies. This gives us concern that our resources are not being fruitfully used and that we 

are missing an opportunity to apply this research in a more helpful way. 




Point 3 

We therefore asked the question “what would be needed in a country for HTA to be helpful? Do we 

have the right policy mix such that we can reap the benefits of HTA”? In discussion with experts and 

from published opinion, we came up with the following conditions that would be necessary before a 

country could benefit from HTA: 

• Clear health priorities 

• HTA should be used to improve the health gain we get for any given resource input rather than to 

control spending in any one sector 

• No budget silos in the health care system or other barriers to the reallocation of resource as might 

be recommended from an HTA analysis. 

• Accountability for quality health care 

• Health targets and accountability for achieving them. 

• Open debate with the public on health issues and priorities 

• Involvement of the public in valuing the outcomes that are indicated by a health technology 

assessment 

Other aspects of the current mode of decision-making in many countries limit the use of the HTA 

analysis such as: 

• Lack of transparency in the decision process i.e. explanation as to how the decision came about 

• Lack of involvement of all stakeholders beyond those who are responsible for one section of the 

budget such as the pharmaceutical budget. 

• Lack of HTA expertise amongst the departments who are asking for HTA analyses such that they 

cannot interpret the information they require. 

Overcoming these hurdles represents major reform in many European countries 

Point 4 

For us really to make HTA a useful tool in Europe, we need to be able to observe real practice. This 

raises the issue of access to data. Pfizer has had the benefit of good collaboration from the OECD 

and WHO data sets on health indicators and costs however these provide only limited precision. We 

need to increase the quality and broaden the type of data available at the country level so that we 

can observe real practice in the local context. Countries need to focus on achieving the infrastructure 

that provides data on care use, prescribing and outcomes in a useable form and the policies that 

allow appropriate access whilst maintaining patient confidentiality. This will be the key success facto 

for determining what is effective practice so that this can be used in setting guidelines. 




Patient involvement in NICE technology appraisals 

Monica Burchell 

What is NICE? 

The National Institute for Clinical Excellence (NICE) provides national guidance to the NHS on 

treatments and care for health care professionals and patients and their carers. Currently NICE 

produces three main types of guidance: 

1. the use of new and existing medicines and treatments within the NHS in England and Wales – 

technology appraisals. 

2. the appropriate treatment and care of people with specific diseases. and conditions within the NHS 

in England and Wales – clinical guidelines 

3. whether procedures used for diagnosis or treatment are safe enough and work well enough for 

routine use – interventional procedures. 

What impact does NICE have on patients? 

NICE decisions are based on research evidence of both clinical and cost effectiveness. NICE 

guidance impacts on patients by standardising access to health care across the country, creating 

national, rather than regional, standards of treatment. NICE also impacts on patients in some 

circumstances by not recommending treatments that are too expensive. This is because, within the 

limited resources available to the NHS, NICE has to balance the needs and wishes of individual 

patients and patient groups against the needs of the wider patient population. 

Patient involvement in NICE technology appraisals 

Technology appraisals are one of NICE’s three main work programmes. Patients and carers have the 

opportunity to get involved in a technology appraisal in a number of ways: 

• Becoming a ‘lay’ member of the technology appraisal committee (the people who consider the 

evidence and make the decision on the technology). As a lay member of the committee, patient 

and carer representatives can ensure that patient issues are addressed in the decision making 

process. 

• Participating as a ‘consultee’ to an appraisal – national patient or carer organisations can 

participate as consultees. Consultees are able to participate in many stages of a technology 

appraisal. They can: 

Comment on the scope of the appraisal 

Submit evidence to the Technology Appraisal Committee 

Comment on an independent compilation and analysis of the data available for the technology 

Comment on the Technology Appraisals Committee’s preliminary views 

Appeal (in certain circumstances) against the Committee’s final recommendations. 




• Attending the Technology Appraisal Committee meeting as a ‘patient expert’. Patient experts are 

able to speak directly to the Committee, and participate in consultation on the Committee’s 

provisional views. The patient experts help the committee understand both the condition and the 

impact (positive and negative) of the technology from a patient perspective. 

Why does NICE involve patients and what does it want from them? 

NICE believes that it is very important to involve patients and carers in the process of making 

decisions about their health care. Patients and carers help NICE to understand what it is like to live 

with a disease or disability and what the impact of a potential treatment means for them. 

NICE wants a balance of positive and negative views on issues that patients consider important. 

These may include patient and carer perspectives on: 

The effectiveness of the technology – how patients and carers value the technology both in its own 

right and compared to other treatment options. 

The appropriateness of the technology – is it appropriate for all patients or only for certain subgroups 

of patients with the condition? 

The acceptability of the technology – what factors influence patients’ willingness to use the 

technology? 

The impact of the technology on factors that matter most to patients including physical or 

psychological symptoms, disability, function, long term outlook, quality of life and lifestyle. 

Equity issues – the perspectives of significant groups or subgroups of patients who may be 

advantaged or disadvantaged in terms of access to the technology 

The Patient Involvement Unit at NICE 

NICE recognises that to be effective, patient, carer and public involvement needs support. The 

Patient Involvement Unit (PIU) is a dedicated team within NICE that provides information and support 

to patients and carers (both organisations and individuals) who contribute to technology appraisals. 

In developing and supporting opportunities for patient/carer input, the PIU: 

• Identifies national patient and carer organisations that may have an interest in acting as 

consultees. 

• Produces written information and runs workshops for patient and carer organisations interested in 

understanding more about how NICE appraisals are produced and how to contribute to their 

development. 

• Works with patient organisations to help identify patient experts. 

• Provides information and support to patient and carer experts. 

• Has just started to work directly with patients and carers to ensure that their views and 

experiences directly inform the work of the Technology Appraisal Committee: the first project 

undertaken involved making a video of people discussing the benefits and limitations of an 

education programme for parents of children with behavioural problems which was considered by 

the committee as part of its decision making process. 




Social insurance 

Josef Probst 

I want to contribute a few principal aspects to the discussion on pharmaceutical policy and HTA: 

1. The political responsibility in health care is shifting from the mere responsibility of making products 

and services available for all citizens to the greater responsibility of managing care in order to 

provide better health outcomes for the population. Input orientation is shifting to outcomes 

orientation, making the process of delivery more important. 

2. The European Countries should make efforts to set up health policy goals according to the “WHO 

21 Goals for the 21st Century” and define the steps and the evaluation criteria. It is interesting to 

watch the broad and thorough process in Germany (www.gesundheitsziele.de). Austria did not as yet 

start a consensual process to develop health policy goals at the national level, while some federal 

states already did so. This will lead to confusion, if we start too late at the national level while the 

federal states already have a set of different long-term goals. 

3. We are aware that 6% of the people need 50% of the resources of a health system. 20% use 80% 

of the resources. Knowing this, we should increase our efforts to ensure effective and efficient care 

for these groups, using the methods of Disease Management and Case Management. 

4. In addition to the responsibility of providing better outcomes, there is still a relentless pressure to 

make all medical goods and procedures available for everybody, regardless of the additional benefit 

and cost. Political decision makers can get trapped between the necessity to justify the reasonable 

spending of public money and the pressure to provide goods and services, -even if not scientifically 

justified - in unspecified individual cases. So there is a need for serious discussion. 

5. In Austria the available resources for HTA are very limited and there is not much international 

cooperation. The level and culture of the discussion is not yet up to international standards. 

6. There has been a stable culture of evaluating pharmaceuticals for reimbursement by the social 

health insurance in the Hauptverband, the Austrian umbrella organisation of social security 

institutions. 

Recently, the Hauptverband established a small HTA unit, responsible for evaluating medical 

procedures. The first task of this unit was to redesign the Austrian “Vorsorgeuntersuchung”, a 

screening programme for people over 19 years of age on the basis of internationally available 

knowledge, in cooperation with other European institutions. 

7. The multinational pharmaceutical industry can use centralised marketing authorisation processes 

in Europe. As a rule, these do not evaluate the additional therapeutic value of new drugs. In spite of 

this fact, industry pretends that new medicines are always better and deserve a higher price than 

previously available alternatives.. 

The health systems and payers do not have a powerful counter-part to industry which could define 

additional value and evaluate the outcomes of new treatments. In some cases it is obvious that the 

patients and the payers for the health system bear the personal and financial risk of unknown 

outcomes. Examples are hormone replacement therapy or VIOXX. 




8. There is an urgent need for an international register of clinical trials of pharmaceuticals, where all 

studies have to be registered before start. 

This is necessary to counteract the bias that results from suppressing studies with inconvenient 

results. 

9. Systematic outcomes research should be financed by the health systems. Up to now research, is 

mostly driven by the supply side not by the demand side. 




Summary 

Sabine Vogler 

Challenges of the pharmaceutical policy in the enlarged Europe 

The key point of Parallel Forum A3 on pharmaceutical policy in the enlarged Europe was the 

challenge which states have to meet by providing effective medicines for the whole population, thus 

encouraging innovation, while handling the issue of financing health care. 

As tight public budgets as well as changing parameters such as an increase in life expectancy or 

medical technological progress have created a need for health care reforms, pharmaceutical pricing 

and reimbursement issues are in the first place of the agenda in almost all European Member States. 

The focus of the reforms in the pharmaceutical sector is on cost containment, which is reflected in a 

restructuring of pricing and reimbursement systems in the course of the last years. 

The instrument of Health Technology Assessment (HTA) has constantly gained importance, which is 

also reflected in the setting-up of specialized institutes or agencies (for example, NICE in the UK). 

While, on the one hand, pharmaceuticals are considered as responsible for the rise in public health 

expenditure, the pharmaceutical industry, on the other hand, plays an important role as economic 

factor and source of innovation. There is fear that the European Union may lack behind the United 

States in innovation. 

The ‘twin issues’ of encouraging innovation and competitiveness versus the satisfactory delivery of 

public health were tackled in the G10 group, composed of high-level representatives of the European 

Commission, Member States, pharmaceutical industry and other stakeholders. 

Meeting the dilemma 

Facing this dilemma in pharmaceutical policy, Parallel Forum A3 was centred around the topics of 

pricing and reimbursement (Wednesday session), and Health Technology Assessment (Thursday 

session). 

The Wednesday session was chaired by Panos Kanavos from the London School of Economics. The 

opening speech was provided by Hugo Hurts, Director of the Department of Pharmaceutical Affairs 

and Medical Technology in the Dutch Ministry of Health, Welfare and Sport, who outlined ideas how 

to develop a public health oriented R&D agenda for pharmaceuticals, urging for a non-competitive, 

transnational research in the European Union. He was followed by Paul Weissenberg, Director from 

the European Commission’s Directorate-General for Enterprise who pleaded for the European Union 

to generate of growth and employment. He praised the efforts made in the G10 process, while 

reminding that the recommendations of the G10 process, which are mainly in the competence of the 

Member States, have to be implemented. The third key-level speaker of the opening session was 

Imre Hollo, Deputy Secretary of State in the Ministry of Health in Hungary, who highlighted 

challenges in pharmaceutical policy from the perspective of a new Member State. He discussed if 

public reimbursement is the only way to further competitiveness of the European-based 

pharmaceutical industry, stressing that competitiveness depends on several factors. 

Following these three key notes, the Wednesday session was devoted to pricing, reimbursement, 




and innovation issues. The ‘Pricing, Reimbursement, and Innovation’ strand was introduced by 

presentations from two key speakers, Brian Ager, Director General from the European Federation of 

Pharmaceutical Industries and Associations, and Kees de Joncheere, Regional Adviser on Health 

Technology and Pharmaceuticals of WHO Europe. A panel discussion with four different stakeholders 

(generic industry, pharmacists, social insurance, research) from different Member States closed the 

strand on pricing, reimbursement and innovation. 

The Thursday session focused on the instrument of Health Technology Assessment (HTA). The HTA 

session was chaired by Professor Finn Børlum Kristensen from the International Network of 

Agencies of Health Technology (INAHTA). With a similar structure as the strand on pricing, 

reimbursement, and innovation, the HTA part started with four presentations by key-speakers: 

Bernard Merkel, Head of Unit, from the European Commission’s Directorate-General for Health and 

Consumer Protection; Bengt Jönsson, Centre Director in the Stockholm School of Economics; Ian 

Gillespie, Head of Biotechnology Unit, OECD; and Chris Henshall, Director of the Science and 

Engineering Base Group in the UK Department of Trade and Industry and President of HTA 

International. Again, the presentations were followed by a panel discussion with six stakeholders 

from different countries (old and new Member States), highlighting the different perspectives (HTA 

institutes, patient, social insurance, medical device and pharmaceutical industry). 

Pricing, reimbursement, and innovation 

In several presentations, the G10 process was highlighted, which speakers considered, in general, 

as an important achievement, while stressing the need for implementing the political 

recommendations developed by the G10 group. 

One of the benefits of the G10 process mentioned in the course of Parallel Forum A3 was its 

bringing together of different stakeholders. Forum participants expressed their opinion that today 

there seems to be a greater understanding by the different stakeholders in pharmaceutical policy for 

the overall challenges, and there was agreement that the process of involving all stakeholders, which 

was also guaranteed in Parallel Forum A3, has to continue. 

Another effort by the European Union, which some speakers referred to, was the reviewal of the 

pharmaceutical legislation. However, Europe is far from harmonisation in the field of pharmaceuticals, 

as pricing and reimbursement are still mainly national affairs. In the course of the last decade, all 

Member States have been trying to control costs, as Ingrid Rosian-Schikuta from ÖBIG showed in 

their introductory overview on pricing and reimbursement in the panel discussion. Paul Bundgaard, 

Vice-President from the Pharmaceutical Group of European Union (PGEU), raised the problem of 

lacking adherence and misuse of drugs, which also has serious economic consequences. 

While cost-containment issues being a reality in the old Member States, the new Member States, 

with a significantly lower health status, are especially confronted with a need for investment in health. 

Furthermore, public administration in these countries have to meet high expectations posed by their 

populations with regard to health care. Kees de Joncheere from WHO Europe, pointed out that a 

penetration of relatively high priced, innovative medicines in the markets of the new Member States 

has been observed during the last years. 

The key point in the presentations and discussions in the Wednesday session was the concern that 

with regard to innovations the European Union lags behind the United States and the gap between 

the EU and US might even widen. Several speakers identified an underinvestment in research, 

training and education and called for actions in the field. One concrete recommendation was to 

establish a ‘European Technology Platform’ within the 7th EU Research & Development framework. 




A key discussion concerned the definition of innovation. While there was consensus that innovation 

should be promoted and rewarded, the opinions of the speakers and participants were divided on the 

point which new medicines are to be considered as real innovations. Imre Hollo from Hungary quoted 

a study by Prescrire that only 0.3% of 2,693 new drugs approved and patented over the past 22 

years provided a major therapeutic advance, and 2.7% provided important therapeutic benefits with 

certain limitations. 

Health Technology Assessment (HTA) 

Health Technology Assessment is the scientific collection, review and synthesis of information. Using 

the tool of HTA, several issues (clinical, organisational, economic, societal, and ethical aspects) 

should be covered. 

HTA is an instrument for decision-making, which has gained importance during the last years. This is 

also reflected in the founding of HTA agencies and institutes all over Europe, whose experts were, to 

a great extent, present in Parallel Forum A3 in their role as speakers, panel participants or delegates. 

While strengthening the cooperation between HTA institutes (for example, the International Network 

of Agencies of Health Technology INAHTA), HTA in the European Union remains mainly a national 

issue. In his key note, Dr Bernard Merkel from the Directorate-General for Health and Consumer 

Protection of the European Commission discussed benefits and risks of HTA at EU level. 

Speakers and panel participants contributed to make the relatively new tool better known, and to 

highlighted its strengths and weaknesses. Chris Henshall, President of HTA International, pointed out 

that HTA reports often only focus on effectiveness, cost-effectiveness and/or financial cost, 

neglecting societal aspects. 

Speakers and panel participants made it clear which role HTA, acting as a bridge between R&D, 

technology and decision, can be play: It is a tool to support informed decisions on health care; 

however, HTA does not make decisions. HTA seeks to inform decisions with science, but the health 

care decisions are made by those accountable for them. In this respect, speakers and participants 

identified a need for the dialogue between HTA experts and decision-makers to be improved. 

Additionally, there was agreement that HTA has be policy-driven. 

The HTA session of Parallel Forum A3 concluded that HTA is just one instrument which decisionmakers 

might take advantage of. For optimising HTA in Europe, more investment in HTA was 

considered as necessary. 

Conclusion 

One of the key observations made in the course of Parallel Forum A3 was that the European Union 

and the Member States have an important role to play in guaranteeing affordability and accessibility 

to effective medicines. Speakers and participants agreed on this point, and there was consensus that 

the involvement of all stakeholders is crucial. 

Parallel Forum A3 covered numerous aspects of pharmaceutical policies in the enlarged Europe, 

ranging from ‘evergreen’ issues like reimbursement and innovation to recent developments with 

regard to enlargement or modern approaches like HTA. Furthermore, there was a wide range of 

speakers and panel participants from different countries (old and new Member States) and a mix of 

different stakeholders. Thus, Parallel Forum A3 offered a confrontation of different perspectives, and 

anticipated one of the recommendations of the forum, i.e. to get all stakeholders on board. 



Forum BI 

What determines health? 





��Joop ten Dam The wider determinants of health: from theory 249 

to practice (abstract) 

��Sarah Wamala Tackling the wider determinants of health – 250 

developing practice (abstract) 

Climate change and extreme weather: new challenges for public health? 

��Bettina Menne and Tanja Wolf Climate change: risks for human health in Europe 251 

Health and the impact of the housing and the urban environment 

��Xavier Bonnefoy Text not available 

Tackling the social determinants of health: the role of the social partners 

��Howard Klee World Business Council for Sustainable Development 266 

(WBCSD) health programme (abstract) 

��Georg Ziniel Text not available 

��Jonathan Mogford Text not available 

��Ineta Pirpktina Text not available 

National health promotion policy to address inequalities 

��Elizabeth Pott Text not available 

��Graham Robertson Text not available 

��Gerard Molleman Health policies to address inequalities: 268 

the situation in the Netherlands 

��Luigi Bertinato National health promotion policy to address 270 

inequalities: the Veneto Region 

��Katrin Saluvere Text not available 

Page 




��Tamsin Rose Text not available 

��Anthony Morgan Summary 271 





Joop ten Dam 

Abstract 

Inequalities in health between and within European countries are widespread, serious, persistent and 

– in most cases – growing. 

Joop ten Dam will describe the facts, and the historical and future trends in inequalities in health in 

Europe. The central question emerging from these trends is: what causes are underlying health and 

these inequalities? What makes inequalities in health so persistent? Following these causes he will 

discuss the opportunities for policy and integrated health policy. Special attention is given to the 

change in paradigm in health promotion from health education to the local or community-approach. 

This shift is analogous to the widely respected slogan: think global, act local! 




Tackling the wider determinants of health – developing practice 

Sarah Wamala 

Abstract 

Population health is determined by a number of factors ranging from genetic predisposition to 

environmental and socioeconomic factors. Wider determinants of health include both down-stream 

and up-stream factors and operate at various levels, including; (i) Globalisation (international policies, 

migrations), (ii) Context (public and neo-liberal policies, political history, cultural context (norms and 

values, religion, discrimination), natural environment (air quality and other contaminants), (iii) 

Community (health services, physical environment (school, housing, workplace, transport), social 

environment (social capital, cohesion, participation, safety), economic environment (employment, 

income distribution, education), public health programs, collective lifestyles (diet, physical activity, 

sexual practices, addiction, health information), and, (iv) Individual characteristics (genetics, early 

childhood, socioeconomic status, behavioural and psychosocial attributes). 

Given this fact, any health-related policies intended to reduce avoidable health inequalities may only 

be effective if they are implemented in a broader perspective. Health policies should be integrated 

with other policies, such as social security, labour market, education, housing, environmental 

protection, immigration and policies. It should be noted that determinants of health vary by gender 

and age, thus health policies need to apply both gender and life-course perspectives. 

Tackling wider determinants requires political action both at national and international levels, thus 

involvement of the state and politicians is inevitable. A similar initiative has been launched by a few 

countries, such as Sweden and UK. As recently as last year, the Swedish parliament passed the 

Government’s Public Health Objectives Bill and presented a national public health policy. The 

Swedish public health policy is pro-equity and is based on 11 objectives containing wider 

determinants of health mainly at societal level. 

In conclusion, ‘multi-thinking’ is the way to go when tackling wider determinants of health. There is a 

need to think in terms of multi-strategies, multi-policies, multi-sectoral, multi-politics, multi-practices, 

multi-levels, multi-points in time, and multi-national health campaigns. 




Climate change: risks for human health in Europe 

Bettina Menne and Tanja Wolf 

Climate change in Europe 

Weather is an ancient human health exposure, says Hippocrates, in ‘On Airs, Waters and Places’, 

circa 400 BC.[1] History has shown that weather and climate variability are important determinants of 

health but can also become a hazard when it operates at the extreme range of ‘distribution’ of natural 

variabilility. Although there is still considerable uncertainty about the rates of climate change that can 

be expected, it is now clear that these changes will be increasingly manifested in important and 

tangible ways, such as changes in extremes of temperature and precipitation, decreases in seasonal 

and perennial snow and ice extent, and sea level rise.[2] Further, climate change may alter the 

frequency, timing, intensity, and duration of extreme weather events.[3] This paper summarizes 

briefly some important research findings and describes some of the important recent political 

developments.* 

For millennia, the greenhouse effect has facilitated a balance between incoming solar radiation and 

outgoing terrestrial radiation; a change in either incoming or outgoing radiation modifies the surface 

temperature of the Earth. Currently, carbon dioxide averages around 370 parts per million (ppmv) in 

the atmosphere, meanwhile pre-industrial concentrations were about 280 ppmv. CO 2 concentrations 

have not been this high in the past 400,000 years. 

Figure 1: Past and future changes in global mean temperature 

Source: Hadley Center for Climate Research 

Human constant 

comparable observations 

of the ‘weather’ at 

multiple sites are recent. 

Since 1861, the global 

surface air temperature 

has increased [4] and for 

most locations across 

Europe, increases in 

minimum temperature 

appear to be greater than 

in maximum temperature 

[5] (Figure 1). Several 

studies observed a 

warming tendency in 

winter extreme lowtemperature 

events and 

summer extreme hightemperature 

events.[6,7] 

* “Climate Change and Adaptation Strategies for Human Health” (cCASHh) was funded by the European 

Commission within its fifth framework programme under Thematic Programme: Energy, Environment and 

sustainable development (EESD-1999) and the Key action: Global change, climate and biodiversity. The project 

started on 1 May 2001 and is expected to end on 31 July 2004. The assessment mainly includes the EU-25 

countries. www.euro.who.int/ccashh 




Figure 2 

Impact of climate change on temperature 

Other authors observed an increase 

of the duration of heat waves.[8] 

Luterbacher, Dietrich, Xoplaki et al. 

show that the summer 2003 was by 

far the hottest since 1500. [9] 

Beniston shows that the 2003 heat 

wave bears a close resemblance to 

what many regional climate models 

are projecting for summers in the 

latter part of the 21st century.[6] 

Schar and Jendritzky show that this 

heat wave is statistically very 

unlikely given a shift in the mean 

temperature.[10] An increase in 

variability is needed to adequately 

explain the probability of such an 

event occurring. This is also 

debated by the IPCC. 

Figure 2 illustrates three possible 

scenarios of climate change with its 

impact on temperature: (1) an 

increase in mean temperature may 

result in less cold weather, in more 

hot weather and more record hot 

weather; (2) an increase in variance 

may result in more cold and hot 

weather as well as in more record 

cold and record hot weather; and 

(3) an increase of mean and 

variance might tend towards less 

change in cold weather, but may 

add to a significant increase in hot 

as well as record hot weather.[4] 

Europe experiences three types of 

floods: flash, riverine, and storm 

surges. The risk of floods will 

probably increase during the coming decades. Two trends point to this. Firstly, the magnitude and 

frequency of floods are likely to increase in the future as a result of climate change, i.e. higher 

intensity of rainfall as well as rising sea levels. Secondly, the impact of flood events may increase, 

because more people live in areas at risk of flooding and also more economic assets (business and 

industry) are located in such areas. Moreover, human activities such as the clearing of forests, the 

straightening of rivers, the suppression of natural flood plains and poor land planning, have 

contributed significantly to increasing the risk of floods. In 2002, the flooding in central Europe was of 

unprecedented proportions, with dozens of people losing their lives, extensive damage to the 

socioeconomic infrastructure, and destruction of the natural and cultural heritage. Germany, the 

Czech Republic, and Austria were the three countries most severely affected. Estimates of the 

economic and insured losses were EUR 11.0 billion in Germany, EUR 3.9 billion in the Czech 

Republic, and EUR 3.4 billion in Austria.[11] 

Using global climate models, climate change scenarios have been developed forecasting what could 




happen under different atmospheric concentrations of CO 2 . In general, temperatures will increase 

over land; the exact amount is not known. There will also be changes in precipitation. In Europe, 

there will be less precipitation in the southern areas and increased precipitation in the northern 

areas. Projections at national, regional, and local levels are uncertain. Included in the range of 

projections for this century are thawing of the permafrost and an ice-free Arctic. 

Climate scientists project the following outcomes for Europe: 

1. More frequent extreme high temperatures and less frequent extreme low temperatures, with an 

associated increase (decrease) in cooling (heating) degree days; 

2. An increase in daily minimum temperatures in many regions that will exceed the increases for 

daytime maximum temperatures; 

3. Daily temperature variability will decrease in winter but increase in summer; 

4. There will be a general drying of mid-continental areas during summer; and 

5. There will be an increase in precipitation intensity in some regions. 

Confidence in such projections exists because trends in observed weather and climate extremes for 

Europe in many ways match the expected outcomes of climate change. 

The health impacts of climate change 

The overall health impacts of climate change might be far reaching and are complex. There will be 

losers and winners. Figure 3 illustrates the complex process of global driving forces, environmental 

changes, human exposure and the potential health effects. 

Figure 3 Climate change and health: pathway from driving forces through 

exposure to potential health effects 

Source: 

adapted from 

McKichael et 

al, 2002. 




In 2001, the WHO carried out the Burden of disease assessment of selected environmental risk 

factors. By using a comparative risk assessment, it was estimated by the WHO, that climate change 

was responsible in 2000 for approximately 2.4% of worldwide cases of diarrhoea, 6% of malaria 

cases in some middle income countries and 7% of dengue fever cases in some industrialized 

countries. In total, the attributable mortality was 154,000 (0.3% of total) deaths and the attributable 

burden was 5.5 million (0.4% of total) DALYs. About 46% of this burden occurred in South East Asia, 

23% in Africa and a further 14% in the Eastern Mediterranean Region.[12] However due to the lack 

of transferable models and studies no further health outcomes could be estimated thus highly 

underestimating the burden of disease due to climate change. 

The health impacts of temperature extremes 

Historically the relationship of temperature and mortality shows a V-like function with an optimum 

temperature (average temperature with lowest mortality rate), which varies with location and climate 

of a place.[13,14] For each degree rise above the 95th percentile of the two day mean, mortality 

increased by 1.9% in London and 3.5% in Sofia and without lag.[15] In several studies in the United 

States a strong association of the temperature-mortality relation with latitude was found with warmer 

temperatures associated mortality in more-northern, usually cooler cities in the United States, 

[13,16,17] however, this seems not to be confirmed for Europe.[18] Several heat waves have 

affected the European Region during the last decades 

Table 1 Heat wave events and attributed mortality in Europe 

Heat wave 

event 

1976 

London, UK 

1981 

Portugal 

1983 

Rome, Italy 

1987 (21/7–31/7) 

Athens, Greece 

1987 

Greece 

(all urban areas 

except Athens) 

1991 (12/7–21/7) 

Portugal 

1995 (30/7–3/8) 

London, UK 

1994 (19/7–31/7) 

Netherlands 

Attributable 

mortality 

(all causes) 

9.7% increase England and 

Wales. 

15.4% Greater London 

1906 excess deaths 

406 in Lisbon in July 

35% increase in deaths in 

July in 65+ age group 

estimated excess mortality 

> 2000 

32.5% increase in deaths in 

July 

Baseline 

measure 

31-day moving average of 

daily mortality in same year. 

Reported 

number of 

diagnosed 

(certified) heat 

deaths 

References 

McMichael and 

Kovats, 1998 

Predicted values 63 Garcia et al., 

1981 

Compared to deaths in same 

month in previous year 

Time trend regression 

adjusted 

Average July mortality for 

1981–1986 

997 excess deaths Predicted values 

11.2% (768) in England and 

Wales. 

23% (184) Greater London 

24.4% increase, 

1057 (95% CI 913, 1201) 

Source: adapted from Kovats et al 


daily mortality in previous 

two years 


previous two years 

Todisco, 1987 

926 Katsouyanni et 

al., 1988 

Katsouyanni et 

al., 1993 

Unknown Rooney et al., 

1998 

Not reported Huynen et al., 

2001 




Table 2 Estimation of excess death in Europe during heat wave 2003 

Country Time period in 

2003 

Excess death Compared to Reference 

Portugal 30.07 – 15.08 1952 Biennium 2000–2001 

Spain (52 capitals 

of provinces 

Italy 

(23 capi luoghi) 

2229 12.07 – 28.07.03 

1848 2001 

1854 1997 – 2001 

Botelho et al, 2004 

1.06 – 31.07 3166 Poisson regression from June– 

August 2003, 1990–2002 

Navarro et al, 2004 

1.06 – 15.08 3134 2002 Centro Nazionale de 

Epidemiologia, 2003 

Italy (Milan) 1.06 – 31.08 559 

Italy (Turin) 1.06 – 31.08 577 

Italy (Rome) 1.06 – 31.08 944 

France 

(12 cities) 

Germany 

(Baden- 

Wuerttemberg) 

England and 

Wales 

Switzerland 

(Tessin) 

Smoothed average of same 

day 1998–2002 

1.08 – 20.08 14802 Smoothed average of same 

day 1998–2002 

1.08 – 22.08 1415 

1.08 – 29.08 1357 

1.08 – 14.08 1193 

Calculations based on average 

of last five years 

Bisanti et al, 2004 

Institut de Veille 

Sanitaire, 2003 

Sozialministerium 

Baden-Wuerttemberg, 

2003 

4.08 – 13.08 2045 Average for the last five years Office for National 

Statistics, 2003 

No significant excess death in summer 2003, slight increase of 

deaths from 9.06 – 30.06 compared to generally expected deaths 

Cerutti et al, 2004 

Impacts have been elaborated in descriptive studies, mainly examining excess mortality. Excess 

mortality is calculated by subtracting the expected mortality from the observed mortality. The 

expected mortality is calculated using a variety of measures to construct averages of similar time 

periods of previous years. Results are difficult to compare because of the different denominators 

used. Table 2 reports excess mortality rates from various country specific reports to the WHO 

following the 2003 heat wave. 

Heat stress seems to most affect the aging population. Vulnerability depends on where you live, your 

age, your pre-existing disease status, access to health care and your public health infrastructure.[19] 

A review of several epidemiological studies on heat and health underlines that persons at highest 

risk of death following heat-waves are over 60, or work in jobs requiring heavy labour, or live in inner 

cities and lower-income census tracts and thus are exposed either to low economic status or higher 

temperature – or both.[20,17] Prominent causes of death in studies of heat waves and elevated 




temperature were cardiovascular diseases, respiratory diseases, cerebrovascular diseases and 

mental illness.[20] People with pre-existing illness, especially heart and lung diseases are at higher 

risk of dying in heat waves. In fact, cardiovascular and respiratory causes of deaths are most 

strongly linked with changes in temperature and this makes elderly people and people with impaired 

health but also those suffering from poor social conditions most susceptible to impact of weather 

changes.[21,22] Also mental illness shows a positive association with heat-related death.[23] 

The adverse health effects of heat are more evident and more often studied in urban areas. The 

Urban Heat Island, as the fact that within cities the ambient air temperature is higher than in the 

surroundings, poses to risk the urban inhabitants’ health.[24] Many of today’s large cities tend to 

amplify extremes of temperature. The heat island in summer is because of the expanse of brick- and 

asphalt heat-retaining structures, the treeless expanses of inner cities and the physical obstruction of 

cooling breezes.[25] The health of urban inhabitants may in addition be impaired due to urban air 

pollution from industry and traffic.[26,27] 

Beneath the demographical risk factors there are behavioural risk factors like living alone, being 

confined to bed, not being able to care for oneself, having no access to transportation or not leaving 

home daily and social isolation.[28] Similar findings have been drawn also from the 2003 heat wave 

in France. A case-control study [29] highlights the significant correlation with death during the heat 

wave of socioprofessional categories (workers at risk), the degree of autonomy (people confined to 

bed at risk or not autonomous in getting washed and dressed), the health status (at risk patients with 

cardiovascular, psychiatric or neurological diseases) and the quality of thermo-isolation of the home. 

To wear less clothes and the use of a ‘refreshment measure’ have shown some protective effect.[29] 

However, much more efforts are needed to understand how best predict, detect and prevent the heat 

waves associated health impacts and how best to target intervention strategies. This will be the 

subject of a EC funded project, called EuroHEAT, which will be starting in 2005. 

Health impacts from cold spells can be classified as being derived from acute exposure (hours, days) 

as well as chronic exposure to cold (weeks, month, years). Exposure to cold temperatures can result 

in several negative health consequences, including death, disease, injury, other health complaints, 

degradation of performance, and degradation of motivation. Accidental cold exposure occurs mainly 

outdoors, in socially deprived people, workers, alcoholics, the homeless, the elderly in temperate 

cold climates. A simple lack of awareness combined with a lack of protective clothing, for instance, 

may carry a risk of death from hypothermia even during outdoor temperatures as mild as 0°C. The 

onset of air-related frostbite appears at an environmental temperature of -11°C. Wind, high altitude 

and wet clothing lead to onset of injury at higher environmental temperatures. The incidence of more 

serious frostbite requiring hospital treatment increases at temperatures of -15°C and below. Mortality 

with respect to chronic exposure to cold is subject to seasonality. In many temperate countries ‘allcause 

mortality’ as well as cardiovascular and respiratory mortality is higher during the winter 

months. Some epidemiologists use the term excess winter mortality to describe this seasonal 

phenomenon. Most European countries suffer from 5–30% excess winter mortality. Ironically, 

increases in mortality because of cold temperatures occur more often in the warmer regions of 

Europe compared the colder regions. By means of protective clothing and a better infrastructure, 

North Europeans seem to be better adapted to extreme cold conditions. However there is significant 

scientific debate and uncertainty on whether the warming occurring will be beneficial in reducing 

winter seasonal mortality. 

Health impacts of extreme weather events 

The Intergovernmental Panel on Climate Change (IPCC) defines an extreme weather event as “an 

event that is rare within its statistical reference distribution at a particular place” and continues: 

“Definitions of ‘rare’ vary but an extreme weather event would normally be as rare or rarer than the 




Figure 4 European Map showing sites of floods since the 19th century 

10th or 90th percentile”.[4] An event may be further considered extreme merely if some of its 

characteristics, such as magnitude, duration, speed of onset or intensity, lie outside a particular 

society’s experiential or coping range, whether or not the event is rare.[30] Figure 4 illustrates a 

European Map of sites of floods that occurred since the 19th century. Events as registered by the 

EmDAT database were used for the compilation of this map. 

The adverse human health consequences of flooding can be complex, far-reaching, and difficult to 

attribute to the flood event itself.[31] Floods can cause major infrastructure damage, including 

disruption to roads, rail lines, airports, electricity supply systems, water supplies, and sewage 

disposal systems. The economic consequences are often greater than indicated by the physical 

effects of floodwater coming into contact with buildings and their contents. Economic damage may 

reach beyond the flooded area and last longer beyond the event.[32] 

Adverse health impacts of flooding can arise from a combination of some or all of the following 

factors: characteristics of the flood event itself (depth, velocity, duration, timing, etc.); amount and 

type of property damage and loss; whether flood warnings were received and acted upon; the 

victims’ previous flood experience and awareness of risk; whether or not flood victims need to 

relocate to temporary housing; the clean-up and recovery process, and associated household 

disruption; degree of difficulty in dealing with builders, insurance companies, etc.; pre-existing health 

conditions and susceptibility to the physical and mental health consequences of a flooding event; 

degree of concern over a flood recurrence; degree of financial concern; degree of loss of security in 

the home; and degree of disruption of community life. 

The physical health effects can be further categorized into direct effects caused by the floodwaters 

(such as drowning and injuries) and indirect effects caused by other systems damaged by the flood 

(such as water- and vector-borne diseases, acute or chronic effects of exposure to chemical 

pollutants released into floodwaters, food shortages, and others) (Table 3).[33] There is a common 

perception that the problems associated with a flooding event end once the floodwaters have 

receded. However, for many victims, this is when most of their problems begin. 




Table 3 Direct and indirect health effects of floodwaters 

Causes Health implications 

Direct effects 

Stream flow velocity; topographic land features; 

absence of warning; rapid speed of flood onset; 

deep floodwaters; landslides; risk behaviour; 

fast flowing waters carrying boulders and fallen trees 

Air pollution and health effects 

Drowning 

Injuries 

Contact with water Respiratory diseases; shock; hypothermia; 

cardiac arrest 

Contact with polluted waters Wound infections; dermatitis; conjunctivitis; 

gastrointestinal diseases; ear, nose and throat 

infections; possible serious waterborne diseases 

Increase of physical and emotional stress Increase of susceptibility to psychosocial 

disturbances and cardiovascular incidents 

Indirect effects 

Damage to water supply systems; sewage and sewage 

disposal damage; insufficient supply of drinking water; 

insufficient water supply for washing 

Possible waterborne infections (enterogenic E. coli, 

Shigella, hepatitis A, leptospirosis, giardiasis, 

campylobacteriosis); dermatitis and conjunctivitis 

Disruption of transport systems Food shortage; disruption of emergency response 

Underground pipe disruption; dislodgement of storage 

tanks; overflow of toxic waste sites; release of chemicals; 

rupture of gasoline storage tanks may lead to fires 

Standing waters; heavy rainfalls; expanded range of 

vector habitats 

Potential acute or chronic effects of chemical 

pollution 

Vector-borne diseases 

Rodent migration Possible diseases caused by rodents 

Disruption of social networks; 

loss of property, jobs and family members and friends 

Possible psychosocial disturbances 

Clean-up activities following floods Electrocutions; injuries; lacerations; skin punctures 

Destruction of primary food products Food shortage 

Damage to health services; 

disruption of ‘normal’ health service activities 

Source: Menne et al., 2000. [33] 

Decrease of ‘normal’ health services; 

insufficient access to medical care 

Climate change and air pollution have one common cause: combustion of fossil fuels. Thus, CO 2 

emissions are paralleled by emissions of other air pollutants such as particles, nitrogens, carbon 

monoxide, sulphur dioxide or volatile organic compounds, causing a broad range of health damage 

including asthma attacks, respiratory symptoms and infections, reduced lung function, doctors visits 

and hospitalisation and premature death. Bernard et al. described, for the USA, the framework that 

links climate and air pollutants.[34,35] The associations may, in some scenarios, not be 




straightforward nor linear in nature and also depend on local adaptive responses to climate change. 

However, large fractions of both CO 2 and air pollutants share the same sources. The public health 

impact of air pollution related ‘side effects’ of greenhouse gas emissions are expected to be 

considerable, both in southern and northern countries.[35] Weather conditions affect air pollution by 

transport and/or formation of a pollutant or its precursor. Climate change may affect exposures to air 

pollutants via several mechanisms [36] such as altering weather patterns (for example, winds and 

frequency of temperature inversions) and thereby decreasing or increasing local and regional 

pollution concentrations, increased combustion because of anthropogenic changes, affecting natural 

sources of air pollutant emissions and changing the distribution and types of airborne allergens (for 

example, pollen and mould spores).[37] The most direct effect of climate change may be the impact 

of increased temperature on concentrations of ground-level ozone but the magnitude of change is 

uncertain, as it will be affected by the changes in the frequency of hot days rather then the mean 

temperature. High temperatures also have acute effects on mortality. Some studies have found 

evidence of an interaction between the effects of ozone and the effects of higher 

temperatures.[38,26] The European APHEA analyses reported larger air pollution effects in regions 

with higher temperature. Whether this modification is a real effect or rather due to reduced exposure 

precision in cold regions where people spend more time indoors in better sealed houses, is not clear. 

Indeed, other studies addressing the combined effects of weather and particulate air pollution have 

not found evidence of such an interaction. Correlations between climate and site-specific air quality 

variables must be further evaluated and, in some instances, needs to include temperature, pollution 

and interaction terms in regression models. The formation and destruction of ozone is accelerated by 

increases in temperature and ultraviolet radiation (UVR). Existing air quality models have been used 

to examine the effect of climate change on ozone concentrations. The models indicate that 

decreases in stratospheric ozone and elevated temperature increase ground-level ozone 

concentration. An increase in occurrence of hot days could potentially increase both biogenic and 

anthropogenic emissions of volatile organic compounds, for example, from increased evaporative 

emissions from fuel injected automobiles. 

The prevalence of asthma, allergic rhinitis, allergic conjunctivitis and eczema in Europe has 

increased during the second half of the 20th century. The sensitization to pollen allergens has also 

increased in many areas in Europe. The geographical distribution of plants with allergenic pollen and 

allergic sensitivity to pollen allergens varies greatly across Europe. But on average the length of the 

growing season in Europe has increased by 10–11 days over the last 30 years. An earlier start and 

peak of the pollen season are more pronounced in species that start flowering earlier in the year. The 

duration of the season is extended in some summer and late flowering species. 

Evidence is growing that climate change might facilitate the geographical spread of particular plant 

species to new areas as they become climatically suitable. Warming is likely to further cause an 

earlier onset and may extend the duration of flowering and pollen season, for some species (such as 

grasses and weeds). Some species, such as ragweed and mugwort, present particular risks for 

health, and require land use measures, maintenance of public areas, or eradication. The impact of 

climate change on the incidence, prevalence, distribution and severity of allergic disorders is still 

uncertain.[37] 

Water- and food-borne diseases 

Environmental temperature is considered an important factor in the transmission infections of 

bacterial agents causing enteritis. Pathogens such as salmonella multiply at room temperature. On 

average, a linear association between environmental temperature and the number of reported cases 

of salmonellosis above a threshold of approximately 6ºC in European populations has been 

found.[39] Higher temperatures around the time of consumption appear to have a greater effect on 

cases than temperature at longer lag periods. All other things being equal, warmer summers in 




Europe may lead to an increase in the number of cases of food-borne disease unless 

recommendations for storage, refrigeration, etc are enforced/complied with. The increase in cases 

would, however, be dependent on the overall baseline incidence of the disease in the population. 

Reported salmonellosis is declining in many European countries due to active control measures. 

Diseases associated with water are varied and cover multiple environmental pathways. Some 

notable outbreaks of water-borne disease (such as cryptosporidiosis) have been associated with 

heavy rainfall events. At present, there is insufficient evidence to estimate the role of rainfall 

extremes in disease outbreaks in Europe, and it is not possible to assess whether climate change 

would have an overall impact on the burden of water-borne disease in Europe. 

The mechanisms by which temperature facilitates infection by salmonellas need to be investigated 

further before recommendations can be made with respect to critical control points. Food safety 

regulation is an area of public health that is already subject to heavy regulation at the national and 

European level. Current regulation and improved compliance, especially with regard to storage and 

refrigeration, is the most important strategy to address the potential affects climate change. 

Vector- and rodent-borne diseases 

There is an observed recrudescent of vector- and rodent-borne diseases caused by factors that 

increase the prevalence, incidence and distribution of vector-borne diseases, introduce new vectors 

into Europe and contribute to the establishment of new vector-borne diseases. Global warming is one 

of the factors together with increased migration and tourism, population densities, changes in land 

use and agriculture practices, as well as delayed diagnoses. Climate change may have a more 

immediate effect on mosquito and tick populations and only later on mosquito- and tick-borne 

diseases. With increased average temperatures, the length of the breeding seasons for mosquito 

populations would be extended and population densities would increase. Warmer northern climates 

would cause an expansion of the distribution of species now found only in warmer climates. Should 

these changes occur, it seems likely that the distribution of mosquito-borne diseases would also 

subsequently expand. 

Extensive literature reviews and empirical studies have been carried out within CASH, a summary is 

reported here. Climate has a direct influence on malaria transmission by either hindering or 

enhancing vector and parasite development and survival. Numerous laboratory and field studies 

have documented the influence of precipitation and temperature, which can be summarized as 

follows: Weather is a primary determinant of whether the conditions in a particular location are 

suitable for malaria transmission. In Europe, mean monthly temperature and rainfall are associated 

with the development of malaria parasites. Note that having a climate suitable for malaria 

transmission does not mean that the disease will be prevalent. The mosquito vectors that transmit 

malaria are present in much of Europe, but the disease is controlled through diagnosis and treatment 

of patients, preventing further transmission. A change in temperature may lengthen or shorten the 

season during which mosquitoes or parasites can survive. Changes in precipitation or temperature 

may result in conditions during the season of transmission that are conducive to increased or 

decreased parasite and vector populations. The effect of recent climatic changes in the region is not 

possible to evaluate due to the lack of consistency of historic data. 

Future changes in climate will without doubt have implications for the endemicity of Visceral 

Leishmania (VL) in Europe. The distribution of the different sandfly vector species are clearly 

temperature dependent. Increased temperatures may cause the vectors’ distribution ranges to 

expand northwards and into higher altitudes. In currently endemic areas, higher temperatures and 

prolonged summer seasons would lead to increased risk of VL through impacts on sandfly 

abundance and biting activity. Higher temperatures are also likely to accelerate the maturation of the 

protozoan parasite. Some localities in southern and Eastern Europe may become too hot and dry for 




vectors to survive, although sandflies may adapt by resting in cool, humid places during the day. 

Ticks may live for 3 to 6 years and are highly sensitive to changes in seasonal climate. Favourable 

conditions for tick abundance are milder and shorter winters; and a longer, warmer and more humid 

period from spring through autumn. During what has in general been the milder climate in Europe 

since the mid-1980s, ticks have been able to establish themselves at higher latitudes in Sweden and 

higher altitudes in Central Europe. Further changes in climate will impact not only the survival and 

abundance of ticks directly and indirectly (the latter through effects on the habitat and reservoir 

animal density) but may influence human exposure to infected ticks. Climate-induced changes in 

land-use and recreational behaviour will, for example have an impact on risk populations and risk 

periods. High-risk populations are people living and working in forested areas. Latitudinal changes in 

TBE incidence have been observed in Sweden; altitudinal distribution changes have been observed 

in the Czech Republic; and a shift of the TBE incidence towards spring and autumn months have 

been recorded. 

Uncertainty on the climate variability and change role exist for West Nile Fever (WNF) and 

Hantavirus infections. The apparent emergence of WNF in Europe during the past decade has 

probably been caused by a whole complex of ecological factors, including simultaneous presence in 

a specific geographic area of (a) favourable weather conditions (temperature, humidity, and their 

appropriate annual distribution); (b) abundant competent mosquito vectors (Culex pipiens pipiens, 

Cx. modestus, Mansonia richiardii), which requires the presence of favourable habitats; (c) infected 

(viremic) migrating birds; (d) abundant competent (viremic) local avian hosts; (e) abundant competent 

bridge vectors (Culex pipiens molestus, Aedes spp., etc.) able to feed on both birds and mammals; 

and Susceptible population of equines and/or humans (as 'dead-end' or occasional vertebrate hosts). 

No quantitative investigations of the relationship between climate and the WNF incidence have been 

carried out to date. Nevertheless, direct influence of temperature on arbovirus infection and 

transmission rates of mosquitoes was shown and thus also the climate influence on intensity of 

arbovirus circulation. Further research is therefore necessary. Hantaviruses are prevalent throughout 

most of Europe. 

Conclusions 

Several major conclusions emerged from the research projects and from several meetings that were 

organized by the WHO between 2001 and 2004. There is growing recognition that climate variability 

and change are causing serious risks to human health. Changes in climate may be experienced as 

gradual changes in mean meteorological variables, such as linear increases in minimum temperature 

or average precipitation; as changes in the variance, such that extreme events become more or less 

common; as changes in both the mean and variance; or as a fundamental shift in the climate. How 

much climate variability may increase over the next decades is highly uncertain. 

There are many challenges to scientists. These can be mainly summarized into five questions: 

1. What are the current health effects of weather and climate variability? 

2. How much disease is attributable to climate change? 

3. What are the early effects of climate change? 

4. Who will be most exposed and vulnerable? 

5. What additional prevention, adaptation is needed to cope with climate change? 

Many of these questions are currently addressed in research and policy activities. However there are 




still methodological and uncertainty 

challenges which not rarely obstacle 

developments. Current health impact 

research approaches on global changes 

focus on observational studies, integrated 

assessment and mathematical modelling. 

There is a lack of long time information and 

spatial and temporal comparabilities. 

Integrated assessments and modelling 

apoproaches are surrounded by increased 

rates of uncertainty, sometimes making it a 

‘best guess’ exercise and thus delimitating 

its value in epidemiology and public health. 

However, there is an increasing need also in 

public health to address ‘futures’ and thus 

increasinly using scenario and modelling 

approaches. 

Despite research challenges, what is certain 

is, that increasing climate variability will 

challenge public health systems. These 

possible changes require policy makers at all 

levels to take a proactive, anticipatory 

approach to designing strategies, policies 

and measures to reduce current and future 

burdens of climate-sensitive diseases. This 

was also reflected in the 4th Ministerial 

Conference for Environment and Health, 

hold in Budapest in June, 2004 (see Box 1) 

In order to effectively prevent potential health effects of climate variability and be sufficiently 

anticipatory, there is a need to develop, improve or strengthen early warning and prediction systems 

as well as imroving the outreach, educational and informational component. This is only possible 

through the collaboration with several actors such as the meteorological services, the media, general 

practitioners and emergency services. Little is known about the cumulative effectiveness of most of 

these systems. 

Further our current available systems available for early disease detection might not be sufficiently 

sophisticated, informatized and not rapid enough to deal with surprises. An example was given 

during the 2003 heatwave in France that the diagnosis of heat related mortality was only possible 

after the exclusion of potential epidemic infectious diseases. Although Europe is well-equipped it will 

not be entirely immune against surprises. Thus prediction, detection and prevention of the health 

impacts of climate change are becoming central elements in public health planning and should be 

further addressed. Monitoring changes over long time periods is essential in this regard. Current 

developments on environmental health infomration system would benefit from including some climate 

change related health indicators. 

References 

Box 1 

“We (Ministries of Health and Environment) recognize 

that climate is already changing and that the intensity 

and frequency of extreme weather events, such as 

floods, heat-waves and cold spells, may change in 

the future. Recent extreme weather events caused 

serious health and social problems in Europe, 

particularly in urban areas. These events will 

continue to pose additional challenges to health risk 

management and to the reliability of the power 

supply and other infrastructure. This demands a 

proactive and multidisciplinary approach by 

governments, agencies and international 

organizations and improved interaction on all levels 

from local to international. Based on the working 

paper Public health responses to extreme weather 

and climate events (Annex 1), we decide to take 

action to reduce the current burden of disease due to 

extreme weather and climate events. We invite WHO, 

through its European Centre for Environment and 

Health, in collaboration with the World Meteorological 

Organization, the European Environment Agency 

(EEA) and other relevant organizations, to support 

these commitments and to coordinate international 

activities to this end. We agree to report on progress 

achieved at the intergovernmental meeting to be held 

by the end of 2007”. 

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Blutorange - Limette 

Sonnenaufgang am Gaumen


World Business Council for Sustainable Development (WBCSD) 

health programme 

Howard Klee 

Background 

Nearly everyone agrees that the current systems of providing ‘health’ (wellness, disease prevention, 

and treatment) are not sustainable today. Concerns cross cultural and social divides, from the AIDS 

patient in China, to the corporate benefits manager in the United States, to the Minister of Health in 

France. Access is limited. Costs are frequently higher than need be, and greater than societies can 

afford on a long-term basis. Delivery is plagued with timeliness and quality concerns. In many 

developed countries, serious chronic diseases are associated with lifestyle choices (poor diet, little 

exercise, tobacco use). In developing economies, infectious diseases and poor sanitary conditions 

pose major health risks. But even in parts of these same developing countries, obesity is increasing, 

with resulting chronic disease conditions. 

Impact on business 

Companies are facing new challenges in terms of costs, employee and customer expectations, and 

political frameworks driven by health-related concerns. Health-care costs—either directly through 

private insurance plans, or indirectly through tax-supported government programs—are rising rapidly. 

OECD countries spend more that 8% of their GDP on health, excluding the cost of lost time and lost 

productivity. Costs are rising more rapidly than the OECD economic growth rates. 

Public and private benefit programmes for both current and retired employees are being reevaluated. 

Are they still affordable? For how long? Patient groups, the legal community, and 

governments are pressuring current business practices for change. Will the business models of the 

last 30 years continue to work in the future? Pricing, and geographic price differentials for products 

and services have become lightening rods for public attention and protest. In Africa, AIDS and other 

infectious diseases are destroying families and devastating local economies. While life-saving drugs 

are provided at no cost by international aid agencies, no business (and therefore no product) can 

survive the long-term on a ‘give it away’ model. What are the alternatives? How do the rules need to 

change? 

Many members of the business community believe that these impacts are serious and worsening. 

They threaten sustainable development at its core, and the economic vitality that underlies healthy 

societies. If it is true that business cannot succeed in societies that fail, the present crisis in health is 

pushing many more companies toward an uncertain future. 

At the same time, businesses can be leaders in innovation, information management, and investment 

in health technology, services and products. Are these efforts as effective as they might be in 

delivering cost-effective, timely results for consumers? If not, what are the barriers? 

WBCSD role and perspective 

The broad cross-section of the business community from 20 different sectors represented within the 

WBCSD offers a unique opportunity for perspective on this topic—from provider to payer to 

consumer. By themselves members of the WBCSD employ 11 million people and meet more than 




two billion customers each day. These contacts provide an enormous opportunity to educate and 

influence behaviour. From safe working practices on the factory floor to dietary habits at company 

food-service facilities, business can assist its employees and customers in making decisions that 

influence their health. 

It is frequently said that a problem is simply an opportunity viewed from a different perspective. The 

WBCSD is filled with many innovative suppliers of products and services addressing health and 

health care. What framework conditions will encourage strong emphasis on innovation and 

investment in new approaches? Examining these complex issues in a business context offers the 

chance to identify some of the potential needs and opportunities for future innovations. 

Project deliverables 

Of course, business alone cannot begin to solve all the complex health issues facing the world today. 

However, the WBCSD is undertaking a scoping study of health systems (emphasizing North America 

and Europe) with a goal of clarifying current issues, conflicts and possible improvements. The project 

expects to produce: 

• A Facts and Trends sourcebook to provide a common baseline level of understanding. This will 

include: 

A review and ranking of the major health issues and dilemmas facing the business community 

and civil society 

A review of the significant ‘actors’ on the health ‘stage’ – their current roles and responsibilities 

A review of current collaborative efforts being undertaken – their focus, structure and 

effectiveness 

• Potential changes/activities within the business community to improve efficiency and 

effectiveness of health delivery, and 

• Identification of potential future collaborative efforts which might contribute to longer-term 

progress in solving these very difficult problems. 




Health policies to address inequalities: the situation in the 

Netherlands 

Gerard Molleman 

At a national level health inequalities are an important issue. The last decade has seen a lot of 

serious studies on determinants, policy and interventions for health inequalities (RIVM Health 

Forecast studies; publications of Mackenbach et al, Ten Dam, etc.). 

The current political climate in the Netherlands is looking for a new balance between individual and 

collective responsibilities. Individual responsibility is becoming more important. 

In 2003, the national government launched a new public health strategy for prevention and health 

promotion: Living longer in good health. The strategy focuses on obesity (healthy eating and physical 

activity), smoking, diabetics and mental health promotion. The strategy also focuses on the approach 

of specific settings, such as the neighbourhood, school and the workplace. It puts an emphasis on, 

and accords more responsibility to, the local level. 

The policy document states that health inequalities are a serious problem in the Netherlands. There 

is a 12-year gap in healthy years between groups at both ends of the social-economic scale.One of 

the objectives of the new policy is to close the gap by three years by 2020. But a special policy on 

inequalities in health is no longer being developed: this is considered to be covered by the general 

policy outline. 

The emphasis on and responsibility for local government is logical. For over ten years there has 

been a growing insight that most of the problems have to be solved at the local level. It is at this level 

that the opportunities for an integrated policy lie, so that specific settings (such as schools) can find 

their own appropriate solutions to specific problems. Up to now health was only for a small part a 

responsibility of local government. 

Local health policies have been much more prominent in the last few years, since every municipality 

has the obligation to make a health plan every four years. 

There is a big cities policy, in which responsibility is given to the local level for all kinds of policy 

areas: the economy, infrastructure, local legislation and topics in the social field. In the coming years 

– and for the first time – health will also be one of the main topics in this big cities policy. 

This shift in responsibilities also means a change in strategy for national support institutes, like the 

Netherlands Institute for Health Promotion and Disease Prevention (NIGZ). The NIGZ aims to help 

local authorities in getting health on the political agenda, and to support them with knowledge, 

advice, capacity building, effective interventions and best practices. The NIGZ especially wants to 

help work out the necessary conditions on the local level for implementing best practices. 

The NIGZ has reached an agreement with the national board of municipalities and the national 

institute of municipal health services to coordinate efforts to support local capacity building for health 

promotion. The NIGZ will spend 65% of its budget on this task. 

An important obstacle in this shift of attention is the question who decides on health on the local 

level; is it the professional from the municipal health services or is it the local politician? 




The choice in the end is clear. It is local politics that are dominant. For an integrated approach to 

tackling health inequalities it is local authorities and local politicians who are in charge. For health 

professionals this means that they have to hand back the responsibility for health to local authorities. 

In practice this does not always appear to be that simple. 




National health promotion policy to address inequalities: 

the Veneto region 

Luigi Bertinato 

There is an urgent need in Europe to develop effective strategies to reduce socioeconomic 

inequalities in health with particular reference to individual population groups living in especially 

unfavourable situations, and to marginalized groups. 

Poverty, according to opinion shared by the majority of observers and experts in the health sector, 

can be considered to be the most significant factor determining bad states of health, being as it is 

associated with higher levels of child mortality, to disease and ill-health, to a growing tendency 

towards the consumption of legal and illegal substances (tobacco, alcohol and drugs), and to a 

higher level of exposure to environmental risk factors (life-style, work-related, and social). Socially 

disadvantaged groups are significantly more prone to health risks. 

This approach, due to the specific needs in health care of each individual population group, 

corresponds more with target-group specific measures than with strategies pertaining to society as a 

whole. Data outlining the correlation between social status and health will be presented with 

particular reference to the following social groups: young people between the ages of 11 and 15 

(HBSC Veneto Study), immigrants and asylum-seekers, unemployed young people and the long-term 

unemployed, the elderly (the Verona Initiative), and people living in poverty. 

The presentation will move from a consideration of socioeconomic determinants of health from a 

more European perspective to an analysis of results of population-based studies carried out in the 

Veneto Region, with a view to drawing the first conclusions on the correlation between health and 

social status. Moving from an overview of health determinants in Europe as a whole, the study will 

focus on a more regional dimension, with particular reference to experiences in the Veneto Region 

within the framework of the Regions for Health Network, and will conclude by suggesting better 

practice methods of addressing health determinants through more effective health promotion 

programmes. 




Summary 

Anthony Morgan 

Introduction 

The purpose of this paper is to summarize the main observations, conclusions and recommendations 

which arose from the parallel forum ‘What determines health’. The forum aimed to stimulate debate 

about the most effective actions required to tackle the growing health inequalities that exist in many 

European countries by focusing on the wider social, economic and environmental determinants of 

health. Presentations included in the forum were not inclusive of all the wider determinants of health 

but served to illustrate the types of actions that are required by policy, research and practice at all 

levels if equity in health is to be achieved across the European Union. 

Experts were invited to participate in the forum to highlight the importance of these wider 

determinants and put forward recommendations for action at the European level. Presentations 

covered the following areas: 

• The wider determinants of health: from theory to practice. 

• Climate change and extreme weather: new challenges for public health? 

• Health and the impact of the housing and the urban environment. 

• Tackling the social determinants of health: the role of the social partners 

• National health promotion policy to address inequalities 

The purpose of this summary paper is to draw out common themes from the presentations included 

in the forum and to set out recommendations for action. Further details of the individual presentations 

are given in appendix 1 and are available from the commission on request. 

What are the wider determinants of health? 

Ten Dam [1] noted in his presentation to the Forum that inequalities in health exist in all western 

countries and since the 1950s these inequalities have been increasing despite continuing 

developments in the welfare state. This suggests that whilst health policies, interventions and 

initiatives have led to general overall improvements in health, they are continuing to fail some 

segments of our societies. 

The influential ‘Acheson Report’ in the UK [2] stated that health inequalities are largely determined by 

the ‘wider determinants’ of health and therefore suggested that the biggest health gains are to be 

achieved by finding solutions to address these factors. 

For the purpose of the forums discussion the wider determinants of health were defined as: 

‘those factors which shape people’s experience of health and well-being, which are 

generally outside of their control but which are potentially modifiable. 

They include: social and community influences (interactions with friends, relatives and 




immediate community); living and working conditions (including agriculture and food 

supplies, education, work environment, unemployment water and sanitation, housing 

and access to essential facilities and services) and overarching societal/ structural 

factors (including the economic state of a country and labour market conditions, cultural 

beliefs, environmental pollution)’ 

Source: Dahlgren and Whitehead, 1991 [3] 

Defining health inequalities and the importance of context. 

There is much debate in the scientific literature about the differences between health inequalities and 

health inequities. The forum noted the following distinction articulated by Whitehead [4]: 

“Health inequality describes differences in health experience and health outcomes 

between different population groups – according to socioeconomic status, geographical 

area, age, disability, gender or ethnic group” 

“Health inequity describes differences in opportunity for different population groups 

which result in for example, unequal life chances, access to health services, nutritious 

food, adequate housing etc. These can lead to health inequalities”. 

However as Leon [5] points out, health inequalities and health inequities within countries are not 

understood in the same way throughout the world. As a consequence solutions to tackling health 

inequalities cannot be universally applied to all situations and the importance of applying these 

solutions in context is noted. Wamala [6] in her presentation to the forum identified a number of 

different contexts which need to be assessed and acted upon if successful solutions to health 

inequalities issues are to be achieved. They include: 

• An assessment of the current political willingness to act which provides the context for the 

most implementable actions. 

• Mapping of the public health systems within which action can take place so that the roles and 

responsibilities of different actors can be made explicit. 

• Assessments of actions that need to be taken at the macro, meso and micro levels. 

• Lifecourse and gender perspectives. 

‘What works’ to reduce health inequalities – the role of policy research and practice. 

It has been noted by other commentators [7,8] that while the current interest in health inequalities 

has given rise to a vast literature on the explanations of the nature, extent and causes of inequalities, 

the literature on intervention research and evaluation on what to do to address them is scant. 

Nonetheless, this vast descriptive research has had a major political effect on getting health 

inequalities firmly onto the political radar and ensuring that governments take seriously the inequities 

question. 

Policy 

Increasingly the issue of inequalities in health and the need to address the wider determinants 

features as a major strand in international and national strategic documents. At an international level, 

the World Health Organization has shown its commitment to support action on inequalities in its 

Health 21 strategy [9]: 




“By the year 2000, the health gap between socioeconomic groups within countries 

should be reduced by at least one fourth in all member states by substantially improving 

the level of disadvantaged groups (Health 21 WHO /EURO)” 

More broadly the World Bank recognizes that inequalities in incomes, in health and in educational 

outcomes have long been a stark fact of life in many developing countries and has dedicated the 

World Development Report 2006 to Equity and Development. It is currently seeking comments, 

questions and views through an online consultation (www.dgroups.org/groups/worldbank/WDR2006 ). 

At a national level, there are a growing number of examples of Governments developing 

comprehensive strategies, programmes and initiatives to tackle inequalities. Examples include the 

English ‘Tackling Health Inequalities: A Programme for Action’ [10] which identifies the need to 

address the wider influences on health by taking action in a number of key areas. 

• Reducing levels of child poverty 

• Improving the quality of poor housing 

• Improving the accessibility, punctuality, reliability and use of local transport 

• Improving educational attainment and tackling low basic skills (education, training and skills) 

• Tackling worklessness and inactivity (Jobs and Income) 

• Strengthening disadvantaged communities through improving access to social and community 

facilities and services (neighbourhood renewal) 

And the ‘Swedish National Public Health Policy’ [6] which outlined 11 strategic objectives to tackle 

inequalities: The first six objectives reflect structural factors which can be influenced primarily through 

public opinion and political decisions at different levels. The last five objectives concern lifestyles of 

the individuals with a strong emphasis on the role that the social environment plays. This strategy 

outlined the importance of: 

• Systematic monitoring 

• Development of indicators 

• Coordination with and active involvement of other government agencies 

• Advocating for health in non health orientated agencies 

• Reporting to the government (decision makers) – regular public health reports 

• Evaluation of the impact of policies on health 

• Intervention and policy analyses 

• Gender based analyses 

In policy terms at least, these two examples highlight the key features of effective strategies on 

inequalities: 

• Use of a combination of upstream and downstream strategies. For example combining health 

education approaches with laws and regulations. 

• Sensitive to the needs of target groups 

• Roles and responsibilities of different players including the health care sector and other 

government departments are explicitly identified. 




• Mainstreaming action on inequalities is maximized particularly through the use of performance 

management systems. 

Such strategies present the first step towards tackling health inequalities in that they demonstrate 

political will and commitment to doing something about them. However as Dam [1] points out 

strategic commitment must be followed through with real support for implementation. He 

distinguishes between ‘effective interventions’ which identify and attack crucial factors linked to the 

wider determinants of health and ‘effective implementation’ which requires sufficient support to 

practitioners, use of long term investments and commitment to monitoring and evaluating the results 

and impacts of strategies. 

At a European level, it is important to note that different countries may be at different stages of 

development. For example in some countries, the task might be to raise awareness and recognition 

of the existence of inequalities by providing evidence for why actions are needed. In other countries, 

it may be more important to find ways of providing support for follow through on implementation, in 

other words on the most effective approaches to ‘how to act’. 

Sustainable strategies for reducing health inequalities can only be brought if there is a recognition 

that policies need to be long terms, that inter-sectoral action is achieved and that there is less of an 

expectation to generate outcome measures in the short term [11]. 

Research 

The point has already been made that whilst we are rich in knowledge about the extent of the 

inequalities that exist in many countries we are much less equipped to know what to do about them. 

There a number reasons why this might be so: 

• The large majority of scientific research in public health seeks to answer research questions of 

interest primarily to researchers rather than of interest to policy makers and practitioners. 

• Much of the research on ‘what works’ to tackle health inequalities is based on a biomedical 

model with still too much emphasis on the randomized control trial as a method for evaluating 

success. 

• Limitations of existing research methodologies to evaluate complex, long term intervention 

strategies required for tackling health inequalities. 

These issues need to be addressed by: 

• Advocating for broad definitions of evidence – not limited to biomedical studies and 

randomised controlled trials e.g. qualitative information from consultation can explain how 

people see the wider determinants of health and individual risk factors linking together and 

connecting with their lives 

• Funders of research, shifting resources to those studies which seek to address the ‘what 

works’ question. 

• Consensus building on the most effective evaluation frameworks required for assessing the 

effectiveness of both the impact of macro policies and the success of local interventions. 

• Making clear the types of research question that are required to be answered by policy makers 

see Graham [12] for discussion paper of different ways to reduce inequalities: improving the 

health of poor people; narrowing health gaps or reducing health gradients). 




It is important to note that some work is already underway to address some of these gaps. For 

example: 

1. The European Science Foundation has funded a very important scientific programme of research 

which is now coming to fruition which seeks to explain the underlying causes of inequalities in terms 

of life-course influences on health, health effects of stressful environments in adult life, the interaction 

of biological and psychosocial factors and macro social determinants of morbidity and mortality ([13]. 

2. The WHO European Office for Investment for Health and Development has set up a new initiative 

called ‘Assets for health and development’ which seeks to redress the balance between knowledge 

about ‘what works’ that comes from the more dominant ‘deficit model’ of disease (which focuses on 

problems and needs of populations), towards an ‘assets based model’ for equal health (which 

accentuates positive ability, capability and capacity to activate solutions) [14]. 

Methodological challenges and re-analysis of existing data sets remain a top priority for knowledge 

development in this area. 

Practice 

Without policies in place which outline the importance of a multi-faceted approach to tackling health 

inequalities, little is likely to change. However policies which do not invest real time and effort to 

understand what is required for these policies to work in practice, might at best have no effect on 

inequalities or worst contribute to increasing the gradients in health experience that already exists. 

In research terms, evidence generated through well resourced experiments can only provide a guide 

or signpost towards the kinds of things which might be successful in real life. It is crucial therefore 

that this type of information is accompanied with information that comes from practice to understand 

both the barriers to effective implementation and to create innovative ways of overcoming them. 

Whilst much information already exists about effective ‘practice approaches’ to tackling health 

inequalities, this information is often not available in a systematic, transparent or rigorous format that 

hold its ground with other types of evidence. Further investments are required therefore to allow 

practice based evidence come to the surface. Two examples of projects already in existence are: 

European Level: for example, the EU-funded ‘Getting Evidence into Practice’ project. 

National level: for example, the Health Development Agency’s ‘Learning from Effective Practice’ 

project. 

Further support for this type of project is required if we are to develop a more substantial evidence 

base on ‘what works to tackle inequalities’ for the future. 

Engaging other sectors in action to tackle inequalities 

The Acheson Report on Inequalities in Health [2] recognized that the solutions to major public health 

problems such as heart disease, cancers, mental health and accidents are complex. These problems 

will require interventions, which cut across sectors to take account of the broader social, cultural, 

economic, political and physical environments which shape people’s experiences of health and wellbeing. 

As noted above some of the biggest impacts health inequalities are to be made by addressing the 

wider determinants of health and many of the solutions to addressing them lie outside the health 

sector. The ability of health departments to reduce health inequalities therefore relies on building 




strong and durable partnerships with a range of other sectors and agencies. These include: 

Health Care 

Social Security 

Education 

Housing 

Security 

Labour Market 

Environment 

Transport 

Agriculture 

Industry and Energy 

Inter-sectoral collaboration will only be brought about if there is a political commitment to ensure that 

health is everybody’s business. Even when integrated decision making processes have been signed 

up to, health champions will still need to: 

1. help other sectors understand why they should get involved in health and health inequalities 

action (‘making the case’) 

2. provide support on the types of things they can do through their own policy development which will 

have a positive impact on health. 

Some of the key questions that need to be answered to support these processes include: 

• How can the health care system set a good example as an employer and purchaser of 

services and contribute to the development of local healthy communities and local economies? 

• How can the health sector contribute to the wider determinants of health? For example, 

supporting other sectors to address health-related issues information for health impact 

assessment, involvement in land use decisions, contribution to urban and rural planning 

• What is the impact of non health sector policies and initiatives on health and health 

inequalities? 

• How can we ensure that other sectors develop policies which are the most beneficial to health 

development, particularly for disadvantaged groups? 

• What is the relative importance of the wider determinants of health and where can we have the 

biggest impact? 

Overall, there is an advocacy role in helping to get inequalities on the agenda of ‘players’ who are 

not convinced of the potential to do something about them and then to make explicit the different 

roles and responsibilities of these different ‘players’. 

Global issues and inequalities 

Participants of the forum repeatedly cited the importance of context when thinking about the most 

effective approaches to tackling health inequalities. Globalisation in general and some global issues 

in particular highlight the importance of context further when thinking about solutions to these issues. 




To illustrate the global context, Menne [15] gave a presentation to the forum highlighting the potential 

effects of climate change on population health particularly for those worse of in society. She 

summarized the issues as follows: 

• Climate affects health in diverse ways, and climate change inevitably affects health 

• Overall, these effects are likely to be negative, potentially large, and concentrated on 

vulnerable groups 

• Europe is not immune, however, how much death and morbidity can be avoided in the nearest 

future? 

More generally McMichael [16] describes the ‘globalisation factor’ as having the potential to widen 

the world’s social, economic and health inequalities further. He calls for a much higher priority to be 

given to global population health as an outcome criterion, in the mainstream policy debate on social 

and ecological sustainability. He argues that achieving better, secure and more equitable health will 

require expanded education and training the international transfer of technologies and enhance role 

of the state as a modern efficient and transparent institution, more equal income distribution within 

countries, international debt alleviation and an international commitment to sharing the world’s 

common resources. 

Three issues arise out of these discussions: 

1. The impacts of global policies on health need to be continually assessed both for individual 

countries and across populations. 

2. Ways of predicting, managing and coping with global issues and their effects on health need to be 

continually assessed at a European level. 

3. National, regional and local health professionals need to think globally when assessing the 

effectiveness of local solutions to problems. 

Economics and health inequalities 

Poor health imposes costs on individuals and society. Wanless (17) identifies these costs as: 

• The resources required to cure or prevent poor health. 

• Lost production whilst the individual is incapacitated, or after he or she has died 

• The discomfort from pain and poor quality of life 

• Anti-social costs, for example, related to crime. 

All these costs impact on society. Investing in the wider determinants of health to reduce health 

inequalities has the potential to reduce the costs associated with these factors. Shifting resources to 

address these factors also has benefits for the overall economic development of local communities, 

regions and countries. Convincing politicians and policy makers to shift resources from health care 

settings to prevention activities can only be brought about if we are able to ‘make the economic case’ 

that these investments are worthwhile. There is therefore an urgency to engage economists in the 

health inequalities debate and to develop new methodologies which allow us to make the economic 

arguments for investments in the wider determinants of health. 




Better quality, access and application of knowledge to support action on inequalities 

Access to good quality information is key to support professionals at all levels to engage in efforts to 

reduce health inequalities. As has already been mentioned, there are many gaps in our knowledge 

about the most effective ways of tackling health inequalities. However, there is an urgent need to 

develop knowledge management systems that allow us to apply the knowledge we already have. 

Often it is not the lack of knowledge that stalls action but it is the inaccessibility of existing knowledge 

and the lack of skills among professionals in how to use it. There are a number of things that can be 

done to improve our ability to improve our knowledge: 

At a general information level: 

Develop knowledge management systems (making full use of interactive technologies) that can be 

sustained through periods of organizational and political change so that we don’t reinvent wheels 

Develop tools for practitioners so they are better able to audit action and progress on inequalities 

within their own contexts (for example, health equity auditing). 

See http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthInequalities/fs/en 

At a research level in order to fill gaps in our knowledge we must address the following: 

• What are the best evaluation models, for which interventions and for which questions? 

• How can health inequalities indicators be built into the design of evaluations? 

• How can the question of attribution be dealt with if randomization to control groups is not 

feasible? 

• How might evidence from macro level policy interventions be systematically reviewed to 

demonstrate the impact of policies and initiatives aimed at tackling inequalities? 

Conclusions and recommendations to the Gastein Forum 

In conclusion this forum served to raise the profile, importance and complexity of health and 

reductions in health inequalities by focusing on the wider determinants of health. In doing so, it has 

raised a number issues that require attention if we are to achieve more equitable societies within and 

between countries of Europe. 

Key messages from the forum are: 

• Health policies to tackle the wider determinants of health can only be effective if they are 

integrated into a number of socio-political interventions. 

• Policies should be clear about what types of inequalities they are trying to address (improve 

the health of the poorest, narrowing the gap, reducing the gradient) 

• Researchers and information scientists also need to be clear about what is being tackled if 

they are to provide evidence to inform policy and assess its impact. 

• Funding agencies need to balance the need to fill the gaps in knowledge with further research 

and to make investments in knowledge management systems which will allow us to use 

existing information 




• Recognition of the effects of globalization should be incorporated into international institutional 

and policy thinking. 

The following recommendations were made to the Commission to support the further development of 

policy, research and practice: 

1. EU public health strategy and legislation should be comprehensively assessed for action on health 

inequalities. 

2. European targets and indicators for health inequalities should be developed so that comparisons 

on progress can be made and the basis for common European actions established. 

3. An EU cross directorate strategy for health inequalities should be developed and include 

collaboration with international agencies 

4. Health impact assessment of EU policies should be routine to ensure that policy actions reduce 

and do not inadvertently increase health inequalities. 

5. International organisations should promote the development of innovative solutions to tackle health 

inequalities through the development of sustainable applied information systems. In particular, 

International organisations should develop shared learning on health inequalities to support the new 

member states. 

6. The Luxembourg and UK Presidencies of the European Union (2005) should address the Gastein 

recommendations on health inequalities . In particular to establish a high level policymaking network 

and information systems to support competent and effective practice at all levels. 

References 

1. Ten Dam J. Inequalities in health: trends, causes and policy. What determines health? Global 

Health Challenges. European Approaches and Responsibilities. 7th European Health Forum Gastein. 

6–9 October 2004. EHFG: Bad Hofgastein, Austria, 2005. 

2. Acheson D. Independent Inquiry into Inequalities in Health Report. London: The Stationery Office, 

1998. 

3. Dahlgren G and Whitehead M. Policies and strategies to promote social equity in health, Institute 

for Future Studies, 1991 Stockholm (Mimeo). 

4. Whitehead M. Perspectives in health inequity. International Journal of Health Services 

1992;22(3):429–45 

5. Leon D, Walt G, Gilson L. International perspectives on health inequalities and policy. British 

Medical Journal 2001;322:591–94. 

6. Wamala S. Tackling the wider determinants of health, developing practice. What determines 

health? Global Health Challenges. European Approaches and Responsibilities. 7th European Health 

Forum Gastein. 6–9 October 2004. EHFG: Bad Hofgastein, Austria, 2005. 

7. Kelly M, Graham H. Health Inequalities: Concepts Frameworks and Policy. London: Health 

Development Agency, 2004. 

8. Mackenback J, Stronks K. A strategy for tackling health inequalities in the Netherlands. British 




Medical Journal 2002;325:1029–32 

9. WHO. Health21: The Health for All Policy Framework for the WHO European Region. 

Copenhagen: WHO Regional Office for Europe, 1999. 

10. Department of Health. Tackling Health Inequalities – A Programme for Action. London: 

Department of Health, 2003. 

11. Exworthy M, Blane D, Marmot M. Tackling Health Inequalities in the UK: The Progress and 

Pitfalls of Policy. Health Services Research, 2003. 

12. Graham H. Tackling health inequalities in England: remedying health disadvantages , narrowing 

gaps or reducing health gradients. Journal of Social Policy 2004;33:115–31. 

13. European Science Foundation. Scientific Programme on Social Variations in Health Expectancy 

in Europe, Final Programme Report. ESF, 2003. 

14. Morgan A, Brown C, Ziglio E. Assets for Health and Development: Summary Overview Paper. 

2004. http://www.euro.who.int/SocioEconomicDeterminants/assets/20030130_1. 

15. Meene B. Climate change and extreme weather events: new challenges for public health. What 

determines health? Global Health Challenges. European Approaches and Responsibilities. 7th 

European Health Forum Gastein. 6–9 October 2004. EHFG: Bad Hofgastein, Austria, 2005. 

16. McMichael A, Beaglehole R. The changing global context of public health. Lancet 

2000;356:495–99. 

17. Wanless D. Securing Good Health for the Whole Population, Final Report. London: TSO, 2004 



Forum BII 

Towards high-performing 

systems: value for money 

and sustainable financing 




The context for reform: what is driving change in today’s health systems? 

��Elizabeth Docteur Towards high-performing health systems: 283 


In search of more value for money: can we improve quality and system performance without 

raising cost pressure? 

��Niek Klazinga Is there a business case for quality improvement 285 

in health care for governments? Reflections on 

the quality-cost relationship (abstract) 

��Alexander Macara Towards more cost effective care: is there scope 286 

for improving prevention and treatment for chronic 

conditions? 

��Karl-Jürgen Schmitt IT in healthcare – what is necessary to increase 294 

healthcare efficiency 

��Jui-fen Rachel Lu Is there a trade-off between cost control and equity? 302 


Stakeholder perspectives 

��Angela Coulter Implications of financial pressures and health system 306 

changes for patients 

Roundtable discussion 

��Diane Lequet-Slama Text not available 

��Peter Pazˇitný Addressing the demand side problems of health 311 

systems by intelligent co-payment scheme 

��Hong-Jen Chan Text not available 

��Gaudenz Silberschmidt Text not available 

��Armin Fidler Text not available 

��Katrin Saluvere Text not available 

��Ellen Nolte Summary 313 

Page 




Towards high-performing health systems: challenges and 

opportunities for reform 

Elizabeth Docteur 

Abstract 

OECD countries can be proud of the progress that has been made over the past three decades, a 

period of change and expansion for modern health systems. Most countries have attained universal 

coverage for a fairly comprehensive set of health services and have taken great steps to ensure the 

accessibility of those services to the population. The population health status has improved steadily, 

even dramatically, driven largely by economic and social development, as well as concerted efforts to 

reduce the prevalence of risk factors and promote healthy living. Advances in medical capability and 

improvements in health care have had direct benefits in terms of both cure and prevention of 

disease. 

Nevertheless, it is clearly possible to improve the performance of health systems well beyond what 

has already been achieved. Serious and significant shortcomings in the quality of health care – at 

levels that would not be tolerated in other high-risk industries – have recently come to light. Patients 

and health-care consumers are demanding more from their health-care systems in terms of 

responsiveness to their expectations and preferences, including more choice of providers and 

services, and shorter waits for services. In a number of countries, there are persistent barriers that 

make it difficult for disadvantaged groups to realize equitable access to health-care services and the 

health improvements such access brings. 

Alongside these pressures for improvement, health systems are also facing major cost and financing 

challenges. Health-care costs are growing faster than economies as a whole in many countries, 

posing particular problems for public budgets, given that, on average across the OECD, threequarters 

of health care are publicly financed. All signs indicate that countries must expect continued 

health cost-growth pressure, reflecting the development of new treatments that affect supply, 

demand, and prices. Population ageing will have implications for the financing of health and longterm 

care services, and is likely to increase the demand for both, raising questions as to the 

affordability and sustainability of health systems. 

There are at least two possible paths for reconciling rising demands for health care with public 

financing constraints. One is to seek improvements in the efficiency of health systems and the costeffectiveness 

of health care. Evidence suggests there is great scope for improving efficiency by 

increasing productivity, reducing waste or enhancing the cost-effectiveness of care, yet experience 

shows that achieving efficiency improvements has proven to be difficult. A second path is to increase 

the role of private sources of financing. A number of OECD countries employ private health 

insurance as a means to expand the pool of resources for funding health care. They have found that 

there are significant challenges involved in ensuring that private health insurance has a positive 

impact on health-system performance. 

Health policy-making involves a careful balance of trade-offs, reflecting the weights assigned to a 

range of important goals and a great deal of uncertainty. The ultimate goal, certainly, is robust 

population health, but promoting health is not the only consideration. Health policy decisions also 

have considerable economic consequences, since the health sector is a strong and important 




component of the economies of OECD countries that provides extensive employment and profitable 

industry. Even when tough choices are made, changing systems so as to improve performance is 

never easy, as the success of making change can be affected by the willingness of various 

stakeholders to embrace the proposed reforms. Given the speed of developments in medicine and 

evolution of health-care goals, reform of health systems is necessarily an ongoing, iterative process; 

there are few one-off solutions or quick fixes. 



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Business-Lösungen.


Is there a business case for quality improvement in health care for 

governments? Reflections on the quality-cost relationship 

Niek Klazinga 

Abstract 

For a long time policies on quality improvement and policies on financing and cost control have been 

dealt with separately by policy makers. Whilst public health researchers and experts from the 

management sciences have contributed to the quality debate, economists have been dominating 

discussions on financing and cost control. More recently these two worlds seem to merge, notably 

with financing initiatives under labels as ‘value based purchasing’ (OECD), ‘strategic purchasing’ 

(WHO) and ‘pay for performance’ initiatives (USA, UK). 

This paper will explore the various relations between quality assurance and quality improvement on 

the one hand and financing and reimbursement mechanisms on the other. The relation will be 

discussed on the micro, meso and macro level of the health care system. On the micro level it will be 

explained that efficiency gains through quality improvement projects do not necessarily constitute a 

business case for the professionals and managers involved given the existing accounting systems 

and internal and external reimbursement methods. Empirical work on the application of the industrial 

quality/cost model in Dutch hospitals will be used to illustrate the point. 

On the meso level the various financing mechanisms of professionals and institutions will be 

discussed and their potential as (dis)incentive for quality improvement. Again the situation in The 

Netherlands (existing and foreseen financing of GP’s hospitals and nursing homes) will be taken as 

an illustration. 

On the macro level more extensive analyses will be presented of the present pay for performance 

initiatives based on a literature review. The analyses includes the following notions: steering on 

health care needs versus steering on health care demands, long term versus short term health 

policies, the ‘health is wealth’ philosophy, health policies versus health care policies, health system 

performance, health care system design, allocative efficiency over the various health care sectors, 

division of responsibilities on quality and cost controls over various actors in the health care system. 

It will be stressed that from a (governmental) macro perspective integration of the rationales of public 

health and health economics is necessary to design a health care system where the incentive 

structures enforce quality improvement in such a way that it results in better health and health for all 

given the available resources. 




Towards more cost effective care: is there scope for improving 

prevention and treatment for chronic conditions? 

Alexander Macara 

Preamble 

There are a wide variety of political philosophies and systems, which influence the provision of health 

care throughout the world. Happily in Europe, or at least within the EU, we have democracies and 

variants of only two basic approaches to the organisation and funding of health care – the 

Bismarckian and the Beveridge models – in which the state assumes responsibility more or less 

directly. Hence, two processes are possible: 

1. Efficient and effective governance of health care systems as a commitment shared by all 

stakeholders – the public and its government, patients and their carers, the professions and their 

managers, suppliers (of pharmaceuticals and devices) and their agents. 

2. ‘Joined-up’ policies across all government departments, involving all sectors of society: civil 

society for health 

It follows that there has to be scope for improvement unless utopia already exists! Which begs the 

questions, how best to achieve realistic improvements, and why focus on chronic conditions? By 

definition, chronic disease lasts a long time as compared to acute conditions, and therefore entails a 

greater burden for the individual and society. Of course, every chronic disease has acute episodes 

and it is neither sensible nor possible to separate policies and programmes for each. But acute 

conditions will always carry the glamour and offer the drama of the urgent challenge, the threat and 

opportunity, the satisfaction of a finite outcome. Clearly, the best policies will benefit all care, but the 

prevention and treatment of chronic disease merits special attention to offset the risk of health being 

the Cinderella to the ugly sisters of acute care. 

I will first review the context within which premature death and impaired quality of life are caused by 

chronic disease, and then consider what improvements can be achieved and by what means. 

The contemporary scene 

There are four features of the current scene which are inter-related and which affect health and 

health care: 

1. The Environment 

The environment, in all its aspects – physical, educational, social, cultural, economic and political – 

the context within which we live and work – is crucial. There is no environmental factor, which does 

not affect health and health care. The initial aim of the National Health Service in the UK was voiced 

as to provide freedom from fear – fear of the giants of disease, unemployment, ignorance, want and 

squalor. Much health care today is still largely futile and certainly ineffective because those in 

greatest need are mired in deprivation of essential criteria for healthy living. “The weight of scientific 

evidence supports a socioeconomic explanation of health inequalities.” [1] 




2. Demography 

The outstanding feature is the universal ageing of the population (with exceptions due to HIV/AIDS 

and civil strife) in which the ratio of the productive to dependant people is declining, leading to 

serious social and economic pressures. Medicated survival contributes significantly to increased life 

expectancy [2,3] and to the vastly greater consumption of resources by the elderly (and especially 

the very elderly) compared to younger age groups. People may be living longer but the Office of 

National Statistics in the UK has recently reported a disturbing decline in the expectancy of healthy 

life years. Other factors include the weakened fabric of society, due to smaller family sizes allied to 

greater mobility, isolation and alienation arising from historically high divorce rates, and the resultant 

social and economic problems. Increasing external migration, refugees fleeing from endemic 

conflicts, and ethnic tensions, add their contributions to an increasingly fluid situation. 

3. Lifestyle 

Whatever the structure of society and the nature of the environment in which they live, the behaviour 

and choices of individuals are ultimately crucial. The perversity of self-destructive human behaviour 

is demonstrated by the salutary fact that as the incidence of chest and heart diseases attributable to 

atmospheric pollution and major traditional infections such as tuberculosis were dramatically reduced 

in the latter half of the 20th century, so cancer of the lung and emphysema caused by smoking have 

taken their place as major killers. Likewise, disease and disability arising from deficient diets related 

to severe poverty have been superseded by the sequelae of obesity, which is related to relative 

prosperity. Thus does one form of malnutrition replace another. Again, people consume excessive 

quantities of alcohol and experiment with other lethal drugs although they can see the evidence of 

such abuse all around them. 

4. The mismatch between demand and supply 

Expectations of care are driven by increased knowledge (not always matched by understanding) of 

advances in medical science and technology including the mapping of the human genome, and an 

increasing awareness of human rights. These factors combine to foster a conviction of a right to a 

perfect delivery, an instant high-tech ambulance, an uncomplicated operation, fuelled by idealistic, 

populist government ‘patients’ charters’, tabloid and tele-journalism and – increasingly – irresponsibly 

misleading internet advertising. Demand becomes infinite whilst supply, quantitative and qualitative, 

is finite. New drugs and clever technology for the diagnosis and treatment of disease are inevitably 

expensive at least initially. Moreover, such advances are frequently unpredicted and unpredictable, 

and until they are available, providers cannot be trained and serviced to apply them. It follows that 

supply must always lag behind demand, but the resentment of impatient patients causes strains in 

the system – any system. 

Moreover, many consumers fail to appreciate the risks implicit in all health care and unavoidable 

delays due to inadequate resources, especially in a system under stress yet anxious to provide more 

and more powerful weapons against disease. This has resulted in a perverse culture of opportunistic 

litigation fostered by predatory lawyers regardless of any consideration of blame. Increasingly, this 

process swallows up resources of time, energy and money, which further reduces supply: a truly 

vicious circle. In a laissez-faire system these factors combine to increase existing inequalities 

because the most knowledgeable patients, who also tend to be most strident about their “rights”, 

most articulate and effective in pressing their demands, and most likely to have ready access to 

supply, commandeer priority for themselves. The resultant inequalities in care can be obviated only 

by the ethical imperative of ensuring that supply is related to relative clinical need and to no other 

factor. 




Principles of approach to improvement 

Political priority for health in all sectors of society – “salus populi suprema est lex”. Insist on 

transparency and openness. 

Health is wealth: expenditure on health, especially on prevention, is a long-term economic 

investment, reducing health care expenditure, occupational morbidity (‘sick leave’) and premature 

retirement due to health problems. Thereby it improves productivity. 

Promotion of massive culture change universally, at all levels, from disease-driven to health-driven 

imperatives, with appropriate incentives. 

Enhance R&D (research and development) and exploit the potential of IT (information technology) to 

secure a strong evidence base regarding causal and associated factors in disease, including 

socioeconomic links between major killers and inequalities and to disseminate crucial information. 

Apply the precautionary principle when evidence is inconclusive, using intelligent extrapolation. 

Develop a philosophy within health care of all care as preventative; not only ‘upstream’ primary 

prevention, but also treatment and rehabilitation (secondary and tertiary prevention) to limit the 

progression of disease and dependency at whatever stage. 

Start at the beginning of life, recognising that the gestation period for the development of chronic 

disease is becoming shorter generation by generation. 

Strategies 

Employ what Derek Wanless in his recent report for the British Chancellor of the Exchequer, 

Securing our future health: Taking a long-term view [4], described as a “fully engaged scenario” in 

which “levels of public engagement in relation to their health are high…the health service is 

responsive…particularly in relation to disease prevention,” and “public health improves dramatically 

with a sharp decline in key risk factors as people actively take ownership of their own health”.[5] Note 

the revolutionary process of a health report being commissioned by the government department 

which is traditionally hostile to a spending sector of the economy. 

Engender a ‘whole systems approach’ which recognises that health care and social care are 

‘inextricably inter-linked’.[6] 

Build health impact assessment into all government programmes. 

Secure the commitment and involvement of all stakeholders, promoting active partnerships between 

providers and consumers by improved communication and understanding of rights and 

responsibilities. 

Challenge trans-national companies based in developed countries to exercise the social 

responsibilities implicit in foreign direct investment. 

Focus on reducing mortality and morbidity rates for the major killers such as coronary heart disease, 

strokes and cancer, with challenging targets and strong incentives, which require auditing to avoid 

perverse effects. 

Get the timing right, with long-term planning to realise the vision of dramatic change over, say, 20 

years and regular ‘milestones’ in the review of progress, for example, in narrowing inequalities, every 




three years or so. 

Place the emphasis on long-term, ‘upstream’ measures (primary prevention) whilst treating urgent, 

short-term needs and demands to relieve acute conditions, which is always the political imperative. 

Resist the temptation to seek a ‘quick-fix’ for problems, which need time and patience for their 

solution. 

Optimise the use of resources in the provision of health and social care: 

• Educating and training appropriate personnel appropriately, matching skills to needs 

• Recognising that capital expenditure on ‘plant’ (buildings) and equipment is cheap relative to 

current expenditure but an essential criterion for an efficient service. Avoid short-term measures 

which carry long term penalties 

• Address the legacy of under-provision and ensure consistency and continuity of funding (over 50 

years in the UK annual increases in funding have ranged from zero to 10% – hardly a recipe for 

stability) 

• Forge agreements for the bulk purchase of supplies, notably of generic pharmaceuticals 

• Employ clinical governance to obtain value for money in a high quality service by simultaneously 

raising productivity and standards 

• Tackle inequalities by a premium of resources to meet greatest need, for example, for ‘failing’ 

hospitals, rather than naming and shaming and demoralising staff and patients 

• Direct resources to provide care as closely as possible to where people live and work 

• Prevent preventable hospital acquired infections and ‘adverse incidents’ such as medication 

errors: primum non nocere. [7] Aristotle described hospitals as dangerous places! 

• Promote self-help by individuals, families and communities 

Recognise the limits imposed by: 

• Human nature; in a democratic society people cannot be coerced to adopt healthy life-styles, to 

submit to scientifically accredited advice or treatment, to cooperate in having their infants 

immunised. Carrots are in, whips are out. 

• Ethical considerations such as those which arise in birth selection facilitated by genetic 

information, withholding of treatment in PVS (permanent vegetative state) or terminal illness, or 

recourse to euthanasia as a personal choice or a communal policy. Beware the slippery slope! 

Delivery 

The role of Government 

The agenda for action in chronic disease prevention and control must be led by government at every 

level of society, including inter-governmental organisations. This is particularly appropriate in 

democratic societies where ‘top-down’ initiatives can stimulate ‘bottom-up’ responses. A lead has 

been given by WHO staff members whose recommendations for the discharge of its role in strategic 

initiatives may be summarised thus: [8] 

• Provide strategic leadership for global governance 

• Enhance capacity – human, financial, institutional 

• Support innovative ‘upstream’ strategies 




• Strengthen health systems 

• Set targets against long-term scenarios (drawing on the UK’s Wanless Report) 

• Strengthen the evidence base and evaluate the impact of policies for health 

• At regional level, develop long-term scenarios in at least one country and strengthen the network 

of collaborating centres 

• At country level, support global strategies with high-level advocacy 

Addressing the European Policy Centre on 15 July 2004 on behalf of the EU, David Byrne [9] 

insisted that the EU and its member states should more actively promote prevention rather than 

focus on treatment, and called for particular attention to be given to diseases linked to life-style, 

which points to obesity and diabetes related to nutrition and inadequate physical activity; 

malignancies, respiratory and cardiovascular disease caused by tobacco, cirrhosis related to the 

abuse of alcohol, and so on. Wisely, to retain a balanced approach, he recognised the need to 

control both old and new communicable diseases. Health should be included in all EU policies 

including social, employment, transport, environment, agriculture and the internal market, which 

raises a question about the adequacy of a ‘shared competency’ for health. He called for member 

states to coordinate national health systems and to maximise the use of spare capacity. Specifically 

and concretely he envisaged an EU Institute for Health that would complement national institutes and 

promote crucial research and development. 

Priorities for action 

Every country is free to develop its own policies and programmes subject to international agreements 

and commitments. But, looking 20 years ahead as Wanless advocates, with intermediate milestones, 

certain general measures and programmes should be instituted to tackle the prevention of the major 

preventable killers. 

1. General measures 

• Surveillance to deal swiftly with new communicable diseases as untamed nature continues to 

challenge us, and to maintain control of old diseases such as tuberculosis and HIV/AIDS, to 

obviate distraction and diversion of resources required to tackle chronic diseases. 

• ‘Fully-engaged’ governments to work towards a health-promoting economy through agreements 

with industry and commerce underpinned by fiscal incentives and penalties with regulation where 

necessary, involving standards in the marketing of unhealthy or potentially unhealthy products, 

especially to children and young people. The tobacco manufacturing industry might be 

encouraged to devise an exit strategy. 

• Agents of civic society to develop a monitoring and campaigning role in relation to government 

and industry. 

• Governments at all levels to form coalitions with health-related NGOs (non-governmental 

organisations) and bodies representing patients to promote a health-orientated culture to inform 

and shape consumer demand for healthier products and services, and to promote access to 

health protection services available locally. 

• Encourage informed debate about costs and benefits involving consumers and providers and the 

insurance industry in making difficult assessments at every level, especially concerning different 




individuals. 

• Governments, in alliance with commercial organisations, employers and Trades Unions, to 

promote enlightened self-interest through improved occupational health services. 

• Adopt a life course approach, starting with expectant and nursing mothers and fathers, children 

and young people, which addresses the specific needs of each age group, with particular 

attention to those disadvantaged by personal circumstances. 

• Develop and encourage the use of drugs, which limit the development or progress of disease 

such as statins to lower cholesterol levels (already, statins are used by an estimated 35 million 

people in the EU) and medical devices to reduce disability. 

• Health promotion and health education fully integrated in all health and social care programmes 

• Cultivate knowledge and understanding of threats to life and health in the environment and in 

disordered personal behaviour, and of opportunities to combat them. 

• Reject claims of cynics who have their own health-defying agenda, that health education does not 

work. To quote Wanless, “there is evidence that some health promotion interventions are not only 

effective but also cost-effective over both short and ten-year time periods.” [10] 

Klim McPherson [11] has shown that 25% of all cancers and 30% of coronary heart disease are 

preventable through public health measures. In 1950, when Doll and Bradford Hill first proved the link 

between smoking and disease, the UK had one of the highest rates of lung cancer in the world, but 

since 1965 mortality from this cause has fallen to one half of what it would have been but for the 

reduction in the number of smokers. Moreover, the savings in costs are incalculable.[12] This is not 

to be complacent. The number of young smokers, especially women, is increasing, and half of them 

will be killed ten years prematurely by tobacco if they do not stop. 

Policies should have as their objective the promotion of the aim of making healthy choices the easy 

choices. This requires the ready availability of information about risks and benefits. A proper concern 

about confidentiality must not be allowed to impede research into the causes of disease and the 

evaluation of the effects of interventions. 

There is a dark side to this: the risks lurking in the recourse of credulous people to dubious remedies 

or “treatments” peddled by quack practitioners, backed by beguiling commercially driven advertising. 

The hazards of UV sunbeds are now well known, but many herbal products and slimming regimes 

are increasingly suspect, especially when they are incompatible with prescribed medication. Physical 

activity is vital but should be measured, graduated and appropriate. Commercial gym chains are a 

double edged development, offering a growing range of children’s classes such as baby yoga 

starting at six months, and toddler aerobics for four-year-olds, evoking a warning from the American 

Academy of Paediatrics that they are ineffective in warding off obesity but can damage underdeveloped 

skeletons. 

2. Specific Measures 

The sky is the limit to action which might be taken to seize the opportunities for the prevention of 

chronic disease presented by increasing evidence of causes and effects, keeping in mind the 

imperative of acting as far “upstream” as possible. Every stakeholder, from governments through 

organisations to individuals, has obligations – ethical, altruistic, economic, social, to invest in action 

which will deliver health bonuses in the longer term with interim bonuses if they are lucky. 




A few obvious priorities suggest themselves; 

• Teacher training courses should encourage students to exploit opportunities to convey health 

education messages in the course of lessons in any subject. Every school should have health 

education programmes from the earliest age. 

• School meals should be healthy meals and fruit should be provided to younger children to 

promote the choice of healthy diets. 

• Food should be clearly labelled with essential information, especially about the content of salt, 

sugar and fat. 

• The marketing of foodstuffs to children should be controlled. 

• Physical activity should be promoted, notably through environmental and transport policies and by 

making public places, streets and parks safe for pedestrians and cyclists, encouraging sport, and 

helping elderly and physically disabled people to remain mobile. 

• Pre-symptomatic diagnostic screening should be available where the evidence base has been 

established and the resources are available to follow-up, especially to identify individuals at risk of 

developing serious conditions such as cardio-vascular disease, diabetes and obesity. 

• Research should be supported to develop improved tests for screening of conditions such as the 

growing epidemic of cancer of the prostate gland. 

• Registers of patients suffering from major chronic diseases or judged to be at high risk of 

developing them, should be universally established and regularly updated. 

• Tobacco is the outstanding priority for draconian action, including full implementation of the 

Framework Convention on Tobacco Control. There should be immediate bans on smoking in 

every workplace and in all enclosed public places including hospitals and public transport. 

Smokers should be encouraged to quit by accessible and skilled services. 

References 

1. Wanless D. Securing Good Health for the Whole Population: Population Health Trends, London: 

HMSO, 2003 [quoting Acheson D, et al, 1998, Report from the independent enquiry into inequalities 

in health] 

2. Bunker JP. Medicine matters after all. Journal of Royal College of Physicians 1995;29:105–12. 

3. Wanless D. Securing our Future Health: Taking a Long-term View. 2002, p. 145. 

4. Ibid p. 35. 

5. Ibid p. 39. 

6. Ibid p. 92. 

7. Ibid pp. 28, 29. 

8. Yach D, Hawkes C. Towards a WHO Long-term Strategy for Prevention and Control of Leading 

Chronic Diseases. WHO, 2004, pp. 8–9. 




9. Byrne D. In the European Policy Centre, 15 July 2004. 

10. Wanless D. Securing our Future Health: Taking a Long-term View. 2002, p. 47 [quoting the 

International Union for Health Promotion and Education. The Evidence of Health Promotion 

Effectiveness: Shaping Public Health in a New Europe. Report for the European Commission, 1999]. 

11. McPherson K. Are disease prevention initiatives working? Lancet 2001;357:1790–92. 

12. Peto R, Darby S, Deo H, Gilcocks O, Whitley E, Doll R. BMJ 2000:321, 323, 329. 




IT in healthcare – what is necessary to increase healthcare 

efficiency 

Karl-Jürgen Schmitt 

The healthcare system as an economic factor 

Health is the most precious commodity of people. Much is spent to maintain it, and when we fall ill, 

much is spent to regain it as quickly as possible. In Germany, the amount approaches 11% of the 

gross domestic product. The actual figure 

in 2002 was 234 billion euros. This ranks 

Germany third in the world, behind the 

US at nearly 14% and Switzerland at 

approximately 12% [1]. Healthcare costs 

in Europe are about 8.6% of GDP. In 

healthcare an average of 10% of all 

employees are engaged, making 

healthcare a job engine providing highend 

jobs with high local value added. 

From a political point of view, these costs 

weigh heavily on public budgets and nonwage 

labor costs, hence the attempts by 

politicians are to bring costs down. The 

general trend in the European countries 

indicates, however, that cost-cutting is not 

in the individual’s best interest. In fact, 

much more attention must be paid to 

making the quality of medical services 

measurable and transparent, to increase 

efficiency in healthcare to serve the 

increasing demand. 

Willing to pay for quality 

The core question is whether health care 

funds are spent accurately and efficiently 

for the patient. In the 2000 health report 

from the World Health Organization 

(WHO), which ranked countries by the 

performance of thrie healthcare systems, 

the countries that spent the most did not 

come out on top. Germany was placed 

25th and the USA 37th [2]. While the 

specific criteria for the comparison can be 

argued, the study nonetheless confirms 

healthcare outlays are not the sole 

indicator of a high-quality healthcare 

system. 

Figure 1: In 2002, Germans spent more on cars 

than on contributions to public insurance funds. If 

health is the most precious commodity, is it 

justifiable to talk only about costs? 

Expenditures of compulsory health insurance 

€ 133 billion (inc. employers’ share: € 66.5 billion) 

Other 9% 

Nursing and 

therapeutic 

services 25% 

Expenditures for cars 

€ 174 billion 

Car rental, inspection, 

parking 12% 

Petrol and 

engine 

oil 21% 

Medical services 33% 

Vehicles 39% 

Prevention/ health 

protection 3% 

Commodities 30% 

Repairs and 

maintenance 26% 

Vehicle tax 26% 

Source: Statistisches Bundesamt, 2004 (data for 2002). 




We might venture to say that people would be quite willing to spend even more on healthcare if the 

quality of service was measurable and more objective. For example, Germans spent EUR 174 billion 

on their cars. In 2002, EUR 133 billion were paid out to public insurance funds. Employers are 

responsible for 50% of contributions to insurers, leaving German citizens to foot the remaining EUR 

66.5 billion (Figure 1). The difference in expenditures and the different willingness to pay for the cars 

on the one hand and for healthcare on the other hand can be explained because the costs for the 

cars and the related services are transparent and the advances in quality and safety are obvious. In 

1960, when the average driving speed was far lower, there were 21,000 traffic-related deaths. In 

2003, there were fewer than 7,000. That is a measurable safety dividend, for which people are also 

willing to pay. 

The highest efficiency potentials 

Reducing errors and improving care for chronic illness are among the strongest drivers of quality 

improvement in healthcare (Figure 2). In 2000, the Institute of Medicine in the US published a study 

that put the number of deaths per year due to medical error at around 90,000 [3]. In hospitals, 7,000 

of these deaths stemmed from medication errors. This report drew considerable attention. Studies in 

the European countries drew similar conclusions [4]. In Germany, mortality due to medication errors 

ranges between 7,000 and 24,000. Using the most conservative estimate, the magnitude equals the 

number of traffic deaths in 2003. However, if you compare outlays on traffic safety to those of 

medication safety, the difference is utterly disproportional. 

Significant potential to improve the quality of the healthcare system 

Costs for the insured 

Early 

recognition 

90,000 Deaths 

‘Adverse Events’ 

Actual 

(without ‘Adverse Events‘) 

Ideal 

Diagnosis Therapy Rehabilitation 

Source: Institute of Medicine. To Err is Human. 1999, p.26. 

American Hospital Association. Hospital Statistics. Chicago,1999 

Figure 2: Medical care 

today is characterized 

by high-quality acute 

medicine. Much 

higher healthcare 

costs arise from 

‘adverse events’. 

Ideally, more would be 

spent on prevention, 

which in turn would 

be offset by lower 

costs for acute care. 

By realizing the ‘ideal’ 

curve, quality of life 

can be improved 

significantly. 

Chronic diseases, with diabetes in the lead, are very much on the rise worldwide. Estimates indicate 

that the number of diabetics will double by the year 2025 to 340 million. According to the WHO, 

chronic illness accounts for 60% of healthcare costs. In cases of chronic illness, for example, 

diabetes or asthma, keeping the disease pattern stable is vital. Usually, the patient’s status is 

reflected in a handful of characteristic physiological values, which often patients can measure on 




their own. The physician reviews the values at regular, but protracted, intervals. If the patient’s 

condition remains stable over time, the serious consequences (for example, for diabetics, leg 

amputation, blindness, kidney failure, etc.) associated with hospital stays can be avoided or 

mitigated. For the individual patient, that means improved quality of life. For the economy, it means 

costs saved. Since the chronically ill typically seek care over time from a number of different 

physicians, in many cases without comprehensive disease-related information, often the patients’ 

state does not remain stable, even in industrial nations like the US. Depending on the type of chronic 

illness, up to 50% of patients receive inadequate treatment [5]. 

IT supports efficient treatment processes 

IT-supported treatment processes can significantly reduce medication errors as well as improve the 

care of the chronically ill. Incorrect or incomplete prescriptions are not only sources for medication 

errors, but take a lot of time to double-check and correct. The Institute of Medicine study resulted in a 

vigorous campaign in the US and parts of Europe to optimize the medication process in hospitals 

and to lower the error rate. The introduction of the Computerized Physician Order Entry (CPOE) 

markedly increased efficiency (Figure 3), for example, in the Ohio State University Health System 

(OSUHS), USA, where the time for dispensing medication dropped by 64%, and in Soedersjukhuset, 

Sweden, where the number of incorrect and incomplete prescriptions fell by 73% [6]. Using a serverbased 

infrastructure that provides the possibility to access to the patient’s medical history and 

relevant risk factors, like allergies, and to an electronic patient card serving as the key to the data, 

similar processes in outpatient care can be introduced, thereby substantially improving safety. 

Proven outcomes: 

eHealth yields medication process improvements and increases patient safety 

Ohio State University health system 

USA 

Medication turnaround time Erroneous or incomplete prescriptions 

5:28 

hours 

Conventional 

(Manual order entry) 

- 64% 

1:51 

hours 

• More timely patient care 

• Enhanced efficiency 

Soedersjukhuset 

Sweden 

POE* Conventional 

(Manual order entry) 

- 73% 

• Higher patient safety 

• Increased nurse satisfaction 

* POE (Physician Order Entry): Automated medication processing and administration system 

83% 

10% 

POE* 

Figure 3: eHealth 

shortens cycle time 

for dispensing 

medication and 

reduces medication 

errors 

An electronic patient 

record that 

accompanies the 

chronically ill patient 

over the entire course 

of his or her illness 

can ensure that the 

various treating 

physicians have 

comprehensive 

information 

immediately. The 

patient takes readings 

at home and transmits 

them by telephone into 

his patient record. The 

values are available right away and completely. An electronic alarm at the physician’s office or with 

the patient ensures that action is taken immediately should the patient become unstable. 

Preventative examinations, for example, to prevent blindness in diabetics, are documented and a 

remainder is deposited to ensure that the follow-up exams do not fall through the cracks [7]. Related 




pilot projects (Figure 4) have shown that patients are much more engaged in their treatment and are 

more willing to cooperate to remain stable. Stable patients enjoy a higher quality of life and incur 

fewer costs. 

Project DIADEM 

Diabetes disease management 

EU sponsored international business development project 

Consortium: Siemens, AOK Bundesverband und 

AOK Rheinland,DCM Munich, DRU Cardiff, ... 

Goal: management of Diabetes Type II 

Method: integrated quality management, 

network of patients, GPs and clinical 

competence centers, guidelines, 

call center, patient monitoring 

Participants: Pilots in Wales and Aachen 

with ~400 Patients 

IT: 

MedStage 

Patient health record 

Process workflow management 

Standardized online documentation and 

evaluation 

Patient monitoring (blood glucose, blood 

pressure…) 

Figure 4: 

In IT-supported 

disease management 

programs, 

comprehensive patient 

information is 

delivered exactly to 

the point of care. The 

patient is motivated to 

participate and, as a 

result, maintains a 

long-term stable 

disease pattern 

In particular, these examples point to the types of healthcare initiatives that can significantly improve 

efficiency. Specifically, chronically ill patients need to be rewarded for obviously contributing to their 

health. Service providers also need to be compensated in keeping with measurable quality and 

receive incentives when their patients remain healthy - even if the frequency of patients visiting the 

doctor is less. 

Optimization of healthcare as a whole 

The whole healthcare process – from prevention, to diagnosis and treatment through rehabilitation 

and care – must be optimized in order to achieve maximum efficiency. All the stakeholders must 

keep this goal in mind and work towards better quality and higher transparency in healthcare. 

Modern information and communication technologies help deliver medical and patient-specific data 

where it is needed (Figure 5, overleaf)) . The whole process chain is optimized, individual steps can 

be measured and therefore evaluated, the quality and cost of care becomes transparent, and 

healthcare as a whole continuously improves. 

Creating interoperability between IT systems 

Different IT systems must be integratable, interoperable, and able to communicate with one another 

clearly – abilities mostly lacking in today’s healthcare systems. Interoperability requires internationally 

accepted standards, such as DICOM and HL7. These standards are necessary, but not sufficient. To 

accurately transmit messages from one system to another requires a precise process definition and 

definition of communication profiles that only the users can provide. To motivate users for this work, 

they must understand the significance and purpose of IT in healthcare and develop a personal stake 

in it. On the part of service providers, this personal interest is not very pronounced. 

Radiologists are one exception: technology and innovations are literally ‘in their face’ every day, and 

they have grown accustomed to them. The fact that a magnetic resonance system and a computer 

tomograph from two manufacturers cannot communicate with one another, or with the digital patient 




Efficiency improvements require workflow optimization throughout 

the entire system 

Healthcare system 

Prevention 

Disease 

Mgmt. 

home 

care 

archiving system from another manufacturer, significantly limits this group of physicians in their dayto-day 

work. For this reason, radiologists unequivocally pressed the industry to integrate the systems 

into the medical process and make them interoperable, enabling seamless radiologic workflow and 

thus increasing efficiency. User participation was vital, since they were the only ones able to define 

the medical processes. The ‘Integrating the Healthcare Enterprise’ initiative was launched by 

radiologists and industry, first in the US and then in individual European countries, to realize this 

interoperability and optimized workflow in radiology. Ten countries are currently taking part in this 

initiative and thus far almost 300 systems from 76 manufacturers have been integrated. 

This initiative is just one example of how needs and concerns can change the way we think and 

behave. Basic conditions, incentives, and the realities of the workaday world will determine the extent 

to which stakeholders, and above all users, will accept IT and how great the demand for integrated 

solutions will be. 

In Germany there is another example how advanced developments are initiated by proper incentives. 

‘Integrated care’ i.e. the trans-sectorial cooperation between private practice physicians, hospitals 

and rehabilitation clinics has been considered the main lever for increasing quality in healthcare for 

many years. Even in this case, IT is key to realizing this objective. Although integrated care has been 

approved by law for five years, there have not been any consequences yet. The reason for this fact 

is again lack of incentives. When in the beginning of 2004, 1% of the expenditures of statuary health 

insurance funds were explicitly dedicated to integrated care it was the first time that a huge number 

of projects – up to now over 10,000 – were submitted to health insurance funds. 

The fate of pilot projects 

ambulatory 

care 


Management 

Cure 

mobile 

care 

Assisted 

Living 

stationary 

care Rehabilitation 

Figure 5: 

Information and 

communication 

technologies 

greatly help to 

optimize clinical 

workflow 

throughout the 

healthcare 

continuum. 

In recent years there have been a number of pilot projects, some initiated by public and private 

partnerships or supported by the European Union. Nearly all have proven the benefits and feasibility 

of information and communication technologies in medical care, but were not carried over into 

general medical practice. The reason is a lack of incentives to integrate and use such processes in 

everyday work. Ultimately, these are missed opportunities to take relatively simple means to increase 

efficiency in healthcare for the benefit of the patient. 




There was, for example, the ‘Talkingeyes’ project conducted in Erlangen between 2001 and 2002. It 

was a joint project by the University of Erlangen-Nuremberg, the Siemens Health Insurance Fund, and 

Siemens Medical Solutions. It was targeted toward stroke prevention through quantifying the 

individual’s risk of stroke. A well-backed study in the US revealed that the vessels of the ocular 

fundus, which can be easily viewed externally, reflect the level of microvascularization in the brain [8]. 

An examination of the retinal vessels allowed physicians to infer the degree of stroke risk. Cameras 

were set up in various sites in Erlangen and a medical technician took photographs of participants’ 

retinas. The photographs were transmitted to a server in digital form and read by qualified 

professionals at the diagnosis center. The diagnosis was entered into the server, where the study 

participant could access it using a PIN (Figure 6). The whole process was released by the States’ 

Data Safety Office. About one-fifth of the participants evidenced a heightened risk for stroke. The risk 

population was invited to participate in a special disease management program to return their stroke 

risk to normal. It is expected that this type of program will raise health consciousness in the population 

and thus cases of stroke will be avoided. The number of participants alone (8,000 in one year) – who 

did bear parts of the costs themselves – indicates the strong interest the population has in prevention. 

Project t@alkingeyes 

Vascular health management 

Goal: Identification of citizens at vascular risk and 

enrolment to health management programmes 

Method: Quick and painless photography of the eye fundus, 

quantitative and qualitative analysis of the small vessels 

of the “eyefundus as a mirror of the vascular system” 

Process: Examination by mobile screening units, for 

example, at large employers, centralized grading, quality 

management and administration 

Participants 

2002/02: ~8,000 in Erlangen, sponsoring State of Bavaria 

2003/04: planned 25–30,000 in 5–6 cities/regions; SBK funded 

IT: MedStage 

Patient portal - including registration, appointment booking and 

retrieval of results 

Workflow management (worklists etc.) 

Secure data transmission from mobile screening units to 

centralized grading 

Quality management 

Figure 6: The 

‘Talkingeyes’ 

prevention project 

was initiated as a 

public/private 

partnership and 

was ultimately 

able to quantify 

the risk of stroke. 

For these quality-controlled and efficient care processes to benefit the broad population quickly and 

effectively, business models and incentives have to be created for all the stakeholders – service 

providers, health insurance funds, and citizens. Only through flexible structures in the healthcare 

system will innovation and improvement be integrated into the overall care process much more 

rapidly. The citizens play a vital role in this process. They decide what risks to take or avoid and 

which incentives to take advantage of in order to maintain good health. The service providers also 

receive incentives to keep their clients healthy, and not exclusively to heal them when they are sick. 

Benefits for the users 

Modern information and communication technologies combined with an electronic patient record 

provide critical support to the care process. Politicians and decision makers in healthcare already 

acknowledge this, but progress is very slow (Figure 7). Health insurers mainly tout the good risks and 

ignore opportunities to analyze quality of care and communicate this to their members. Opposition of 




the users is still high, because their advantages have neither been comprehensively defined nor 

communicated. Administrative tasks especially could be greatly simplified given the right framework 

conditions. Payment for services could be made online. In fact, all activities not directly connected to 

patient care, such as administration and logistics, could be made much more simple. To realize all 

these advantages, however, requires open and cooperative teamwork on the part of all stakeholders. 

IT in healthcare – a European challenge 

Figure 7: 

At the ‘eHealth 2003’ 

European Ministerial 

Conference, 

industry proposed 

prerequisites for 

implementing IT in 

healthcare 

The advantages of IT in healthcare have also been recognized at the European level, and the 

European Commission has offered support for the Member States to introduce international 

interoperable eHealth platforms. The Member States have accepted this offer and first discussions 

are initiated. Especially in Europe, it makes economic sense for all the Member States to agree on a 

single concept for synchronizing systems in order to benefit from quick and efficient improvements. 

The healthcare systems must be able to exchange information to handle the growing number of 

patients seeking healthcare across boarders. For this reason the European Commission has 

assigned an independent group of all stakeholders to identify international standards for IT in 

healthcare and to give directions how to establish interoperability of different systems. Even in this 

instance, however, the only way to reach a viable solution is to invite users to join the discussion and 

actively participate. The advantages of new technologies in healthcare are great. To use them we 

desperately need much more flexible structures and appropriate incentives, especially to overcome 

the challenges of the future. 

References 

Actions 

1. OECD Data 2004. 

From Siemens „eHealth 2003“ 

presentation to European Health 

Ministers in Brussels 

• Embrace and commit to IT in healthcare 

• Reduce regulations with the goal of an open and 

transparent competitive healthcare market 

• Achieve a reasonable balance between data privacy 

regulations and efficient data exchange 

• Create a legal environment for trans-European 

healthcare delivery 

• Use proven international technical industry standards 

• Establish European benchmarks / best practise sharing 

• Link provider performance to payment: 

no outcome, no income 

• Include healthcare into European infrastructure funds 

2. World Health Organization. The World Health Report 2000 – Health Systems: Improving 

Performance. Geneva: WHO, 2000. 

3. Institute of Medicine. To Err is Human: Building a Safer Health System, IOM, 2000. 

4. Smith J. Building a Safer NHS for Patients: Improving Medication Safety. London: Department of 




Health, 2004 

5. World Health Organization. Adherence to Long-term Therapies: Evidence for Action. Geneva, 

WHO, 2003. 

6. Baldauf-Sobez W, et al. How Siemens’ computerized physician order entry helps prevent the 

human error, electromedica 2003;71(1):2–10. 

7. Zahlmann G, et. al. Progress in networked disease management and screening services, 

electromedica 2001;69(2):91–94. 

8. Wong TY, et al. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk 

in Communities Study, Lancet 2001;358:1134–40. 




Is there a trade-off between cost control and equity? 


Jui-fen Rachel Lu 

Introduction 

While most of the European Union member states have long achieved fairly universal coverage of 

health care for their population, many countries may still view universal coverage an unaffordable 

policy objective to achieve in developed economies as well as developing ones. Quite ironically, 

while US still lacks universal coverage, we also see Mongolia being the first and the only low-income 

developing country to have successfully extended universal coverage to a largely rural population. 

A common fear about universal coverage is the cost associated with its implementation, given that 

the rapid increase in health expenditures has been a major concern to many nations around the 

world. Heated debates centre on finding the ‘best’ financing mechanism for funding health care 

systems to ensure sustainability. However, some countries opt to keep cost down by instituting “hard” 

budgets, while compromising access to care. In other countries people enjoy the “convenience” of 

high access to care which may incur significant health expenditures. Essentially, any health care 

financing system involves trade-offs between cost control and equity performance of the health care 

system, to some extent. However, some approaches may have unique features that can minimize the 

trade-offs. Using Taiwan’s National Health Insurance as an example, this presentation demonstrates 

the potentials of a single-payer approach in minimizing the trade-offs. 

Single-payer approach 

The single-payer approach is often viewed as a ‘non-market’ approach. In a market approach, 

“goods” (in the context of health care, it can be viewed as health services) are distributed on the 

basis of supply and demand, and the price mechanism will affect production and consumption 

decisions. In the case of high demand and a shortage of supply, the market price will rise until 

enough people are priced out of the market (demand curve will fall) and supply once again 

equilibrates with the new demand curve at the new market equilibrium price. However, this is 

probably not a favourable scene for people believing in egalitarian approach in delivering health care 

to those in need. 

A single-payer approach, strictly defined, is often referred to as one single administration operating 

the insurance scheme and the representing countries are Taiwan and Canada. It can also be 

extended to a health insurance system where there are multiple insurers governed by the same rule, 

in the case of Belgium and France. The National Health Insurance system in Canada is one example 

which is built on recognition of the limits of markets in distributing medically necessary care.[1] 

Canadian researchers have also pointed out that the advantages of adopting a single-payer 

approach in Canada include lower cost for universal coverage (as opposed to pluralistic funding 

approached) and the avoidance of risk selection. This publicly funded ‘single-tier’ principle is well 

defended by the Canadian health policy analysts not only on the grounds of equity but also on the 

grounds of economic efficiency [1]. 




The case of Taiwan 

Overview 

Taiwan implemented its National Health Insurance program in 1995, which is a payroll-tax financed 

social health insurance program, providing comprehensive health care coverage to its 23 million 

citizens. Its major objectives are to provide people with financial risk protection and appropriate 

access to health care, regardless of their socioeconomic status. The Bureau of National Health 

Insurance (BNHI), a quasi-governmental agency which by law is the only administration that operates 

the insurance program, manages an annual budget of roughly USD 10 billion. In economic terms, 

BNHI is the monopoly as well as monopsony in the market place. In other words, BNHI is the sole 

supplier of the health insurance scheme with the most comprehensive health services coverage 

(some private health insurances are available upon purchase, but rather supplementary to the 

coverage provided by NHI) and also the main buyer of the services rendered by the care providers. 

Taiwan has a market-driven health care delivery system with a mix of publicly and privately owned 

hospitals (public: 35% of beds; private: 65%). Sixty-three percent of physicians are employed by 

hospitals and paid on a salaried basis; some receive bonus payments based on productivity. The 

remainders are fee-for-service private practitioners.[2] Taiwan spent approximately 6% of GDP in 

health care in 2002.[3] While the public sector (including social insurance premiums) contributes to 

61% of total national health expenditures (NHE), out-of-pocket payments have accounted for roughly 

one-third of the total bill. Compared to South Korea (50%) and Japan (13%), which also operate 

payroll-tax financed social insurance programs, Taiwan stands in the middle (30%), in terms of 

financial burden imposed upon private payment (data from EU funded research project, EQUITAP, 

complete paper, please refer to O’Donnell, van Doorslaer, Rannan-Eliya, et al, 2004 [4]). Examining 

the progressivity of the health care financing system in Taiwan, research results have shown that the 

better-off pay more in absolute term but less as a proportion of income, nonetheless, it is rather 

proportional (with a Kakwani index of -0.0749 and -0.0292, for social insurance financing and total 

financing, respectively). 

Are the health care costs well contained? 

The cost containment efforts were examined through analyzing the residuals for NHE growth rate for 

the pre-NHI years and post-NHI years. The residuals were computed and compared after 

decomposing the nominal annual rates of increase in NHE from 1993 to 2000 into various known 

causes: the increase in population, aging of the population, change in demand due to increases in 

income, and increases in input factor prices. As Taiwan didn’t have any political and socioeconomic 

shocks that affected health expenditures other than the NHI in those years, the differences in the 

residual levels are likely due to NHI. The residual has been approximately 2% per year between 

1993 and 1995, similar to the average rate in years 1970-1986. However, the residual jumped to 

close to 7% in 1995 when NHI was implemented, which may be interpreted as the insurance effect of 

NHI. Then the residual fell measurably below the historical level, averaging close to 0% from year 

1996-2000. As shown by the evidence, the total increase in National Health Expenditures between 

1995 and 2000 was not more than the amount that Taiwan would have spent, based on historical 

trends.[2] 

As a single-payer, NHI produces some direct savings through its market power. Its operational 

efficiency was enhanced through a universal uniform reporting procedure and claim filing system 

which substantially reduces administrative costs and achieves economies of scale, while instituting a 

uniform fee schedule for services rendered by the contracted providers. The single-payer system 

also offers the information and tools to effectively manage health care costs through a stringent claim 

review process. Taiwan was able to manage its NHE growth at an affordable rate through a single- 




payer mechanism. 

Is equity in use of services sacrificed while costs are well contained? 

We adopt the horizontal equity principle which can be stated as “equal treatment for equal medical 

need” to examine the equity performance of the Taiwan health care system. Empirically, the equity 

principle is tested by employing the index of horizontal inequity developed by Wagstaff and van 

Doorslaer [5] which standardizes for differences in need, proxied by age, gender and common health 

indicators, such as self-assessed health status measurement (SF-36). The empirical analyses were 

performed on a national representative sample from the 2001 Health Interview Survey (HIS) which 

included 7,632 household totaling 31,436 individuals. The results show a pro-poor distribution of 

utilization of the services that are more extensively covered by NHI, such as hospitalization, western 

allopathic physician visits and emergency visits. For services with limited NHI coverage (such as 

dental, traditional healer, and Chinese medicine practitioner visits), the distribution tends to be prorich. 

Standardization for differences in need shifts all distributions in a pro-rich direction, although the 

actual use distribution is more pro-poor. Violation of the principle of “equal treatment for equal need” 

by income is modest. However, the empirical results only refer to differences in quantities of uses 

across different income deciles, and quality issues were not explored in the analyses. 

A recent paper derived from the ECuity II Project examining the income-related inequalities in doctor 

utilization in Europe, has found little or no evidence of income-related inequity for the GP visits, 

however, substantial pro-rich inequity emerges with respect to specialist visits [6]. Although the 2001 

HIS in Taiwan did not break up physician visits by those to GPs and to specialists, a tentative 

comparison was made in the income-related inequity in doctor visits between Taiwan and the 

selected European countries. We found that Taiwan shows a similar equity distribution as that for GP 

visits in Austria. 

Conclusions 

So, is there a trade-off between cost control and equity? 

My answer is, not necessarily. Taiwan offers an opportunity to study how a single-payer system can 

minimize the trade-off between cost control and equity in access to care. As shown by the evidence 

presented above, I believe that the trade-off can be minimized through a single-payer approach 

which can achieve gains in economic efficiency by design. Taiwan was able to manage its NHE 

growth through the adoption of a single-payer approach and has shown fair (compared with western 

developed countries) equity performance of the health care delivery system. However, I do want to 

conclude this presentation by reminding the audience that the empirical research results presented 

here have rarely touched upon quality issues, and the researcher has no means of controlling for 

differences in the quality of services examined in the study. The focal point of examining the equity 

distribution in uses of services has largely centred upon whether socioeconomic factors are 

deterrents to access to care. 

Health care systems have unique features which are embedded in their historical development for 

each country. Hence, system features which serve well for one country may not necessarily do so for 

the other. Nonetheless, the exchange of hard-earned experiences may still minimize the chances of 

painful lessons. 

References: 

1. Deber RB. Health care reform: lessons from Canada. American Journal of Public Health 

2003;93(1):20–24. 




2. Lu JR, Hsiao WC. 2003. Does universal health insurance make health care unaffordable? Lessons 

from Taiwan. Health Affairs 2003;22(3):77–88. 

3. Department of Health. Health and Vital Statistics, Republic of China. Department of Health, 2002. 

4. O’Donnell O, van Doorslaer E, Rannan-Eliya RP, et al. Who Pays for Health Care in Asia. 

EQUITAP Project: Working Paper No. 1, 2004. 

5. Wagstaff A, van Doorslaer E. Measuring and testing for inequity in the delivery of health care. 

Journal of Human Resources 2000;35(4):716–33. 

6. Van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilization 

in Europe. Health Economics 2004;13(7):629–47. 




Implications of financial pressures and health system changes for 

patients 

Angela Coulter 

Strategic goals 

In seeking ways of dealing with the cost pressures that afflict all western health systems, 

governments and payers are becoming more interested in demand management. A key element in 

managing demand is recognising the patient’s role as a significant player in protecting their health, 

coping with acute episodes of ill-health and managing chronic disease. 

Patients can play a distinct role in their own care by diagnosing and treating minor self-limiting 

conditions and preventing occurrence or recurrence of disease or harm, by selecting the most 

appropriate form of treatment for acute conditions in partnership with health professionals, and by 

actively managing chronic diseases. Recognising these roles and seeking to strengthen them is 

fundamental to securing a more patient-centred approach to healthcare delivery and may also offer 

the best and most cost-effective means of matching demand to supply of healthcare. 

In a review of future funding needs for the health service carried out on behalf of the UK Treasury 

department, Derek Wanless called for a new focus on moderating demand by investing in effective 

health promotion and disease management with the active involvement of individual patients and 

local communities.[1] The fully engaged scenario, which involved a radical change in professional 

and public roles, was the most ambitious of the three alternatives modelled by his team, but they 

concluded that it offered the best and most cost-effective means of matching demand to supply of 

healthcare in the longer term. By providing information to ensure that patients make appropriate use 

of services and by encouraging effective self-management, Wanless hoped that demand for doctors’ 

services would decline. The report was bold enough to put an estimate on the potential impact of this 

strategy: “…visits to GPs could decline by over 40% and outpatient visits by 17% as a result of 

increased self care… for every £100 spent on encouraging self-care, around £150 worth of benefits 

can be delivered in return.” 

A growing body of evidence demonstrates that patient engagement in treatment decisions and in 

managing their own healthcare can lead to more appropriate and cost-effective utilisation of health 

services and better health outcomes.[2] The key to greater patient engagement lies in building health 

literacy and ensuring that clinicians help patients to help themselves. Paternalistic styles of practice 

tend to create dependency and undermine self-reliance. What is needed is a change in the way 

clinicians and patients think about their roles. Patients should no longer be seen simply as hapless 

victims of ill-health with a duty to follow doctors’ orders. Instead their right to make autonomous 

choices must be better understood and facilitated by clinicians. Meanwhile patients need to 

understand the limits of medical care and the uncertainties surrounding the effectiveness and 

outcomes of most interventions. They must be actively encouraged to use health services 

appropriately and responsibly. Recognition of the patient as an autonomous player in the healthcare 

system could have profound consequences for the way in which healthcare is delivered, but only if 

clinicians, especially doctors, are willing to adapt their practice styles to accommodate a partnership 

approach. 

In addition to the potential for achieving greater efficiencies in resource use, encouraging patients to 




take more control when they are ill may also prove to be an effective tool for improving public health. 

Promoting involvement, empowerment and a sense of ownership of their healthcare might be the 

best way to ensure that people adopt healthier lifestyles and support healthy public policy. In the UK 

there is a tendency to treat health promotion as entirely separate from healthcare delivery. 

Professionals tend to focus on one or the other and the connection between the two is rarely 

acknowledged. Yet it makes no sense to exhort people to behave responsibly and adopt healthy 

lifestyles while treating them as passive victims when ill. Replacing paternalism with active 

encouragement to participate should help to enhance a sense of self-reliance and responsibility. So it 

seems possible, although by no means proven, that encouraging greater engagement when people 

are using health services could help achieve health and behavioural targets, as well as controlling 

demand for health care resources. The rationale for encouraging patient engagement in managing 

illness and the types of initiatives that might be encouraged are described in more detail below. 

Minor illness 

Self-care – actions that lay people take to recognize, treat and manage their own health problems 

independently of the medical system – is the most prevalent form of healthcare. Most people cope 

with minor illnesses without recourse to professional help. In looking after themselves and their family 

members, lay people provide a far greater quantity of healthcare than do health professionals. The 

metaphor of an iceberg has been used to illustrate the point that health professionals, even those 

working in ‘first contact’ care such as general practice, see only a small fraction of the afflictions that 

could potentially trigger a consultation.[3,4] 

Nevertheless, GPs often feel besieged by patients who do not really need their help.[5] They report 

that a relatively high proportion of their daily consultations are for conditions that people could treat 

themselves. There is a vicious circle at work here. Struggling to cope with the large numbers of 

patients who queue in their surgeries every day, few GPs have the time, or perhaps the inclination, to 

help their patients to help themselves. Instead, by providing tests and prescriptions for minor 

everyday illnesses they reinforce the notion that doctor input is necessary, and in the process 

undermine patients’ confidence to cope with these problems themselves. The same is often true of 

care provided in hospital emergency departments. If health professionals act in a way that 

undermines people’s coping skills, they can expect to see patients calling on their services with 

increasing frequency. On the other hand, if they could help their patients to help themselves they 

might be rewarded by fewer unnecessary consultations, giving them more time to help those who 

really need their services. 

Evidence from the US suggests that well-organised public education programmes and advice on selfcare 

can have beneficial effects, leading to increases in self-efficacy, self-care skills and overall 

satisfaction.[6] This type of support can also help to reduce utilisation of primary care. The effects are 

strongest when reinforced by a clinician. Evidence also suggests that tailoring information to meet 

individuals’ specific needs and delivering it ‘just-in-time’, i.e. at the point when it is needed, can have 

a positive impact on health behaviour and healthcare utilisation. This has led to calls for ‘information 

prescriptions’ to be provided routinely at relevant points along a clinical pathway and built into 

electronic record systems accessible to patients and clinicians alike.[7] 

Acute illness 

It used to be assumed that doctors and patients shared the same goals and that only the doctor was 

sufficiently informed and experienced to decide on appropriate treatments or management options, 

but nowadays patients are much more likely to challenge the notion that ‘doctor knows best’. 

Informed consent is now accepted as an essential component of ethical care delivery and many 

patients want to play an active role in decisions about their care. This does not apply to everyone, of 




course, and it can be difficult for clinicians to determine what role an individual patient wants to play. 

Certain patients may prefer a directive consulting style, but there are signs of increasing frustration 

with the paternalistic attitudes frequently encountered in the NHS. For example, 46% of respondents 

to the 2002 national inpatient survey in England said they would have liked more involvement in 

treatment decisions.[8] 

In modern clinical practice there are often multiple options for treating a problem and the best choice 

depends on how an individual patient values the potential benefits and harms of the alternatives. In 

these situations it makes sense to involve the patient in deciding on the best course of action. In 

shared decision-making the intention is that both the process of decision-making and the outcome – 

the treatment decision – will be shared. This is a partnership approach based on the notion that two 

types of expertise are involved. The doctor is, or should be, well informed about diagnostic 

techniques, the causes of disease, prognosis, treatment options, and preventive strategies, but only 

the patient knows about his or her experience of illness, social circumstances, habits and behaviour, 

attitudes to risk, values and preferences. Both types of knowledge are needed to manage illness 

successfully, so both parties should be prepared to share information and take decisions jointly. 

Shared information is an essential prerequisite, but the process also depends on a commitment from 

both parties to engage in a negotiated decision-making process. The clinician must provide the 

patient with information about diagnosis, prognosis and treatment options, including outcome 

probabilities, and the patient must be prepared to discuss their values and preferences. The clinician 

must acknowledge the legitimacy of the patient’s preferences and the patient has to accept shared 

responsibility for the treatment decision. 

Despite fears that this approach will lead to an increase in demand for medical treatments, the 

opposite appears to be the case. When patients are provided with appropriate information and 

encouraged to express their preferences, they often choose less expensive options. For example, a 

large randomised trial of decision support for patients with menorrhagia carried out in the west of 

England resulted in a reduction in hysterectomy rates. As a result, the intervention, which included a 

booklet for patients setting out the treatment options and outcomes, a video and nurse counselling, 

was cost-effective. 9 Patients who are well-informed about the options and the potential harms as 

well as benefits of medical interventions tend to make more conservative choices than those who are 

not. 

Chronic illness 

Chronic diseases constitute the major proportion of the burden of ill-health, so helping people to selfmanage 

wherever possible, coupled with proactive monitoring and intensive targeted support for 

those who need it most, should be a more effective way to manage scarce healthcare resources than 

the current system of reactive, paternalistic care. Management of chronic diseases usually depends 

on patients playing an active role and people with long-term health problems often become quite 

expert in managing their treatment. For example, people with diabetes have to monitor their blood 

sugar levels and give themselves regular injections, people with asthma must become 

knowledgeable about inhalers and use them appropriately, and people on long-term medication must 

take their pills at regular intervals. They also have to adapt their lifestyles to cope with long-term 

symptoms. We would not expect health professionals to take on these responsibilities without 

education and training, but patients are often expected to do it without such support. 

There is now a substantial body of evidence that shows that enhancing patients’ role in selfmanagement 

of chronic diseases and reducing dependence on health professionals can produce 

beneficial results.[10] Given appropriate training and clinical support when necessary, patients with 

long-term conditions can look after themselves effectively and their quality of life can be improved. 

For example, arthritis patient education can be effective in reducing pain and disability;[11] and a 




systematic review of 22 randomised controlled trials of asthma self-management programmes found 

that they led to reduced hospitalisation rates, fewer emergency room visits, fewer unscheduled visits 

to the doctor, fewer days off work or school and fewer disturbed nights due to inability to sleep.[12] 

Effective clinician-patient communication is critical to the management of chronic conditions. If 

patients’ beliefs and fears are not fully addressed in clinical consultations, there is a strong likelihood 

that problems will be missed and treatment may be ineffective. For example, if the doctor does not 

understand the patient’s attitude to medicine-taking or does not adequately communicate the reasons 

for prescribing a particular drug, the patient may fail to take the prescription as recommended, 

reducing its efficacy. The quality of clinical communication can have an effect on outcome.[13] 

Patients who are well-informed about prognosis and treatment options, including benefits, harms and 

side-effects, are more likely to adhere to treatments, leading to better health outcomes.[14] They are 

also less likely to accept ineffective or risky procedures.[15] Patients want the doctor to listen to their 

concerns, but failure to address the patient’s agenda is common.[16] Meanwhile patients often fail to 

take medicines as prescribed, resulting in a significant waste of resources and possible health 

risks.[17] 

Evidence suggests that successful prescribing and medicine-taking depends on a true exchange in 

which patients are encouraged to express their views and beliefs about medicines and clinicians take 

time to increase patients understanding of, and involvement in, treatment decisions.[17] However, a 

recent review of 124 studies found that communication about medicines and medicine-taking is 

usually doctor-led with patients playing only a passive role.[18] The necessary skills for achieving a 

true partnership in prescribing and medicine-taking can be taught and a number of intervention 

studies have demonstrated that progress is possible. When doctors encourage patient participation 

and listen attentively to patients’ views and outcomes, patients are more likely to adhere to 

recommended regimes and health outcomes improve.[19] 

Conclusions 

Health systems throughout the world are searching for ways to make their services more responsive 

to patients and the public, but the patient’s role as a key player in protecting their health, coping with 

acute episodes of ill-health, and managing chronic disease, is often ignored. There is plenty of 

evidence that a majority of European patients want to play a more active role.[20] Policy-makers and 

health professionals should recognise and support this trend because it could help ensure the 

sustainability of current health systems. 

References 

1. Wanless, D. Securing our Future Health: Taking a Long-term View (final report). 2002. London, 

HM Treasury. 

2. Coulter A. The Autonomous Patient. London: Nuffield Trust, 2002. 

3. Hannay DR. The Symptom Iceberg – A Study of Community Health. London: Routledge and 

Kegan Paul, 1979. 

4. Vickery DM, Kalmer H, Lowry D, Constantine M, Wright E, Loren W. Effect of a self-care education 

program on medical visits. Journal of the American Medical Association 1983;250:2952–56. 

5. Dunnell K, Cartwright A. Medicine Takers, Prescribers and Hoarders. London: 1972. 

6. Doyle, L., Joyce, J., Caplan, W., and Larson, P. Strengthening Self-care, Self-management, and 

Shared Decision-making Practices throughout Kaiser Permanante. Kaiser Permanante, 2001. 




7. Kemper DW, Mettler M. Information Therapy: Prescribed Information as a Reimbursable Medical 

Service. Boise, ID: Healthwise Inc., 2002. 

8. Coulter A. Engaging patients and citizens. In: Leatherman S, Sutherland K (eds). The Quest for 

Quality in the NHS: A Mid-term Evaluation of the Ten-year Quality Agenda, London: Nuffield 

Trust/TSO, 2003. 

9. Kennedy ADM, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR et al. Effects of decision 

aids for menorrhagia on treatment choices, health outcomes, and costs. Journal of the American 

Medical Association 2002;288:2701–8. 

10. Lorig KR, Bodenheimer T, Holman H, Grumbach K. Patient self-management of chronic disease 

in primary care. Journal of the American Medical Association 2002;288:2469–75. 

11. Warsi A, LaValley MP, Wang PS, Avorn J, Solomon DH. Arthritis self-management education 

programs. Arthritis and Rheumatism 2003;48:2207–13. 

12. Gibson, P. G., Coughlan, J., Wilson, A. J., Abramson, M., Bauman, A., Hensley, M. J., and 

Walters, E. H. Self-management education and regular practitioner review for adults with asthma 

(Cochrane review). The Cochrane Library (Issue 4). 2000. Update Software. 

13. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health 

outcomes: a systematic review. Lancet 2001;357:757–62. 

14. Mullen PD. Compliance becomes concordance. British Medical Journal 1997;314:691. 

15. Wolf AMD, Nasser JF, Wolf AM, Schorling JB. The impact of informed consent on patient interest 

in prostate-specific antigen screening. Archives of Internal Medicine 1996;156:1333–36. 

16. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general 

practice consultations: qualitative study. British Medical Journal 2000;320:1246–50. 

17. Marinker M, et al. From Compliance to Concordance: Achieving Shared Goals in Medicine 

Taking. London: Royal Pharmaceutical Society of Great Britain, 1997. 

18. Stevenson F A, Cox K, Britten N, Dundar Y. A systematic review of the research on 

communication between patients and health care professionals. Health Expectations 2004;7:235–45. 

19. Haynes, RB, Montague P, Oliver T, McKibbon KA, Brouwers MC, Kanani R. Interventions for 

helping patients to follow prescriptions for medications (Cochrane review). The Cochrane Library 

(Issue 4). 2000. Oxford: Update Software. 

20. Coulter A, Magee H. The European Patient of the Future. Maidenhead: Open University 

Press/McGraw Hill, 2003. 




Addressing the demand side problems of health systems by 

intelligent co-payment scheme 

Peter Patzˇiny´ 

Although most of the reform changes do not have clear winners in the short term (direct expenditures 

by patients are increasing, while revenues of strong interest groups are declining), many partial steps 

bring forth almost immediate palpable improvements that are important for gaining and maintaining 

trust of the society. Typical for its fast commercialization of the sector, Slovakia’s health care reform 

draws the attention of other countries. 

The Slovak health care reform 

The reform aims to lower the expectations of citizens associated with the health care system, and to 

strengthen their responsibility for their own health. From the public finance perspective, it means the 

introduction of a clearly defined system in three categories: fully covered, partially covered and noncovered 

health care. 

The goals of the reform are: 

1. Creating an environment supportive to incentive mechanisms to improving the health of the 

population. Increasing the safety of treatment and trust of patients in the health care system. 

Position of the state shifts from a health care services producer, a price maker, a network 

manager and a distributor of finances to the position of a regulator. 

A patient, as an individual owner of a health commodity, takes over higher responsibility for her 

or his own health status, including covering some prevention as well as treatment costs. 

The provider takes over higher responsibility for correct provision and quality of health care, 

including the possible risk of penalties. 

A health care insurer takes over responsibility especially for the management of patients within 

the system, and solvency in purchasing health care complying with hard budget constrains, 

with the risk of facing bankruptcy. 

2. Maintaining balanced financing of the health care system. 

3. Increasing the flexibility of the health care system that would respond to the needs of citizens, 

changing environment, shifts in structures of diseases, and technological progress. 

4. Providing financial protection of individuals from so-called catastrophic expenses on health 

care. 

Stabilizing measures 

Stabilizing measures consisted of introducing fees (SKK 20 and 50), changes in pharmaceutical 

policies and pilot projects of hospital restructuring. To start any changes it was first of all necessary 

to create a modern definition of the term “health care” and define relevant services (food, lodging and 

transportation). 




Table 1: Estimated efficiency of stabilizing measures in 2003 (in SKK billion) 

Measure Effective Estimate of savings 

in 2003 

Decentralization and establishment of NGOs January 1.3 

New definition of health care and introducing fees for 

physician consultations and pharmaceuticals 

June 2.3 

Introducing amendments to contracts of hospital 

directors 

October 0.1 

Restructuring hospitals in Bratislava and Kosˇice October 0.1 

Pharmaceutical policy November 0.2 

Total 4.0 

Source: (Slovak Republic Ministry of Health, 2003) 

Systemic measures 

The goal of systemic (or concept-focused) measures is to create a new system of providing health 

care, fair in distributing health care commodities and financially sustainable in the long-term. Unlike in 

other areas of public finances, there is no list of best practices for health care. Therefore, this 

concept has to be innovatory, and many countries are closely watching its introduction. One of the 

measures is the ‘Intelligent Co-payment Scheme’.* The Scheme is based on low co-payments for 

priorities and higher co-payments on non-prior diagnosis. The Slovak approach is as follows: 

1. Separation of non-health care services (setting small, flat co-payments). 

2. Define the national priority list (`~7000 diagnosis with no co-payment) – the Basic Benefit 

Package. 

3. Establish catalogization committees (defines the catalogue of procedures). These will result in 

standard diagnostic and therapeutic standards. 

4. Establish categorization committees (defines the financial co-payment of patients for so called 

non-prioritized diagnosis – ~4000 diagnosis). 

5. Increase patient’s responsibility and involvement. 

* This term was first time used by Dr. Rigmar Osterkamp from ifo Institute Munchen on a conference held in 

Bratislava in April 2004 and perfectly described the approach which we are developing in Slovakia. Elements of 

an intelligent design of co-payments are as follows: 

1. High co-payments (may be 100%) for small, frequent, cheap and every day diseases. 

2. Low (or non) co-payments for rare, severe and costly diseases. 

3. Lower co-payments for the poor than for the wealthy. 

4. Upper limit of health-care costs as a percentage of individual annual income. 

5. Disburdening the employer: once-and-for-all increase of wages by former employer contribution. 




Summary 

Ellen Nolte 

Rationale 

Health systems vary widely across OECD countries, with differences in organisation, financing 

structure, types and amounts of resources used and health outcomes achieved. Yet, OECD countries 

are also facing similar challenges and are striving to achieve similar goals: ensuring accessible 

health care of high quality, that is responsive and affordable and financially sustainable. Countries 

have employed a variety of approaches to address these challenges. International comparisons offer 

a means to use this experience so as to inform efforts to enhance health system performance 

elsewhere, thus offering opportunity for mutual learning, cross-fertilisation or even policy transfer 

where appropriate. 

At the same time it is recognised that the spectrum of potential interventions that may be adopted will 

very much depend on the actual context of any particular health system and will also need to 

consider differences in the actual starting point for introducing changes towards improving health 

system performance. There is general understanding that there will be no perfect or ‘one-size-fits-all’ 

type solution to the various challenges health systems are facing. While all countries are aiming to 

balance the trade-offs between different health system goals, each country will assign specific 

weights to these goals and these are likely to differ between countries. Still, although harmonisation 

in that respect does not appear feasible or indeed desirable, several common themes were identified 

that appear critical in any system striving towards improving health systems performance. 

Towards high performing health systems: strategies and approaches 

Long-term perspective 

Many reforms have been limited through adopting a short-term perspective only. However, ensuring 

high-quality health systems requires a long-term perspective not only to ensure sustainable financing 

but also more explicitly long-term population health. The emphasis should be placed on health as 

generating wealth as a key driver behind reforms, i.e. making the (business) case for investing in 

health as a long-term strategy. 

Whole systems approach and prioritisation 

There is a need to integrate the health (care) system across the continuum of care linking health 

care and social care and including enabling/supporting patients to take on self-care and selfmanagement 

in case of chronic disease. There is a need to re-focus health care towards prevention 

and strengthening primary care. 

At a broader level a whole systems approach also requires integration across sectors, i.e. assessing 

the impact of policies in other sectors on health (Health Impact Assessment, HIA). The overarching 

aim should be to move health up higher on the political agenda, that is to prioritise health at the 

national level. 




Patient engagement/involvement 

There is a need to strengthen the role of the individual in the health system: “Patients are the most 

valuable resource in health systems” (A Coulter). However, strengthening the role is not merely seen 

in the patient/user role as a payer for services (of taxes, social health insurance contributions, direct 

out-of-pocket payments) but perhaps more importantly as strengthening their role as an actively 

involved/engaged citizen. Here, a particularly important role is being assigned to policy-makers who 

have the responsibility to establish conditions that support citizens to take on this active role so as to 

enable them to take responsibility for their own health and to make decisions. ‘Conditions’ are being 

interpreted broadly and extend along a continuum from providing adequate information so as to 

inform individual decision-making up to addressing underlying socioeconomic conditions. 

Information and monitoring 

Improving health system performance requires information systems to be put in place so as to 

enable monitoring any progress being made. This also means identifying and collecting indicators 

that adequately reflect performance. By extension, this further means investing in information 

technology and eHealth both at the system level and the individual level of care so as to facilitate 

and improve information flow. 



Pre-Conference Workshop 1 

Issues in pharmaceutical 

policy 

Provision of information to patients 




Summary 

David McDaid 

Workshop co-chairs, Jeffrey Sturchio (Merck & Co., Inc.) and Panos Kanavos (London School of 

Economics), opened the workshop. Dr Sturchio noted that patients have the right to information, and 

that they are increasingly engaged in decision-making regarding their own health care. A recent 

study by the Stockholm Network entitled Impatient for Change found that most Europeans agree 

patients need increased access to information about health and health care, and that better access 

to balanced, accurate and reliable information will benefit all. Where people differ on this issue is 

where that information should come from. Pharmaceutical companies believe they should be able to 

deliver the information regarding their products directly to the public. It is ironic that in Europe today 

the most scientifically rigorous information is the least available to patients. 

David McDaid (editor, eurohealth, LSE Health and Social Care) provided some observations on the 

provision of information to patients in Europe. He stressed that the consumption of prescription 

medicines and prescribing patterns vary widely across the EU, with cultural factors, health systems 

and even different definitions of disease contributing toward differences. Patients are becoming more 

empowered to participate in decisions affecting their care, and this has generated greater demand 

and greater access to such information. 

The doctor-patient relationship is changing from a paternalistic model to a more patient-centred 

approach. Evidence shows that misunderstandings between patients and their providers can still lead 

to inappropriate prescribing, incorrect use of medicines and non-adherence to therapy. This problem 

might be helped by increased provision of information to patients. However, there are complex 

factors relating to concordance, so better information might be a necessary but insufficient condition 

for improvement. 

In order to fully express their autonomy, patients need access to reliable and comprehensible 

information that is relevant to their needs. However, it is often difficult to judge the quality of 

information provided to patients, for example that which is available on the internet. In addition, the 

information might not be conveyed in a helpful way; for example, the patient information leaflets 

required by EMEA are written in language difficult for the average person to understand. Effective 

delivery methods and simple, jargon-free language are essential to help patients retain information 

about medicines, specifically the name of the drug and what it is supposed to do, how long to take it 

and when, common side effects and interactions, and the benefit to the patient’s health. 

Direct to consumer advertising from the pharmaceutical industry is one delivery mechanism. While 

the US and New Zealand permit DTCA, it is a highly contentious issue in Europe, where EU law 

bans this type of communication. The purported benefits of DTCA include raising awareness of the 

availability of certain medications and raising awareness of disease. However some worry that DTCA 

will cause a weakening of the doctor-patient relationship, as patients increasingly request products 

that are perhaps inappropriate to their needs. 

The changing context of the health care environment – such as the increasing use of OTC 

medications and the resulting shift in costs to consumers, the growing role of pharmacists as a 

source of information, the increasing use of health promotion campaigns by governments and the 

rise of patient and consumer groups – also affects the role of information for patients. Patient and 

caregiver support groups in particular have an important role in providing information. 




Some challenging questions include: Do patients really want information and if so, what kind of 

information do they want? Does the general public want information or is this demand being driven 

by specific patient groups with specific needs? Who should provide information on medicines to the 

public – industry, patient groups, independent agencies? How can the needs of minority populations 

be met? How do we balance information on treatments with information on prevention and health 

promotion? How can we ensure the quality of information provided? Is the issue of information to 

patients a slippery slope toward a market-oriented approach to health care systems, with adverse 

effects on solidarity? Would allowing greater access to information necessarily lead to direct to 

consumer advertising in Europe, and if so, would what be the consequences? 

Anders Olauson (Agrenska Foundation) described the work of Agrenska, which provides help and 

support for families of disabled children. He asserted that better information for those in need 

reduced reliance on the health system and demand for limited resources. However, while more 

information should be available to people, the pharmaceutical industry should not be the only source 

of information. Industry must work in partnership with people who know patients -- patient groups, 

who can ensure the quality of information being provided. US-style direct to consumer advertising 

has to be modified into another kind, in order to function for European patients. 

John Hutton (Medtap) spoke from the economist’s perspective. He described the doctor/patient 

relationship as imperfect, and asserted that the real problem was not having more information, but 

better information. This need implies sub-optimal decision making in the present system. Improved 

access to information should be for all citizens, not just some patients, because everyone has an 

interest in having the information available. He referred to industry’s disease awareness activities, 

which are permitted under EU law; in this connection, governments might learn from industry 

regarding communicating messages about health promotion. On the issue of accuracy, he noted that 

all parties have some conflict of interest; therefore quality assurance cannot be delegated to a single 

body. Maximum exposure of information and scrutiny from all angles is the best solution, but difficult 

to implement; even the peer review process is imperfect. Mutual policing may be the best workable 

solution. On the issue of direct to consumer communication by industry, he commented that if 

advertising were really dangerous, then this implied much more fundamental problems with health 

systems themselves. 

Sandy Macara (National Heart Forum, European Standing Committee of Physicians) noted that the 

shift toward patient-centred care and public involvement in health care is laudable. However patients 

do still need some degree of paternalism; the problem with concordance is that people still forget 

instructions on medicine taking. The goal should not be informed choice but valid choice, wherein the 

doctor understands and is satisfied that the patient has and understands the information being given. 

Advertising medicines makes sense (that is why it bothers people so much); however, there needs to 

be a balance between advertising and information that patients feel they can trust. There also needs 

to be a balance between treatment and prevention – the availability of pills affects incentives for 

healthy living. Companies have to provide correct information on their products – they are legally 

bound to do so. Patients then need to discuss this information with a doctor they trust. Quality 

assurance is everyone’s responsibility. 

Tamsin Rose (European Public Health Alliance) asserted that people need information not just about 

products, but also about their conditions, lifestyle implications, how to cope, etc.; people get this kind 

of information from sources they trust. These sources act as filters to sort out appropriate 

information. There is already an overabundance of information available on pharmaceuticals; people 

need more information on health, but not medicines. The media are not helpful, because they report 

messages based on PR initiatives that are often inconsistent over time. Good quality information is 

not against the law, but direct to consumer advertising is, and should stay that way. 




Discussion 

Panelists discussed the problem of asymmetry of information between doctors and patients. Ms 

Rose agreed that the role of pharmacists as filters was critical, but pointed out that they have 

commercial interests in selling certain products (vitamins, homeopathic medicines) in addition to 

medical/professional interests. 

Mr Hutton pointed out inconsistencies in the existing regime. Industry can communicate about 

diseases to the public, but not their products. They can communicate to doctors about their products, 

but if doctors need reminding, then can’t patients remind them better? If we permit advertising of 

OTC products and unproven alternative medicines, then why aren’t we worried about misuse of 

these products also? 

A comment from the audience brought up additional concerns – that the information content of 

advertising is low, that advertising generates greater health care costs, and that there are inherent 

conflicts of interest. Mr Hutton responded that conflict should be accepted as a natural state of 

advertising, and not something to be concerned about. Regarding costs, freedom of choice implies 

spare capacity to respond to consumers’ demands; effective choice does not come without extra 

cost. Since we treat other forms of advertising with a healthy degree of skepticism, there is no 

reason why advertising of pharmaceuticals should not be treated in the same way. 

Mr Olauson commented that advertising has two purposes – to provide information and to sell 

products. No one takes responsibility for the information put up on the internet, but pharmaceutical 

companies are responsible for what they say, with very serious consequences if they misrepresent 

their products. Subliminal advertising crosses the line – consumers need to make and take 

responsibility for conscious choices. He reiterated the need for partnership between companies and 

patient representatives to provide good quality information. 

Ms Rose asserted that people want information that comes with experience; that’s where patient 

groups come into play. Advertising in magazines will not give this perspective. She called for full 

disclosure of clinical trials, so that patient groups could sort through data and provide solid 

information to others. 

One audience member explained a public/private partnership under development in The 

Netherlands, where pharmaceutical companies provide information on their products to a third party, 

whereupon the information is certified according to 196 criteria, and then made available to patients 

via a special website. This idea was received as good example of public/private partnership, which 

might be a good basis for a European shared system. However the question that remains to be seen 

is whether patients will use it when it is completed. 

Another audience member pointed out that patients and consumers have very different interests in 

the kind of information they seek. Thus the information made available has to meet a variety of 

needs and circumstances in order to be maximally useful. 

An additional audience member brought up the issue of how to ensure quality. Ms Rose argued that 

it was wrong for the government to delegate responsibility for medicines information to the 

pharmaceutical industry. A range of different services and options involving many stakeholders is 

needed. Mr. McDaid offered that having a quality mark for websites would be one way of giving the 

public some assurances. 




Conclusion 

Dr Sturchio commented on the workshop discussions by saying that there appeared to be “more heat 

than light” in this continuing debate over health information and its provision to the public, and that 

more research and debate would need to take place before the issue is resolved. While some people 

have asserted that direct to consumer information is not useful to patients, the available evidence, 

including studies by Prevention Magazine, the Kaiser Family Foundation and the US Food and Drug 

Administration, suggests the opposite. Previously discussed concerns about advertising raising 

health care costs are equally unfounded. As has been suggested, pharmaceutical companies are 

legally responsible for what they say about their products and such communications must conform 

with regulatory requirements; it makes little sense that legitimate, scientifically rigorous information 

about innovative medicines be kept from people while unproven herbal remedies, for instance, can 

be advertised without any regulation. Also, contrary to earlier statements, no one from industry’s side 

has ever argued that industry should be the sole source of information about medicines; what is 

needed is accurate, well-regulated information about the medicines people take – available to 

everyone from a variety of public and private sources. 

Panos Kanavos concluded that the over-arching themes in the discussion were (a) the quality of 

information and the presence of unbiased filters to deliver it, (b) the need for consumers to have 

access to balanced, accurate and reliable information from diverse sources they trust, in formats to 

suit their needs, and (c) correcting any imbalances between information at prevention and treatment 

levels. 



Pre-Conference Workshop 2 

Addressing 

arthritis/rheumatism 

The biggest single cause of chronic disease 

and physical disability in Europe 

Reducing society costs and individual pain 




��David McDaid, Alex Watt The economic burden of musculoskeletal disorders 322 

��Birte Glusing Summary 325 

Page 




The economic burden of musculoskeletal disorders 

David McDaid and Alex Watt 

Why should musculoskeletal disorders be of economic interest? 

Musculoskeletal disorders including arthritis have substantial health, economic and quality of life 

effects.[1] As many as 25% of all adults have pain related to the musculoskeletal system and they 

are the 8th leading cause of disease burden across Europe with osteoarthritis and rheumatoid 

arthritis accounting for 3.75% of all disability adjusted life years lost. The prevalence of physical 

disabilities in people with musculoskeletal disorder is estimated to be around 4–5% of the total 

population. The contribution of these disorders to overall disease burden continues to grow as the 

European population ages, with joint diseases now accounting for over half of all chronic conditions 

in older people. Other risk factors such as the growing prevalence of obesity may also contribute to 

future increased burden. 

Poor musculoskeletal health generates substantial health care costs, but these may be far exceeded 

by the costs of absenteeism, sickness leave and early retirement from the workplace. This impact on 

economic performance is of clear importance given the EU’s commitment to its so called Lisbon 

agenda promoting economic growth and social inclusion. In addition to health and workforce costs 

individuals may also suffer from discrimination and stigmatisation while family members may have to 

provide substantial amounts of care and support. 

If we want to tackle these problems what do we want to know (in economic terms)? 

Economic evidence can be a very powerful tool in helping to build a case for greater investment in 

tackling a health problem such as arthritis. Generating evidence on the costs of poor musculoskeletal 

health can help raise awareness at policy making level that it does indeed have substantial economic 

costs, especially when taking into account the impact on the labour market. However, it is not enough 

simply to state that the costs are high, effective interventions both to promote good health and to 

treat problems as they occur need to be identified. The cost effectiveness of investing in these 

strategies can then be considered. 

Since scarcity is a permanent and pervasive feature of all societies, the level of resources available 

for all health problems will never be enough to meet all needs. In the face of such scarcity, choices 

have to be made. By combining information on both the costs and effectiveness of different policies 

and interventions, economic techniques such as cost effectiveness or cost benefit analysis can 

provide decision makers with data that can inform and assist decisions on how to make the best use 

of available resources to maximise benefits not just in the health sector but across other sectors such 

as housing, education, defence, or transport. 

While evidence on cost effectiveness can therefore be a powerful tool to aid in the decision making 

process it is of course important to recognise that such decisions should never be made on the basis 

of economic evidence alone. For instance consideration must be given to ensuring that all individuals 

have fair access to effective interventions, and there may also be ethical and political factors. 

What are the economic costs of musculoskeletal disorders? 

The economic costs of musculoskeletal problems are substantial. One analysis of early retirement in 




Sweden in 2001 estimated that 60% of retirees were diagnosed as having a musculoskeletal 

problem. In the Netherlands these disorders accounted for approximately 6% of all health care costs 

in 1994. The indirect costs of lost employment or informal caring costs can more than outweigh the 

direct health care costs, for instance in one UK study in 1996, these indirect costs accounted for 52% 

of total costs.[1] A Finnish study estimated that there was a 77% decrease in working capacity of 

people with arthritis.[2] More recently another study in Finland estimated that 23% of those with 

rheumatoid arthritis had discontinued work within two years of diagnosis and 38% had retired due to 

the condition over a ten year follow up period.[3] In the Netherlands around 50% of all patients with 

rheumatoid arthritis (mean duration 2.8 years) in a survey reported that it had a negative impact on 

their ability to perform paid work, and had also reduced educational and promotional opportunities.[4] 

Much data is also available outside Europe. In Australia the costs of arthritis were estimated to be 

equivalent to 1.4% of GDP in 2000 (almost $A 9 billion) with more than 75% of total costs due to lost 

productivity, early retirement and the input of family caregivers. Overall musculoskeletal disorders in 

Australia were the third leading cause of health system expenditures behind circulatory and digestive 

diseases.[5] Studies from the United States and Canada also indicate that lost employment and other 

indirect costs account for around three quarters of all costs. 

The knowledge gap 

While much has been written on the cost effectiveness of pharmaceuticals and technological 

interventions for musculoskeletal disorders, much less attention has been placed on evaluating the 

cost effectiveness of strategies for maintaining and promoting good musculoskeletal health. Through 

effective health promotion the costs of drug, surgical and other therapies (including the risk of 

adverse side effects) may be avoided or delayed if disease onset and progression can be slowed; 

moreover some of the long term negative impacts on employment may also be avoided especially if 

interventions also consider the use of adaptations in the workplace. 

This lack of information is partly because evaluation of health promoting interventions is typically 

more complex and may require a long time period stretching over decades to demonstrate 

effectiveness; policy makers operating over short timeframes may therefore overlook potentially 

highly effective and low cost promotion strategies in favour of immediate health care interventions 

that can been seen to have a short term effect. 

Across Europe while conducting long term trials of interventions to promote musculoskeletal health 

may be expensive much can still be learnt from undertaking smaller scale qualitative studies, 

combined with estimations of long term costs and consequences through the construction of simple 

models. Inputs into such models can be varied to take account of uncertainty and different 

circumstances across countries. It is also important to recognise that such health promoting 

strategies should not be assessed purely in respect of musculoskeletal disorders. Many elements of 

strategies such as healthy eating and not smoking will generate many physical and mental health 

benefits. 

Barriers to the use of economic information 

Many of the economic benefits associated with promoting good musculoskeletal health and treating 

problems such as arthritis may occur outside the health care system, most notably in the 

employment sector. This may make investment in tackling these problems less attractive to health 

budget holders, so it is important to promote coordination and an intersectoral approach, so that 

ministries of employment actively are involved in implementing and investing in effective strategies. 

Such coordination inevitably requires political will, but demonstrating the clear economic benefits in 

terms of reduced need for early retirement, disability pensions and sickness leave in economic 




analysis can help to build a persuasive case for a multi sector approach. 

At a European level another challenge to consider is whether the results of an economic evaluation 

in country X can be transferred to country Y. Cost effectiveness will be dependent on the level of 

resources and organisational structures within countries. These can vary considerably, especially 

between old and new Member States in the EU. One way of approaching this is by ensuring that 

studies are conducted in a transparent manner, separating unit cost from resource utilisation data, 

making it easier to adapt results across countries. The EU and other bodies might also play a role in 

facilitating the exchange of such information across regions and countries. 

Another key challenge even where information is available is to present this in an accessible format. 

Too often information from economic evaluations is presented only in long highly technical reports 

limiting usefulness. Messages need to be tailored to different audiences and should always include a 

one page summary with key messages. Involving all stakeholders, including consumers, in the 

knowledge generation process from an early stage can help to promote acceptance of messages. 

Conclusions 

There are substantial health, social and economic costs associated with musculoskeletal problems. 

Using economic evidence as well as evidence on effectiveness of strategies can help strengthen the 

case for investment. In particular a case needs to be built for the promotion of good health, as much 

of the focus of economic evaluation so far has been solely on the evaluation of pharmaceutical 

treatments. 

Working across sectors is vital given the impact that arthritis and similar conditions have on the 

ability to work and participate fully in society. At the European level there is a strong case to be made 

for strengthening links with public health groups to ensure that arguments made for greater focus on 

public health need also to indicate not only benefits in terms of reduced mortality and improved 

cardiovascular health but also the positive impact for musculoskeletal health (and indeed other health 

problems). The recently published EC co-funded project European Action Towards Better 

Musculoskeletal Health. A public health strategy to reduce the burden of musculoskeletal conditions, 

is a welcome development, but much more needs to be done. 

References 

1. European Bone and Joint Health Strategies Project. European Action Towards Better 

Musculoskeletal Health. A Public Health Strategy to Reduce the Burden of Musculoskeletal 

Conditions. University Hospital Lund: Bone and Joint Decade, 2004. 

2. Makela M, Heliovaara M, Sievers K, et al. Musculoskeletal disorders as determinants of disability 

in Finns aged 30 years or more. J Clin Epidemiol 1993;46(6):549–59. 

3. Sokka T, Kautiainen H, Mottonen T, Hannonen P. Work disability in rheumatoid arthritis 10 years 

after the diagnosis. J Rheumatol 1999;26(8):1681–85. 

4. van Jaarsveld CH, Jacobs JW, Schrijvers AJ, Van Albada- Kuipers GA, Hofman DM, Bijlsma JW. 

Effects of rheumatoid arthritis on employment and social participation during the first years of disease 

in the Netherlands. Br J Rheumatol 1998;37(8):848–53. 

5. Access Economics. The Prevalence, Cost and Disease Burden of Arthritis in Australia. Canberra: 

Access Economics, 2001. 




Summary: Addressing arthritis/rheumatism – the biggest single 

cause of chronic disease and physical disability in Europe – 

reducing society costs and individual pain 

Birte Glusing 

About arthritis/rheumatism 

Arthritis simply means ‘inflammation of the joints’. The word rheumatism is even more general, and is 

used to describe aches and pains in joints, bones and muscles. There are more than 200 types of 

arthritis and rheumatic diseases. Possible symptoms include pain, stiffness or swelling in the joints 

for three or more days a week over a period of a month, stiffness in the joints, especially after not 

moving for an extended period of time, and/or pain or discomfort in a joint that has a history of injury. 

In Europe, more than 100 million people have some form of arthritis/rheumatism. For example, in 

Germany there are more than five million people with severe osteoarthritis and another two million 

people with arthritis or other inflammatory conditions of the joints and the spine.[1] More people in 

Europe are affected by arthritis/rheumatism than any other chronic medical condition. Anyone can be 

affected by arthritis, not only adults. One child in every thousand has arthritis. 

The recently published report on the burden of musculoskeletal conditions presents the following 

data:[2] 

• lower back pain affects about 80% of people at some time of their life 

• 40% of people over 70 years of age have osteoarthritis (OA) of the knee, and 25% of those with 

OA cannot perform daily activities of life, and additional 55% have some disability; 

• approximately two million people world wide suffer from hip fractures, usually in the context of 

osteoporosis 

A very severe form of arthritis is rheumatoid arthritis which can cause functional disability and 

significant pain and joint destruction, leading to deformity and premature mortality.[3] Rheumatoid 

arthritis is estimated to affect between 0.5 and 1% of the adult population,[3] or more than 20 million 

people worldwide in 2004. 

For most people, arthritis pain and inflammation cannot be avoided because as the body ages, joints 

naturally degenerate. There is no general cure for arthritis/rheumatism, but it can be managed 

through effective therapies that provide symptom relief and slow the disease progression. These 

therapies include a combination of medication, physiotherapy, rehabilitation, occupational therapy, 

self-help measures, rest, weight-management, nutrition, and, in some cases, surgery. 

Introducing EULAR Social Leagues and PARE Manifesto 

The European League Against Rheumatism (EULAR) was founded in 1947 and aims to stimulate, 

promote, and support the research, prevention, treatment and rehabilitation of rheumatic diseases. 

Today EULAR includes 43 scientific organisations as well as 30 patient groups (known as social 

leagues). The EULAR Social Leagues Committee brings together representatives of arthritis and 




other musculoskeletal user groups around Europe to work together towards improved quality of life 

for the more than 100 million people living with these conditions around Europe. Its vision is of 

people with arthritis and other musculoskeletal conditions in Europe being empowered to lead full 

and independent lives (www.eular.org). 

PARE (People with Arthritis/Rheumatism in Europe) Manifesto is the campaigning arm of the EULAR 

Social Leagues. It addresses the most important key objectives in the European Manifesto: a 

document containing ten calls to action in order to ensure a better quality of life for people with 

arthritis/rheumatism. Its concerns range from access to treatments and services, to issues associated 

with access to buildings, transportation, employment and research (to read the full version of the 

European Manifesto in your language please visit www.paremanifesto.org). The calls to action are: 

• to raise public awareness of arthritis/rheumatism 

• to empower people with arthritis/rheumatism by funding user led programmes 

• to involve people with arthritis/rheumatism in policy development 

• to develop and recognise national and international organisations of people with 

arthritis/rheumatism 

• to provide prompt and good quality health and community services 

• to ensure doctor and health professional awareness of arthritis/rheumatism 

• to involve people with arthritis/rheumatism in helping to determine relevant medical research 

priorities and budgets 

• to expand research into the societal impacts of arthritis/rheumatism 

• to strengthen laws and regulations 

• to provide fully accessible education/training programmes 

The European Manifesto is a lobbying tool and has uniquely been developed by people with 

arthritis/rheumatism for people with arthritis/rheumatism, as people affected by arthritis know first 

hand the impact the disease can have on their daily lives. The European Manifesto has been 

translated into more than 24 languages so far, and is supported by a network reaching into more 

than 34 European countries. 

The role of the patient group 

Patient groups are bodies representing and involving people with arthritis/rheumatism and lobbying at 

the national level,for example using the ‘European Manifesto’ to raise awareness of the disease, civil 

rights of people with arthritis/rheumatism, access to the latest treatments. Patient groups are a 

valuable resource of information specifically developed for a non-medical audience. Patient groups 

are a platform through which people with arthritis/rheumatism can obtain safe information about their 

disease and contact other people affected by the same problems. This way they are able to get 

helpful information about how to deal with the disease and have access to important resources for 

disease management/self-management, such as physiotherapy, social programmes, psychological 

assistance, information events with specialists, telephone help line, legal consultations etc. 




Self-management 

A very cost effective approach to managing arthritis/rheumatism is self-management training. 

Empowered people with arthritis who have received appropriate training can live independently and 

are motivated to take responsibility for their own health. The umbrella charity in the UK working for 

better lives for people with long term conditions, the Long Term Medical Conditions Alliance (LMCA), 

states: ‘Our vision is of a society in which people with long-term health conditions have control over 

their lives and can live them to the full’. To enable people to do so, the following areas have to be 

considered and discussed together with health professionals, patient support groups, relatives and 

friends: 

• goal setting / action planning 

• problem solving 

• exercise 

• symptom management techniques 

• fatigue management 

• dealing with emotions 

• communication 

• medication; and 

• community resources 

People developing these conditions can be supported to work and to live independently if treated 

sufficiently early. By investing resources into self-management a number of things could be achieved. 

Physical deterioration can be slowed, self-efficacy and a person’s psychological state can be 

improved, the use of health promoting techniques can be increased, the number of visits to doctors 

can be reduced, and the communication with doctors can be improved. In other words, we should 

work together not only to prevent the onset of rheumatic diseases, but to prevent their impact from 

becoming unnecessarily severe once diagnosed. The aim is to move people from being passive 

recipients of care to become decision makers in the treatment process. Patients gain greater control 

of their condition by being empowered to take some responsibility for its management and to work in 

partnership with their health and social care providers. 

European public health policy and arthritis/rheumatism 

For the first time public health was given a legal base as a theme to address in the Maastricht Treaty 

in 1993. Before it was under the direction of the member states only. Even more recognition was 

given to this important issue with Art. 3/152 in the Amsterdam Treaty (1998) which raised health 

protection to the rank of a European Community objective. The European Community should 

contribute to a high level of health, encourage cooperation among the member states and improve 

the prevention of diseases. The new reference did not include any harmonisation of laws and 

regulations and most power remains in the hands of the member states. The European Community’s 

role is subsidiary and mainly involves supporting the efforts of the member states and helping them 

formulate and implement coordinated objectives and strategies. However, the Community was 

empowered to adopt measures aimed at ensuring a high level of health protection. 

People with arthritis and related musculoskeletal conditions comprise the largest part of the 

population living with a long-term medical condition. It is also the single biggest cause of physical 

disability. However, this is not yet reflected in the European health agenda, which refers only to the 

threats of HIV, SARS, lifestyle related illnesses, diabetes or cancer. 




The number of people affected by arthritis and related musculoskeletal conditions will steadily grow 

over the next decades due to the ageing population. Lifestyle related diseases such as the alarming 

increase in obesity are also putting more people at risk of developing some kind of arthritis. Many 

organisations at the national but also at the European (European League Against Rheumatism) and 

international level (UN-endorsed Bone and Joint Decade, Arthritis and Rheumatism International) are 

raising awareness of a condition that is not yet receiving the necessary attention. Arthritis and related 

musculoskeletal conditions are a European public health issue as much as a medical issue and 

require a similar level of attention as is given to conditions like diabetes and cancer. Recent research 

also indicates that the chronic condition of arthritis could lead to a higher risk of cardiovascular 

problems. People with arthritis should have access to the safest and most effective treatment 

available, no matter where in Europe they live. Poorly treated or undiagnosed arthritis and related 

musculoskeletal conditions lead to an increase of mental health problems due to the psychological 

burden for those affected and their families, thus magnifying the hidden costs of arthritis. A 

European-wide strategic approach could prevent the onset of disability in the majority of people with 

arthritis, therefore saving the European economies substantial costs. 

Thus, although arthritis and related musculoskeletal diseases strike more frequently, more severely, 

and are more costly than conditions of any other kind, people with arthritis have to fight harder for 

access to the best care. Even if it improves quality of life and prevents sick-leave and disability, 

scientists in the field of rheumatology have difficulties in finding an appropriate space in the 

European Community’s research funding programs. In fact, the current Framework Program 6 of 

EU’s Research Directorate offers special actions for dealing with cardiovascular diseases, neurologic 

disorders, diabetes and cancer, but rheumatologists have to search for niches where they can place 

applications, competing against scientists from all other fields of medicine and basic research. 

What PARE Manifesto has achieved so far 

With a supporter network in 34 European countries PARE Manifesto is solidly established. The work 

programme is driven by a Steering Group which involves voluntary representatives of different 

European patient organisations. Since 2001 its work is administratively supported by a secretariat 

with one full-time post and is currently hosted by Arthritis Care, London, United Kingdom. PARE 

Manifesto has ten issues of its newsletter to date and the latest has been produced as a special 

edition for the Gastein conference. It is an important medium to keep in touch with the network and 

to inform friends and supporters about ongoing activities. On 1 December, PARE Manifesto 

relaunched its website www.paremanifesto.org, which contains news and information. PARE 

Manifesto is involved in many exciting projects, for example: 

• On 9 November 2004, the EULAR Social Leagues and PARE Manifesto hosted a lunch debate to 

discuss the European Union health policy as it affects people with arthritis and related 

musculoskeletal diseases. Key stakeholders were present, including members of the European 

Parliament, representatives of the Commission and other institutional bodies of the European 

Union. 

• The seventh Worldwide Conference of Arthritis and Rheumatism Patient Societies took place 7–9 

November 2004. More than 60 delegates representing social leagues from 26 European countries 

took advantage of the invitation to attend this year’s Arthritis Patients on the Move (APOM) 

conference in Brussels, Belgium. It was the first time that the conference had been hosted 

together by the EULAR Social Leagues and PARE Manifesto. 

• In June 2004, PARE Manifesto contacted candidate members of the European Parliament to find 

out their attitudes to arthritis/rheumatism. The response rate was better than expected and it 

turned out that candidates were overwhelmingly sympathetic to the cause. Of those that pledged 




their support to people with arthritis/rheumatism in Europe, 16 were elected into the new 

parliament. 

• Every year on October 12, people with arthritis from around the world join together to make their 

voices heard and raise awareness of arthritis, a disease that affects millions of individuals across 

the globe. This year, PARE Manifesto supported activities by national arthritis organisations 

across Europe. To find out about the activities that took place on the day, please go to the World 

Arthritis Day website www.worldarthritisday.org 

Identify barriers and future steps – group discussions 

What are the barriers? 

• Arthritis/rheumatism is seen as a condition that older people but not young people get 

• Lack of information – arthritis/rheumatism not acknowledged as a disease; not enough relevant 

and timely information 

• Lack of awareness – no knowledge concerning the incidence of the disease 

• Communication problem between doctors and patients 

• Arthritis/rheumatism not perceived as important as deadly infectious diseases; although older 

people might die, some medication might have side effects and long-term pain can also lead to 

mortality 

• Costs associated with arthritis/rheumatism are not understood or known, as many costs are 

indirect, intangible or hidden 

• No cure for the disease 

• Stigma 

• Need for early diagnosis 

What can be done to raise awareness and get the message across? 

• The project focus should concentrate on certain topics – not spread out too much 

• European versus national/regional – European level should be in line with the Amsterdam Treaty 

and PARE Manifesto should find ways to link the demands to the whole issue of public health, as 

a more general approach would probably make the messages carry more weight 

• Focus is very much on exercise and obesity – why not people with arthritis/rheumatism? 

• The ‘silo’ problem was raised: there is a need to think across disease areas, across sectors – 

think multidisciplinary. Planning and thinking need to be integrated 

• PARE Manifesto should identify a champion (or a few) to give a strong voice to its cause 

• Lobby efforts at the European level by national/regions more effective – robust lobbying is a must 

to be successful 

• Mobilise people to start present both personal stories and hard facts 




• Better ‘marketing’ of arthritis/rheumatism and all the issues related to it 

• Remember that pressure groups are also voters – can change policies 

• Show the figures – how much benefit when dealing with disease treatment effectiveness 

• More use of media – advertisements with sense of humour 

• Information exchange – support from authorities 

• Introduce incentives for companies in order for them to employ people with arthritis/rheumatism 

Personal stories 

Sandra Canadelo is a member of the Liga Portuguesa contra as Doenças Reumáticas (Portuguese 

League Against Rheumatic Diseases) and joined the league in 1999 after having been diagnosed 

with rheumatoid arthritis in 1997 at the age of 24. She experienced the difficulties most patients do, 

such as extreme pain, joint swelling and stiffness, difficulty in dealing with emotions, problems at 

work due to periods of sick leave. She felt at this stage that information about the disease was very 

important as one of the things that troubled her most after the diagnosis was not to know what was 

happening to her. She wanted to be actively involved in the work to prevent other people from going 

through the same situation she had experienced herself. In 2000, Sandra was appointed as the 

Portuguese co-representative for the PARE Manifesto beside Fernanda Ruaz and since then has 

represented Portugal on many occasions such as the Eular congress, the 1st PARE National 

Representatives Meeting 2002, APOM 2 and the ’Access to treatment workshop’ in Brussels. Sandra 

is deeply committed to the principles of the Manifesto at all levels and she thinks the participation in 

the Steering Group is a wonderful opportunity. 

Robert Johnstone has lived with arthritis since the age of three. He studied international relations and 

spent two years in full-time employment. Since then, he has been involved in a wide variety of 

unpaid activities for voluntary organisations. These include Arthritis and Rheumatism International 

(ARi), the Long Term Medical Conditions Alliance, the Disabled Living Centres Council, and the 

People with Arthritis and Rheumatism in Europe (PARE) Manifesto. Mr Johnstone sits on a number 

of advisory bodies to the national healthcare service (NHS) in the UK. Mr Johnstone is also a 

disability equality/action trainer. 

References 

1. Zahlen und Fakten zu Rheuma, Bonn: Deutsche Rheuma-Liga Bundesverband, 2001. 

2. WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New 

Millennium. The Burden of Musculoskeletal Conditions at the Start of the New Millenium: Report of a 

WHO Scientific Group. World Health Organization. Geneva 2003. 

3. Kvien TK. Epidemiology and burden of illness of rheumatoid arthritis. Pharmacoeconomics 

2004;22(2 Suppl):1–12. 



Workshop 1a 

Workplace health 

promotion: 

Healthy employees – successful companies 

How to manage an ageing workforce? 




��Martin Gleitsmann Towards high-performing health systems: 333 


��Georg Vana Health promotion is one of the key principles for Pfizer 335 

��Oskar Meggeneder The Austrian Network Workplace Health Promotion 336 


��Ludwig Grillich A key to a healthy working life. Recommendations for 343 

workplace health promotion and age management 

in small and medium-sized enterprises 

��Brigitte Geißler-Gruber Age-oriented careers and work in medium-sized 354 

enterprises – from theory to practice 

Page 




Workplace health promotion: healthy employees – successful 

companies 

How to manage an ageing workforce? 

Martin Gleitsmann 

Health Promotion and especially work place health promotion (WHP) is one of the most important 

topics of the future. Why? 

The European economy and the future workplace face multiple challenges. Increased flexibility, 

increased mobility, the use of new technologies, higher demands on employees and most of all an 

ageing workforce. These facts already indicate that the solutions must be based on the investment in 

human capital. 

To tackle these challenges the concept of WHP has to make its way into every workplace. But this 

goal can only be reached by introducing WHP into every workplace. Therefore it is necessary to 

companies and stakeholders to fully integrate WHP into their company policies. In order to convince 

companies and stakeholders, it is necessary to propose arguments and justifications that point out 

the advantages and benefits of WHP. The Austrian Economic Chamber has recognized what an 

important instrument WHP can be for companies and therefore supports the idea since the very 

beginning. To promote WHP and to show what a powerful tool it can be we organised this workshop. 

The Austrian Network 

To promote WHP Austria was the first country to set up an nationwide Network. The network offers 

help and advice to enterprises who are interested in this topic. In this workshop we will find out who 

the partners of the network beside the Austrian Economic Chamber are and how the network 

successfully supports enterprises in the field of WHP. 

The study 

In the last years the interest on WHP has grown and the number of WHP projects especially in big 

enterprises is rising constantly. The main results of a successful project are lower rates of 

absenteeism, less medical costs, less legal costs and most of all motivated employees. For example, 

with a successfully completed WHP project an Austrian company managed to lower their 

absenteeism rate by 30%. Additionally, individual employees profit as their health improves along 

with their working conditions and job motivation. This automatically leads to higher productivity and 

an improving company profile that also attracts more applicants. This clearly marks that WHP 

programmes on company level create a win-win situation for both the company and the employees. 

But 90% of Austria´s companies are small and medium sized enterprises (SMEs) who often lack the 

human and financial resources necessary for a WHP project. 

To find out how many SMEs have implemented a WHP project and to reach a better understanding 

of the problems and needs of SMEs focusing on an ageing workforce, the Austrian Economic 

Chamber launched a study carried out by thepartners.at, sponsored by Pfizer Corporation Austria 

and supported by the Fund Healthy Austria. One of the main parts of the study is an analysis of the 

costs and benefits of WHP (for example, return on investment...), that includes various national and 




international studies on the matter. 

Current figures show that absenteeism due to illness costs Austria´s economy € 2.5 billion per year. 

Recent estimates point out – granted that all Austrian employees could be reached by a WHP 

programme – that the effect on the economy will be a reduction of costs up to € 3.6 billion. That 

equals 1.7% of the GDP. 

This workshop will not only give you an answer on the costs and benefits of WHP and the 

possibilities for SMEs, it will also show what an effectively working Austrian Network on WHP can do 

to promote all these. Finally, the representative of a ‘best practice"’company will describe his 

experiences with WHP and how it works. 




Health promotion is one of the key principles for Pfizer 

Georg Vana 

Health promotion and disease prevention awareness are powerful tools for maintaining a healthy 

community. We believe prevention is as important as the cure. At Pfizer, we believe strongly that our 

involvement with the community – whether locally or globally – begins with individuals who care. For 

the community especially the elderly employees will become more important. We want to be part of 

filling the possible gap between unaddressed needs and development of solutions like the project 

‘Health Promotion for elderly employees’. 

Pfizer as employer has very high principles concerning the health promotion and health care of its 

employees. Pfizer’s Employee Health and Wellness Program is a direct outgrowth of our company’s 

core values – two of which are respect for people and performance. We’re in a very competitive 

industry – and one in which human capital is the key factor. I believe that Pfizer’s people are our 

most valuable asset. They give us a major competitive advantage. They’re skilled, well-educated, 

and highly motivated. And that’s why we’ve established such a wide range of employee support 

services – including our health promotion programs. We have a responsibility to give our people the 

resources they need to stay as healthy as possible. 

As an innovative pharmaceutical company we are always interested in new innovative developments. 

For this reason we are happy to collaborate with the Chamber of Commerce in this important project. 

This reports represents also for us a basis for further enhancements of health promotion for our 

employees. 




The Austrian Network Workplace Health Promotion 


Oskar Meggeneder 

The Austrian Network Workplace Health Promotion offers help and advice on workplace health 

promotion (WHP) nationwide to enterprises who are interested in this topic. The aim is to collect 

information on all important activities in this field from the whole of Austria and to spread the concept 

of WHP. This network makes Austria the first country in the EU to set up a comprehensive national 

network for WHP. 

Initial situation 

WHP began in Austria in 1993 with the launching of a pilot project in an Austrian enterprise under the 

guidance of the Upper Austrian Sickness Fund. From then on, WHP developed constantly both in 

Upper Austria and beyond its borders. The legal basis for the Sickness Fund to develop health 

promotion activities is given by §116, paragraph 1, no. 5 of the General Social Insurance Act 

(ASVG), which states ‘health insurance should make provision for health promotion.’ The ASVG 

understands health promotion particularly as the encouragement of healthy behaviour through health 

education, advice on health, and complementary health projects, and expressly mentions the 

possibility of cooperating with other health facilities. The scope and content of health promotion is left 

relatively open by the act, and so the Sickness Fund has plenty of leeway for health related activities. 

In 1995, the European Network for Workplace Health Promotion was launched at the request of the 

European Commission. A year later the Austrian Contact Office was set up, supervised by the Upper 

Austrian Sickness Fund. The primary aim of the European National Network was, and is, the 

dissemination and regionalisation of the ‘WHP strategy’. 

The Austrian Contact Office carried out the task of spreading information about WHP by holding an 

annual Information Day, publishing regular newsletters and by appearances in the media. They were 

soon successful; there were more and more enquiries asking for support, also from outside Upper 

Austria. However, only in a few provinces was it possible for the regional sickness funds to provide 

the support requested: only the Salzburg Regional Sickness Fund and the Insurance Institute of 

Austrian Mineworkers offered help to enterprises who wanted to implement workplace health 

promotion. In Lower Austria, support was offered by The Health Forum for Lower Austria; an 

institution funded by the Province of Lower Austria, the Lower Austrian Regional Sickness Fund and 

the Lower Austrian Medical Association. By founding this national network, with partners in all 

provinces, and with the participation of the social partners, it was possible to satisfy the increasing 

demand and also the requirement of the European Commission to disseminate WHP nationally. 

The foundation phase 

The first step was to ask all regional sickness funds if they were prepared to cooperate with such a 

network and take on the role of regional office for their province. Styria and Lower Austria were 

exceptions, as here the Insurance Institution of the Austrian Mining Industry and the Lower Austrian 

Health Forum were invited to take part on account of their experience in WHP. It was a basic 

principle to look for partners amongst non-profit organisations and sickness funds, as these have a 

statutory requirement to carry out health activities. At the same time, the social partners (Federal 

Chamber of Labour, Austrian Chamber of Commerce) were invited to participate in the creation of 




the new network, so that from the very beginning a wide basis of consensus could be ensured, and 

the benefits of WHP for both employers and employees could be emphasised. 

In February 2000, a three-day foundation workshop took place with the support of the Austrian 

Health Promotion Foundation (Fonds Gesundes Österreich). In this workshop, the first ideas were 

developed for the future structure, tasks and methods, and also what the main focus would be. The 

provinces of Vienna, Lower Austria, Styria, Carinthia, Salzburg, Tyrol and Upper Austria took part in 

the workshop. The Regional Sickness Fund for Burgenland had announced its participation, but was 

unable to send anyone. Of the social partners, the Federal Chamber of Labour participated; the 

Federal Chamber of Commerce sent no participant, but promised their support. During this workshop 

it was possible to find a definition of the main tasks of the Austrian Network: 

• Development of a common understanding 

• Development of joint material (folders, posters, overhead transparencies) 

• Mutual support through transfer of know-how 

• Arrangement of the annual information day in a different province every year, together with the 

respective regional office 

• Joint project initiatives 

• Development of joint activities 

Structure, mode of operation and funding 

Now the Network can look back on a four year history, in which there has been a lot of further 

development and also important new partners have been gained (Federation of Austrian Trade 

Unions, Federation of Austrian Industry, Main Association of Austrian Social Security Institutions, 

Austrian Social Insurance for Occupational Risks, Social Insurance Institution for Trade and Industry). 

The Austrian Network for WHP has developed in these four years to a partner which is much in 

demand, not only for enterprises but also for many different parties both within the structure of 

enterprises and also externally. A cooperation contract was developed in which not only the aims and 

tasks, but also the mode of operations and funding of the Austrian Network WHP were laid down and 

made binding through the signatures of all the regional offices, social partners and other partners. 

The structure of the Austrian Network for WHP 

The Upper Austrian Sickness Fund carries out the coordination of the Austrian Network in its function 

as the Austrian Contact Office of the European Network for Workplace Health Promotion (ENWHP). 

It provides the personnel for the administration and organisation of the joint tasks and represents the 

network externally. 

Contact Office: Upper Austrian Sickness Fund 

Regional Offices: Burgenland: Burgenland Sickness Fund 

Carinthia: Carinthian Sickness Fund 

Lower Austria: Lower Austrian Sickness Fund 

Salzburg: Salzburg Sickness Fund 

Styria: Insurance Institution of the Austrian Mining Industry 

Vienna: Viennese Sickness Fund 




Social Partners: Austrian Chamber of Commerce 

Austrian Chamber of Labour 

Federation of Austrian Industry 

Federation of Austrian Trade Unions 

Partners: Main Association of Austrian Social Security Institutions 

Austrian Social Insurance for Occupational Risks 

New partners can only be taken on by the Network jointly with a simple majority: only non-profit 

organisations are eligible to apply. 

Mode of operations 

The members of the Network convene twice a year for a two-day meeting, each time in a different 

province. The meetings are organised by the Contact Office in cooperation with the regional office 

concerned. Organisations which are interested (for example, Fonds Gesundes Österreich) can 

participate at any time. 

The annual information days are organised in cooperation with a regional office and held each time 

in a different province. The preparation is done by the local regional office together with the Contact 

Office. 

Joint activities and initiatives are discussed at the meetings and, after a decision has been taken, 

working groups implement the ideas. 

Funding of the Austrian Network for WHP 

The Austrian Network possesses no funds of its own. Participation in the network meetings is paid 

for by the regional offices, social partners and other partners who are themselves participating. The 

funding of joint activities is negotiated according to the occasion. Administrative tasks (for example, 

the upkeep of the homepage, design of the newsletter, etc.) are carried out by the Contact Office. 

Aims and tasks 

The Austrian Network WHP feels bound by the Luxembourg Declaration (European Union, 1997) on 

WHP and the quality criteria developed by the European Network, and has the following goals: 

• Carry out joint work on the further development of workplace health promotion 

• Ensure a common understanding of WHP throughout the federal states 

• Establish competent partners in each province 

• Involve institutions important for WHP, especially the social partners, also at a regional level 

• Ensure the exchange of information between the European Network and the Austrian Network. 

This has resulted in a range of tasks for the members of the Network: 

Information: A wide range of information work is done both at national and regional level: 

• Distribution of jointly developed material 

• Holding of an annual information day on the topic of WHP 

• Publication of the newsletter 4 times a year 




• Joint internet page at www.netzwerk-bgf.at 

• Presence at relevant events 

Advice and support: The whole Network and the regional offices in particular offer their services as 

contact partners to any companies and organisations interested in workplace health promotion. The 

Network and the regional offices offer concrete support to enterprises. At present, what is offered 

varies considerably. The goal is to develop a standard service which can be offered in all of the 

provinces, whereby the regional offices can of course offer their own additional services. Whether the 

regional offices/social partners/partners ask for financial compensation for their services, and to what 

extent they do so, is their own decision. 

Development and implementation of joint projects: To encourage the further development of WHP, 

the Network will develop joint initiatives and projects to the best of its ability. To implement this 

intention, cooperation with other organisations (e.g. Fonds Gesundes Österreich) is to be sought. 

Joint publicity work: The regional offices, social partners and other partners will do their best to 

disseminate the idea of WHP in Austria. The Austrian Network has had its own logo developed. This 

is to be used by the regional offices, social partners and other partners next to their own logo at joint 

events. 

Work focus to date 

Exchange of information plays a large role in the network meetings. This enables existing knowledge 

to be made available and contributes greatly to the continuous improvement of quality. Additionally, 

the network members have carried out a number of joint initiatives and projects in recent years using 

experience gathered by the Austrian Contact Office: 

Annual information days 

From the very beginning of the network the Information Days have been held in different provinces: 

2000 Salzburg ‘Health Promotion needs partners – strategies and practice in small and 

medium-sized enterprises’. 

2001 St Polten ‘Factors for the success of workplace health promotion’ 

2002 Vienna ‘Workplace health promotion and organisational development’ 

2003 Klagenfurt ‘Challenges of WHP in SMEs – new opportunities in small and mediumsized 

enterprises’ 

Newsletter, joint folders and joint overhead transparencies 

In the newsletter, which appears four times a year, not only is information given about the activities of 

the network, the activities and projects of various other organisations are also presented. One 

thousand-two hundred copies are produced, and the newsletter can also be downloaded from the 

homepage. Since the beginning of 2004 it has also been possible to receive the newsletter by 

electronic mail. A small working group produced two folders which are used by the regional offices, 

social partners and other partners at events and which are also distributed to interested parties: 

Workplace health promotion – what does it mean? A short description of the basic idea, the 

benefits and the instruments of workplace health promotion 




The Austrian Network for WHP. A description of the work of the Austrian Network and also of 

the Austrian Contact Office of the European Network and all the regional offices, social 

partners and partners. 

During the foundation workshop there were already suggestions that a set of overhead 

transparencies should be provided in order to ensure a basic understanding of the topic and also to 

show the joint aims. The transparencies were developed according to a module system in order to 

provide greater flexibility. The layout is similar to the network homepage, and enables all users to 

insert the logo of their own institute. The set of transparencies covers the following areas: 

• General information on health promotion 

• Preventative behaviour and preventative conditions 

• Quality characteristics and benefits of WHP 

• Project phases 

• Sick leave analysis 

• Workforce survey instruments: 

Salutogenetic subjective work analysis (SALSA) 

PROFIT (developed by VAdÖB) 

• Health circles 

• European Network for WHP 

• The Austrian Network for WHP 

Homepage www.netzwerk-bgf.at 

This homepage was developed as a comprehensive source of information in order to further the 

development of WHP. It includes information on the activities of the Network, the relevant contact 

offices of the European Union and the Network partners in the different provinces, comprehensive 

information on WHP, advice on project work and also a data bank with information on projects and 

health circle facilitators. It was set up on-line in June 2002 and is the joint internet page of the 

network. As well as the general information on WHP there are also pages for the regional offices’ 

use. The homepage thus provides a further pool of communication and information for experts and 

parties interested in WHP through which contact persons and network partners in all provinces can 

be reached. The website of the Austrian network contributes considerably to the publicity work for 

WHP. As well as theoretical information and basic documents, the homepage offers help to project 

leaders in the planning of their activities. 

All the regional offices and partners have their own pages which they can design and use according 

to their needs. This means that information which is important for a particular region can be shown. 

The homepage is constantly being expanded. The next step will be on-line packages for enterprises. 

WHP Oscar 

In cooperation with the Austrian Health Promotion Foundation, the Austrian Network announced the 

Austrian Award for Workplace Health Promotion (WHP Oscar) for the second time. The aim of this is 

to give the many innovative activities in Austrian enterprises in this field more publicity. Through the 

giving of the awards to future-oriented projects, other enterprises should be encouraged to take up 

workplace health promotion. The award is intended to be a contribution to quality development in 

WHP in Austria. All enterprises who had conducted projects to optimise the health of their employees 

in the last two years were invited to participate. However, projects which were still running but were 




in the end phase could also be entered. Again, there were two categories for the award, whereby the 

number of employees was decisive: enterprises with less than 200 employees and enterprises with 

over 200 employees 

An independent jury of experts evaluated the entries and selected the winners. In order to ensure an 

objective choice of winners, the jury were provided with clearly defined evaluation criteria and 

guidelines. The ‘Quality Criteria for Workplace Health Promotion’ of the European Network for 

Workplace Health Promotion were used as a basis for this. The award-winners were: 

Category for enterprises with less than 200 employees: 

1. NetCare “well@work – healthy with NetCare” 

2. ifsec Holding Ges.m.b.H “well@work - health promotion at ifsec” 

3. Sabtours GmbH “Active together” 

Category for enterprises with over 200 employees: 

1. GKB-Bergbau GmbH „Pro-fit“ 

2. pro mente Bildungsinstitut OÖ 

“VIVA – health promotion project at pro mente OÖ” 

3.. Salzburger Flughafen GmbH “WHP at Salzburg Airport” 

The awards were presented during a public event on ‘Quality in workplace health promotion’ at the 

beginning of 2003. The three best projects were presented here by representatives of the companies 

concerned. All the project entries were documented in a final publication. In this way the enterprises 

which were not among the winners also received public acclaim, and examples of good practice 

were documented and collected. 

Canteen award 

About 1.5 million Austrians dine in company canteens every day, but good healthy food is not found 

everywhere. This is why the Austrian Health Promotion Foundation decided to hold a company 

canteen competition ‘Modern Canteens – Satisfied Guests’, together with the Austrian Contact Office, 

the Forum for Austrian Health Committees, the Working Committee of Canteens in Austria and the 

Austrian Federation of Dieticians. The idea was to find meals which fulfilled the criteria ‘balanced, 

healthy, seasonal and with a regional orientation’. A jury of experts judged 45 meals submitted by 

canteens, looked at the kitchen facilities and considered each canteen’s use of healthy foods. At the 

beginning of October 2002, the awards were presented at a special event in Vienna. The BMW 

company restaurant in Steyr took first place; second was Domus Facility Management in Vienna. 

Third place went to the canteen of Lenzing AG. The remaining participants received a token award in 

recognition of their participation. 

Project ‘Health as a factor for economic success’ 

Austria has now a considerable amount of experience with models of workplace health promotion, 

most of which, however, is based on activities in large multi-nationals. Up to now there have only 

been a few isolated projects in small and medium-sized enterprises (SMEs), although these make up 

the majority of enterprises in Austria. The Austrian Health Promotion Foundation therefore 

announced a forthcoming project for SMEs, for which the Austrian Contact Office applied together 

with the Salzburg Regional Sickness Fund and the Insurance Institution of the Austrian Mining 

Industry. Fortunately, this project was approved, and the project ‘WEG’ began in 2003. In a total of 12 

SMEs in Upper Austria, Salzburg and Styria, practical modules were developed for SMEs which 




should be transferable and which will be published online on www.network-bfg.at after being tried 

out, so that any enterprise and its staff can use them. 

Training course for project leaders and health circle facilitators 

The quality of workplace health promotion naturally depends on the qualifications of those who 

participate in the project. Many enterprises wished to have competent facilitators on hand in the 

company permanently. To fulfil this demand, the Austrian Network worked together with the Austrian 

Health Promotion Foundation to develop a concept for a training course. 

For several months now, enterprises have had the opportunity to avail themselves of such a training 

course which suits their project time schedule and takes place nearby. The two-day course is offered 

by FAA Holding GmbH. This company also offers a three day training course for prospective project 

leaders. 

Future perspectives 

Looking back over the development of workplace health promotion, particularly since the foundation 

of the Austrian Network, the term ‘success story’ does not seem an exaggeration. Nevertheless, 

there are some points for criticism: 

• It has not yet been possible to offer similar services for enterprises in every province, which of 

course leads to dissatisfaction occasionally. Enterprises often show little understanding if their 

regional office does not provide the support they had hoped for. Without wishing to 

compromise the autonomy of the institutions, which are hesitant about new developments 

because of their precarious financial situation, it does appear necessary to resolve this 

situation in the near future. 

• At present, the Austrian Network only offers support for those enterprises which undertake the 

challenge of setting up a comprehensive workplace health promotion project. More easily 

accessible projects, concerning nutrition and exercise, for example, are lacking, although it has 

become apparent that such small projects can function as a ‘door-opener’ for more 

comprehensive activities. The Austrian Network should therefore develop high quality services 

on nutrition and exercise in the near future. 

• Members of the Austrian Network have shown little reaction to the latest results of scientific 

studies, nor have they encouraged universities or relevant institutes to view health promotion 

as a rewarding field of research. There are new perspectives for development here, too. 

• Expert knowledge is a basic requirement for high quality work in the future. Network members 

agree that it is an important task for the future to pay more attention to the further education of 

those active in this field. Network meetings in the future will also be used to gain more expert 

knowledge. 

The ambitious content of the planned innovation project health promotion and prevention should 

ensure that the positive developments become permanently established and that there is a 

qualitative and quantitative development of workplace health promotion in the future. 




A key to a healthy working life 

Recommendations for workplace health promotion and age 

management in small and medium-sized enterprises 

Ludwig Grillich 

Introduction 

Imminent demographic developments (decreasing birth rates, ageing of the baby boom generation) 

and the raising of the legal retirement age in many countries will pose new challenges to companies 

in the near future: the supply with prime-age workforce will be drastically reduced while the 45+ age 

band will constitute the largest group of the workforce. In order to cope with these demographic 

changes and other labour-related developments, a successful strategy has to go beyond simply 

employing people for a longer period of time under unchanging working conditions. What is required 

instead are programmes leading to better age management within companies and to a healthoriented 

workplace and job design. We need to realise long-term workplace health pro-motion 

projects that include all generations of a company’s workforce. 

Workplace health promotion as a successful implementation model has been established primarily in 

large enterprises. However, 98% of all Austrian enterprises have less than 100 employees and 

employ approximately 50% of the total workforce. Since it is not possible to simply use the same 

strategies and methods in SME, there are hardly any tried and tested concepts of workplace health 

promotion for these enterprises. 

Therefore, the present study ‘A key to a healthy working life’ aims at developing concrete measures 

and models of WHP and age management for SME, to present good reasons for using such an 

approach and to recommend an innovative approach to the stakeholders. The study was carried out 

by diepartner.at in the period from February to September 2004. It was commissioned by the 

Austrian Federal Economic Chamber, sponsored by Pfizer Austria and received funds from the 

Fonds Gesundes Österreich (Fund for a Healthy Austria). The study focuses on projects and 

initiatives of workplace health promotion in SME with up to 100 employees with a special focus on 

age and ageing. 

Context 

Demographic trends 

Europe is faced with far-reaching demographic changes. Decreasing birth rates, increasing life 

expectancy and the ageing of the baby boom generation lead to significant population ageing. 

According to recent prognoses of demographic trends, the number of Austrians aged 60+ will 

increase massively from 1.7 million in 2001 to approximately 2.9 million in 2050. In the same period, 

the size of the 15–60 age band and of the youngest age group (persons up to age 15) is predicted to 

decrease. This phenomenon is, of course, not limited to Austria; comparable trends may be observed 

throughout Europe. 

Naturally, these developments have repercussions on the world of work: the proportion of the 

working age population decreases, employees aged 45+ for the first time represent the majority of 

the workforce whereas the proportion of young employees decreases considerably. In 2025, the 




50–64 age band will be twice as large as the 15–24 age band. More than half of all enterprises in 

Germany today have no employees aged 50+. In many enterprises, they will constitute the largest 

age group in just a few years time. 

Companies are therefore faced with the challenge of maintaining their level of productivity and 

competitiveness with an older workforce. They have to start taking measures now to make sure that 

their employees grow older in a healthy way and that the company remains attractive for young 

employees. 

Measures to prolong working life 

In the last few years, many European countries have raised the legal retirement age and taken 

measures to raise the employment rate of older employees with the intention to ensure the 

sustainability of state pension systems in the future. On a European level, the 2001 European 

Council in Stockholm set a 50% employment rate target for the 55–64 age band until 2010 (in 2003, 

the relevant Austrian figure was 30.4%). In this context, the Council emphasised that these measures 

are not only relevant for older people but for all age groups. They aim at ensuring the employability 

of all persons until retirement age. 

Changes in the world of work and in work-related stress factors 

According to experts, several factors such as the increasing speed of the globalisation process, the 

resulting increase in cost pressure, a higher level of customer orientation and growing profit 

expectations of shareholders result in companies neglecting their employees’ needs, their well-being 

and health.[1] Despite increasing automation, work-related stress factors were not generally reduced 

during the last decades – the spectrum of stress and pressures has simply shifted. The level of 

physical demands remained the same while psychological and psycho-social stress increased 

significantly in almost every field of the world of work.[2] 

Another obstacle for healthy ageing within a company (i.e. the adjustment of workplace and job 

design to the capacities changed as a result of ageing or sickness) is the increasing use of modern 

management and corporate strategies. Many traditional jobs like janitor or warehouseman were 

reduced in number or completely abolished in the course of lean management programmes. This 

trend eliminated a major opportunity for continued employment especially for elderly employees who 

were no longer fully employable in their former positions due to reduced working capacity and 

increasing health problems.[2] The tendency to adopt flat hierarchies in companies poses another 

obstacle to long-term employment: it is more difficult to stay with a company for a lifetime; this was 

often connected with a reduction in work pressures. 

Older employees in a company – challenge and chance 

The phenomenon of demographic change has not attracted much attention so far. The topic was only 

considered in the context of how to guarantee the financial viability of our social security systems. 

The impacts of demographic change on the labour market and on the world of work do not play an 

important role in most companies’ considerations. However, they will face new challenges in the 

future due to the demographic trends and to the higher legal retirement age: the supply with young 

workforce will be reduced drastically, and employees aged 45+ will represent the largest age group in 

many companies. 

It was a common practice for quite a long time to reduce the number of older employees by sending 

them into early retirement. Naturally, this had immediate effects on the world of work: there was no 

need to design jobs and in-house careers so that people could work there until retirement age and 




the integration of elderly employees into training programmes was not encouraged. Today, it is 

impossible to ignore that this practice cannot be continued for much longer. However, the required 

changes in company culture need a significant period of time before they produce results.[3] The 

creation of adequate frameworks within the companies has to go hand in hand with a change in the 

awareness of all those concerned. 

The assessment of the performance and efficiency of older employees in a company of today is often 

deficit-oriented. Ageing is regarded as synonymous with a general decline in work ability. The work 

ability of employees of different age groups has been assessed by results and compared in more 

than 100 studies. These studies show that older employees are not less capable or efficient than 

younger ones, but that their abilities change with the age.[4] While physical strength declines 

between the ages 20 and 60, the psychological capabilities remain the same and mental and social 

capabilities increase. 

Maintaining and promoting working capacity 

It is not feasible to attempt maintaining and promoting the working capacity and motivation of 

employees by simply employing them in the same company for a longer period of time under 

unchanging conditions. Instead, specific measures have to be taken to improve the working 

conditions in a company for the employees of all age groups. This will help create the conditions that 

will allow all employees – regardless of their age – to make the best-possible contribution to the 

success of the company. As a result, employees will not suffer from health problems due to their 

work. Instead, working will contribute to their health and well-being. 

There are two basic approaches which aim at maintaining and promoting working capacity albeit with 

a different focus in some respects: workplace health promotion and age management. Integrating the 

dimension of ageing into workplace health promotion is an essential factor in the design of 

successful strategies to cope with the challenges of working life today and in the future. 

Workplace health promotion 

The ‘Luxembourg Declaration’ contains a definition of the term ‘workplace health promotion’ which is 

recognised throughout Europe. It comprises the combined efforts of employers, employees and 

society to improve the health and well-being of people at work. A combination of the following three 

approaches will help promote workplace health: improving the work organisation and working 

conditions, promoting active participation of employees and encouraging personal development.[5] 

The vision of WHP is the ‘healthy organisation’. This means that we do not simply focus on single, 

isolated working conditions and work patterns but use a comprehensive perspective of the entire 

organisation with its risk factors and health potentials. Enterprises may be regarded as social 

systems, the characteristics of which can have beneficial or detrimental effects on the health, wellbeing 

and working capacity of its members. Making an organisation healthy involves the systematic 

and continuous effort to implement health-promoting structures and processes in the company and to 

see to the WHP empowerment of employees.[1] 

In Austria, workplace health promotion was established during the last few years mostly in the shape 

of projects with a limited duration but in part also in the spirit of sustainable integrated organisational 

health management. The majority of findings were, however, gathered in large enterprises; SMEs still 

have to catch up in this field. The issues of ageing and age-adequate work design have not yet been 

part of WHP initiatives in Austria. 

Age management and working capacity 




Persons of different age groups have different needs, qualifications and capabilities. Therefore, the 

organisation of work should take into account the strengths and weaknesses of employees of 

different age groups. The term age management refers to this inclusion of age-related aspects into 

decision-making processes related to day-to-day management, job design, work organisation and 

design of working environments. Age management within a company aims at empowering all 

employees, regardless of their age, to attain their personal goals and the goals of the company.[6] 

Since everyone grows old, age management systems in a company should include all age groups. 

The measures promoting an employee’s 

capabilities and securing his/her employability 

should not be taken at the end of his/her 

working life but during the entire working life. 

Instead of focussing on solving problems, we 

choose a holistic approach which prevents 

discrimination on grounds of age and makes 

working in good health until retirement age 

entirely possible and also desirable. 

The Finnish Institute of Occupational Health 

(FIOH) has been investigating the factors that 

determine work ability in its context for 20 

years. These factors are outlined in the ‘House 

of Work Ability’. 

If we wish to promote and maintain the work 

ability and employability during the entire 

working life and ensure good health also for 

the post-retirement period, we have to 

approach the issue on four different levels: 

Health is the basic factor determining the 

individuals’ efficiency in their working lives. In 

addition, they need to have an opportunity to 

acquire relevant capabilities and know-how in 

the course of their working lives, thus enabling 

them to acquire sufficient technical and/or 

social competence. Other important factors are the social and ethic values of employees, their 

attitudes and their personal concepts of how to contribute to the success of the enterprise. The 

interplay of the individuals’ concepts and the corporate working culture is especially significant in this 

context. The fourth floor of the house, finally, deals with the work itself in all aspects of its design, of 

its physical, psychological and organisational demands. This is where the management and their 

approach to leadership play an important role. According to the Finnish survey on the promotion of 

work ability, good leadership and competent superiors are the single most significant factor that could 

be attributed to an improvement of the working capacity of employees of the 51–62 age band. 

Future- and ageing-oriented WHP 

Figure 1: The ‘House of Work Ability” 

Family 

Work ability 

Work 

working environment 

type of demands 

community and organisation 

management and leadership 

Values 

attitude motivation 

Competence 

know-how capibilities 


functional capacity 

Source: based on Ilmarinen and Tempel.[7] 

Relatives 

Friends 

The demographic changes and their implications and accompanying phenomena described above 

require a type of WHP that takes into account the different capabilities, backgrounds and needs of 

employees of all age groups. In this context, Morschhäuser speaks of future- and ageing-oriented 

workplace health promotion.[8] This approach to WHP aims at maintaining and promoting health and 

working capacity during the entire working life and using the necessary and adequate instruments for 

this purpose. 




If we wish to maintain and promote workplace health in the long run, we have to extend our concept 

of workplace health promotion to encompass more than the individual components. Instead, we have 

to create an adequate balance of the relevant areas in an in-house discussion and participation 

process. All activities in the context of this type of WHP are planned and implemented with regard to 

the aspect of ageing. 

The following areas should be considered: 

• Leadership and management 

• Corporate culture and working climate 

• Attitude towards (older) employees in the company 

• Values and attitude towards work of the employees 

• Communication and cooperation 

• Social support 

• Qualification and training, lifelong learning 

• Recruiting of staff, human resources development and management 

• Retirement, transition to post-retirement life 

• Design of the working environment 

• Organisation of work, demands 

• Working time 

• Career planning, career design 

• Health programmes (healthy lifestyle and behaviour) 

• Preventive medicine 

SME – an important target group 

The Austrian business sector is characterised by a very large proportion of SMEs. Very small 

enterprises (with 1 to 9 employees) make up approximately 84% of Austrian enterprises. More than 

98% of all companies employ less than 100 persons and employ more than 50% of the total 

workforce. 

Small enterprises are therefore an important target group for initiatives to promote the working 

capacity of employees. In the ‘Luxembourg Declaration’ of 1997, the members of the European 

Network for Workplace Health Promotion already emphasised that SME deserve special 

consideration in WHP activities. 

Current activities and existing models in Austria and in Europe 

European context and national policies 

Policies to stimulate workplace health promotion projects in SMEs are adopted both on a European 

and on a national level. On the European level, the efforts to include SMEs in WHP (European 

Network for Workplace Health Promotion) resulted, for instance, in the ‘Luxembourg Declaration’ 

(1997), in the ‘Cardiff Memorandum’ (1998) or in the brochure ‘Criteria for and examples of good 

practice in WHP in SME’ (2001). National measures are, among others, the three-year programme 

(2001–2004) of the Gesundheitsförderung Schweiz (Health Promotion Switzerland). In the framework 

of their SME-specific initiative ‘KMU vital’, WHP projects were carried out in ten Swiss SMEs and 




practice-oriented modules were developed for the specific requirements of an SME setting. As per 

today, the main initiator of such activities and initiatives for SMEs in Austria is the Fonds Gesundes 

Österreich (Fund for a Healthy Austria) which, for example, defined a target group specific focus on 

SME employees in its three-year programme (2003–2005). Two model projects of WHP for 

employees of SME are being implemented in this context. 

In recent years, the issue of the ageing workforce has gained importance throughout Europe. 

Especially Finland recognised the importance of this topic early on by launching extensive national 

action programmes, for instance ‘Finnage – Respect for the Ageing’ (1990–1996) or the ‘Finnish 

National Programme for Ageing Workers’ (1998–2002). The activities aimed at promoting the 

employment of older employees, reducing the number of older employees retiring early from working 

life and preventing their exclusion from the labour market. In Germany, interdisciplinary projects are 

funded in the framework of the funding focus on demographic change and the future of employment. 

In Austria, the actual realisation of most workplace age management projects has been limited to 

large enterprises. 

Existing approaches and models 

WHP and age management projects are implemented in the context of national programmes (see 

above), regional initiatives and on company level. Joint initiatives and programmes may focus on a 

certain business sector, on a certain region or also on a combination of the two approaches. 

Examples of such projects and initiatives are, among others: NWGU - Netzwerk Gesunde 

Unternehmen Steyr (a regional network in Austria), Ha(a)rmonie – Gesunde Friseure im Bezirk 

Amstetten (a sector-specific and regional initiative for hairdressers in Austria), go 2.20 – gesunde 

organisationen (a EU-funded regional project in Austria), Arbeitsgemeinschaft Netzwerk Gesundheit 

und Qualifikation für die Bauwirtschaft im Kreis Heinsberg (a sector-specific and regional network of 

the German building industry) or the regional network for workplace health promotion in Skåne 

(Sweden). The size of the companies participating in all these projects gives evidence of a significant 

lack of WHP and age management experience in very small enterprises with less than 20 

employees. 

In the majority of WHP and age management projects on a company level we reviewed, the classical 

management cycle structure was adopted: diagnosis – planning – action – evaluation. Most large 

enterprises have the resources to design extensive individual phases in terms of time and content. 

The implementation in small enterprises, on the other hand, requires adequately adapted and, most 

importantly, viable methods and approaches. 

Costs and benefits of WHP and age management 

The advantageous effects of WHP and age management in many fields are documented by a large 

number of scientific studies and practical examples; most WHP experts of today recognise the 

existence of such positive effects. Many factors indicate that health and ageing oriented job design 

will lead to a triple win situation (for employees, employers and society). Sustained beneficial effects 

may be observed especially as a result of extensive, long-term programmes. 

Evident beneficial effects for employees are, for instance, improved health and well-being, increased 

work ability and employability, a higher level of (job-related) competencies, an increased life 

expectancy, a lower risk of being downsized, an better quality of life and improved working 

conditions. 

According to numerous studies, companies benefit from the following aspects: fewer sickness 

absences, a reduction of unproductive costs, increased workforce availability, even distribution of the 




workload, low fluctuation rates, increased productivity, product and process optimisation, higher 

quality, a higher level of customer satisfaction, maintaining and improving the level of 

competitiveness, a better public image, a higher level of employee satisfaction, a constructive 

working climate, improved communication and cooperation as well as retaining the know-how, 

competencies and capabilities of (older) employees within the organisation. The price to be paid for 

these advantageous effects consists of higher internal labour costs and expenses for third-party 

services (for example, coaching). 

The following beneficial aspects may be observed for society at large: lower medical treatment costs, 

avoiding sick pays, reducing the risk of accidents and fatalities, avoiding invalidity pensions, widow’s 

and orphan’s pensions, longer working life and contribution periods, shorter pension periods, a lower 

unemployment rate and the sustainable development of the entire social security system. 

Several studies draw the conclusion that WHP and age management definitely pay off for companies 

also in terms of money: in their meta-analysis, Kreis and Bödeker report a return on investment (ROI) 

between 1:2.5 and 1:10.1.[9] Ilmarinen [10] and Ilmarinen and Tempel [11] report similar positive 

results for the Finnish studies for the promotion of work ability; in their analyses, the ROI is between 

1:3 and 1:20. However, several authors criticise that an evaluation exclusively in terms of money 

does not do justice to the effects of WHP and that such a reduction to financial considerations leaves 

aside some essential aspects of WHP. Therefore, classical cost-benefit analyses should never be the 

only decisive criterion for the evaluation of a programme. 

Views and recommendations of experts 

In the course of this study, we held interviews with 14 WHP experts to determine success factors and 

viable procedures for the implementation of workplace health promotion and age management 

projects in small enterprises from their point of view. 

According to the experts, long-term information and awareness campaigns are required to make 

(small) enterprises take notice of the issue at all. This, they say, is the only way to achieve a higher 

level of awareness within the companies and in society. A general awareness of the issue is, 

however, not enough: it needs to be complemented by a company-specific approach. Personal 

contacts are the most effective means of approaching a company. Therefore, they say, it is 

necessary to identify potential ‘multipliers’ who have the right contacts in the companies and to offer 

them adequate training. Especially for small enterprises, they could be contact persons from the 

numerous networks (sector-specific networks, SME networks, cluster etc.) or from the guilds. 

According to the experts, economic considerations are still the decisive factor for a company to 

implement a WHP policy. 

Essential factors for the success of WHP projects in a company are the full support of the 

management, the participation of employees and concise and viable instruments. 

Views and recommendations of company representatives 

The interviews with 15 company representatives aimed at compiling the experiences of companies 

with the implementation of WHP and age management measures from the decision-makers’ point of 

view in order to determine success factors and identify good reasons for other SMEs to take action in 

this field. 

The interviewed persons gave a large number of different reasons and considerations that led to their 

decision to implement health promotion programmes. The following reasons were given most often: a 

general interest in health matters, the firm belief that good health is essential for a high level of 




motivation, performance and success, the perspective of fewer sickness absences, an improvement 

in the satisfaction and well-being of employees and a better working climate and working 

environment. 

When it comes to the benefits of the WHP projects for the company, several employers emphasised 

how difficult it is to pinpoint them, since a systematic evaluation was hardly ever part of the projects. 

The beneficial effects they perceived are related to personal aspects and to the working conditions. 

The following personal aspects were mentioned most often: more satisfaction, motivation and wellbeing 

of the employees. 

According to the company representatives, the following aspects were central to the success of the 

individual projects: acceptance of the WHP project by the employees and their active participation, 

the commitment of the management, expert counselling and coaching and a comprehensive design 

and realisation of the WHP. 

Most companies are well aware of a general future need to adopt age management policies, but their 

willingness to take action now is still on a very low level. 

Recommended measures 

There is no standardised method or the one correct way of promoting the health and work ability of 

employees until retirement age. Several different strategies may be adequate for the different groups 

and fields of employment within a company. Their viability depends on many concrete factors related 

to the social context and to the company in question. Apart from technical criteria, the viability (that 

is, the possibility to implement the programme into day-to-day routines) plays an important role 

especially in the project design for small enterprises. The specific context of a small enterprise 

requires a good combination of reasonable and success-oriented project design with pragmatic 

viability considerations. 

We developed several approaches for the implementation of WHP projects in small enterprises on 

the basis of the experts’ findings and the experience gathered by the interviewed employers, on 

findings from current or past SME initiatives as well as on recommendations in the latest 

publications. The results are supposed to initiate and advance a discourse on different methods of 

how to maintain and promote the working capacity in SMEs. 

Small enterprises need more financial support in the realisation of projects and generally have a 

lower (or virtually non-existent) level of awareness for the issue of working capacity. The project 

design for WHP in SMEs needs to take into consideration the specific context of these enterprises 

and create the required framework. 

Accompanying measures: 

WHP and age management projects and initiatives have to be supported by adequate accompanying 

measures and inserted in the context of a bigger strategy (for example, information and awareness 

campaigns, changes in the relevant legislation etc.). The aim of information and awareness 

campaigns in this context is to improve the public image of elderly persons in general and especially 

that of older employees and to emphasise the importance of WHP with a special focus on age and 

ageing. 

In a strategy coordinated with an information campaign, we recommend approaching especially 

those persons and groups who are in permanent contact with companies and provide them with 

information and training on WHP and age management. According to the interviewed experts, such 

personal contacts are in many ways very promising for the dissemination of information. Relevant 




multipliers for training programmes are, for instance, representatives from guilds, special interest 

groups, social partners, trade unions, regional managers etc. The first step here is to inform these 

multipliers on the approaches, targets and methods of WHP and on the relevant experts and service 

centres. This will help start a discourse in the companies, provide interested companies with 

adequate first information and further relay them to the service centres. 

Since the financial resources in small enterprises tend to be very limited, financial support is required 

for the implementation of extensive WHP programmes. The funding of pilot projects is essential for 

very small enterprises, where we have only a few reference points of how to design and implement 

WHP projects. Pilot projects will help to test specific approaches and instruments as well as develop 

and optimise them. 

How to approach companies 

Judging from the findings compiled in the course of all projects carried out so far, the biggest 

challenge is to make companies take an interest in WHP projects and actually participate in them. 

The huge number of different companies makes it quite impossible to approach them directly – in 

most cases it is only possible to get into contact via an existing structure, for example, a network. 

Small enterprises, especially manufacturers, are often organised in guilds. The benefits of WHP have 

to be immediately evident for the company. Therefore, WHP should be limited to significant problems 

and to practical, viable solutions. Relevant topics can be identified in questionnaires that will make 

people more aware of the issue at the same time; the focus on the effects of WHP projects (also in 

terms of economic benefits) will stimulate the companies’ willingness to participate. Apart from using 

contact persons from regional networks, several initiatives are successfully using the method of 

targeted telephone marketing. 

Regional approach 

The regional approach seems an obvious solution to make WHP and age management projects 

available for a large number of small enterprises and to install such projects firmly in the region. 

Thus, WHP projects will reach beyond company level and become a reliable factor and a permanent 

process in the region. The advantages of this approach lie with the potential use of existing regional 

structures and networks and in the opportunity to include all stakeholders in a certain region (that is, 

all persons and organisations who are contacting the companies anyway), to use their know-how and 

their existing contacts with the companies. 

We recommend the following steps to implement a regional initiative for the promotion of WHP and 

age management in small enterprises: form a regional control unit or network, create a regional 

coordination centre or a regional competence centre, develop a regional expert network and provide 

financial resources for the funding of the initiative. 

In addition to the realisation of company projects, the regional approach allows us to go beyond 

company level and promote networking activities. Several problems cannot be solved within a 

company, especially if we are talking about small and very small enterprises. One essential field of 

activity in the context of work ability promotion is the training and qualification of employees; 

adequate measures to promote it can be realised on a regional level. 

Company approach 

Small enterprises need customised offers of WHP and age management. It is not possible to simply 

transfer concepts and instruments that were successfully used in large enterprises to SME and use 

them there. For instance instruments to determine typical stress situations (invalidity analyses, 




standardised employee questionnaires) are only useful to a limited extent for companies with less 

than 50 employees for reasons of data protection and because of the limited informative value 

resulting from the small number of cases. Using the classical instrument of WHP, organised health 

activities, in small enterprises requires its adaptation to the specific context (e.g. the activities must 

not be overly time-consuming). 

For this reason, we developed viable solutions for small enterprises. 

The design of working conditions and a culture of organisational health in small and very small 

enterprises depend largely on the owners. They take all decisions relevant to the design of these 

structures, and their personal attitudes are the decisive factors in the management of the enterprises. 

Therefore, it is only logical to appeal to the owners’ personal awareness of the health issue and to 

raise their level of awareness for organisational health matters so that they will initiate health 

promotion processes in their enterprises. 

It seems a promising approach to offer coaching to company owners or managers to raise their level 

of awareness for their own health and for their employees’ health, help them identify the roots of 

health problems, and motivate them to realise WHP projects for their employees. Coaching will 

provide them with the basic know-how for this purpose. 

As a next step, we recommend conducting a half-day health workshop for the employees of larger 

enterprises. This workshop will help develop new concepts of organised health activities; their extent 

and duration will depend on the size of the company. 

For enterprises with approximately 25 employees, we recommend conducting the traditional WHP 

procedure with organised health activities (again, they must not be overly time-consuming). 

Another option for companies of all sizes would be to organise their own self assessment units or 

single, topic-centred modules. This helps saving costs and developing relevant health-related knowhow 

within the companies. An important factor in the success of WHP projects is providing them with 

simple procedures and useful instruments and tools. These can be made available via internet 

download. 

Naturally, sufficient funding is a precondition for the implementation of WHP projects. Counselling 

and coaching by third parties should be co-financed or made available for free. 

We strongly recommend a professional evaluation of the projects. The results of the evaluation will 

serve as a reason for continuing and a basis for necessary adaptations of the projects. In additions, 

they play an important role in the presentation of the model to third parties and help convincing other 

SMEs to adopt similar projects. 

For a detailed presentation of the recommended models and policies, please refer to the study ‘A key 

to a healthy working life’. 

References 

1. Badura B, Hehlmann T. Betriebliche Gesundheitspolitik. Der Weg zur gesunden Organisation. 

Berlin: Springer, 2003. 

2. Krenn M, Vogt M. (2004). Ältere Arbeitskräfte in belastungsintensiven Tätigkeitsbereichen: 

Probleme und Gestaltungsansätze. Studie im Auftrag der Kammer für Arbeiter und Angestellte Wien 

und der Gewerkschaft Bau-Holz. Wien: Forschungs- und Beratungsstelle Arbeitswelt (FORBA). 




3. Buck H, Kistler E, Mendius HG. Demographischer Wandel in der Arbeitswelt – Chancen für eine 

innovative Arbeitsgestaltung., 2004 (in German). 

[www.die-rente.info/download/BMBF_Demographie_Arbeitswelt.pdf, accessed 24 May 2004] 

4. Kruse A. Psychologische Beiträge zur Leistungsfähigkeit im mittleren und höheren 

Erwachsenenalter – eine ressourcenorientierte Perspektive. In: Ch von Rothkirch (ed), Altern und 

Arbeit: Herausforderung für Wirtschaft und Gesellschaft. Berlin: Sigma-Verlag, 2000, pp. 72–87. 

5. European Network for Workplace Health Promotion, ENWHP. Luxembourg Declaration on 

Workplace Health Promotion in the European Union. Essen: ENWHP Secretariat, 1997. 

6. Ilmarinen J. Erhaltung und Förderung der Arbeits- und Beschäftigungsfähigkeit: Konzepte, 

Ergebnisse und Erfahrungen aus Finnland. Presentation given at the Swiss WHP Conference. 

Zürich, Switzerland, March 2004. (in German). 

www.bgf-tagung-2004.ch/Hauptreferate/Praesentation%20Ilmarinen%20(d).pdf, accessed 22 April 

2004] 

7. Ilmarinen J, Tempel J. Erhaltung, Förderung und Entwicklung der Arbeitsfähigkeit – Konzepte und 

Forschungsergebnisse aus Finnland. In: B Badura, H Schellschmidt, C Vetter (eds). Fehlzeitenreport 

2002. Berlin: Springer, 2003, pp. 85–99. 

8. Morschhäuser M. Betriebliche Gesundheitsförderung angesichts des demographischen Wandels. 

In: M Morschhäuser (ed). Gesund bis zur Rente. Stuttgart: Bundesministerium für Bildung und 

Forschung (brochure of the German Federal Ministry of Education and Research, in German), 2000, 

pp. 10–21. 

[www.demotrans.de/documents/BR_DE_BR_10.pdf, accessed 23 April 2004] 

9. Kreis J, Bödeker W. Gesundheitlicher und ökonomischer Nutzen betrieblicher 

Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz. IGA- 

Report 3. Essen und Dresden: BKK Bundesverband und HVBG/BGAG, 2003. 

10. Ilmarinen J. What the social partners can do to improve employment opportunities for older 

workers. Summary of the EU expert presentation on ‘Age management in the workplace and the role 

of the social partners’ at the Ninth EU-Japan Symposium ‘Improving Employment Opportunities for 

older workers’. Brussels, Belgium, March 2002. 

[http://europa.eu.int/comm/employment_social/international_cooperation/other_files/eu_japan_ 

symposium9/speech_ilmarinen_en.pdf accessed 22 April 2004] 

11. Ilmarinen J, Tempel J. Arbeitsfähigkeit 2010. Hamburg: VSA-Verlag, 2002. 




Age-oriented careers and work in medium sized enterprises – from 

theory to practice 

Brigitte Geißler-Gruber 

Under the framework of the EU initiative ‘Equal’ and especially in the development partnership 

‘AEIOU’ (obtaining employability for individuals, organisations and companies) for the research and 

advisory centre ‘Humane Arbeitswelt’, the practicalities of implementing age-oriented working careers 

are being tested. The project takes place in a medium-sized Austrian mining company. 

The strategies for active maintenance and promotion of work and employability to a higher age fall 

into two areas of action: 

1. Age-oriented workplace design, that allows work with transformed work capacity 

2. Age-oriented organization of horizontal working careers: enabling a systematic change of strain 

(pressure, stress, impact) to maintain health and cope with work throughout the entire working life. 

The model ‘age-oriented working careers’ presents a scope of design, when certain working areas – 

despite ergonomic efforts – remain physically and mentally demanding and can only be effectively 

coped with by temporary measures. The working life of an employee is not left to chance: a healthrelated 

change of strain/exposure and development potential should be possible in the course of a 

working life. This concerns mainly horizontal career transitions without excluding career 

advancements. This systematic plan of career should contribute to operational and personal welfare. 

The operational benefit not only accrues from the maintenance of employees’ workability, but also 

from increased employee flexixbility in the context of fast moving economic developments. 

The concept of ‘age-oriented careers’ is founded on a model developed by Frevel. based upon: 

• Adapting working conditions to employees advanced in age by specific changes of production 

schedules and workplaces and therewith changes in strain and demand and 

• Adapting the employee to altered working conditions and demands by the means of learning, 

qualifying and compensation of age-related changes in efficiency.[1] 

As an operational planning method workplaces will be standardized: 

• Entry (limited initial skill adaption training period) 

• Transfer/development for alterations in strain/exposure and (or) further development 

• Temporary staying (unlimited duration of working operations, adapted to ageing conditions) 

• Exit (qualified upon a higher level, adapted to ageing conditions) 

Steps for establishing age-oriented working careers will be introduced during the lecture, pointing out 

components for included and stage-oriented decisive factors. 

Reference 

1. Frevel A. Partizipation beim lebenslangen Lernen. Ein Fallbeispiel für alter(n)sgerechte 

Personalentwicklung und Arbeitsgestaltung. Logistik + Arbeit 1997;9–10:30–33. 



Workshop 2a 

Meeting the challenges of 

a healthy heart for 

European women 




��Suzanne Wait Summary 357 

��Bengt Jönsson Health economics 372 

Page 




Summary 

Suzanne Wait 

Introduction 

On 7th October 2004, a workshop was held on the topic ‘Challenges for a healthy heart for European 

women’ at the 7th European Health Policy Forum in Gastein, Austria. The objective of this workshop 

was to explore the breadth of issues facing the newly enlarged Europe in the promotion and 

management of cardiovascular health for Europe's 228 million women. 

The event featured speakers from a wide array of perspectives from across Europe – the practicing 

cardiologist, the gynaecologist, the pharmaceutical industry, the EU policymaker, the patient 

advocacy group, the health economist, the health promotion organisation and the health 

management academic were all represented. The mix of speakers made for a lively discussion. Yet 

all speakers relayed similar strong messages: heart disease is the major killer of women in Europe, 

awareness of its importance is dismally low, and the time is ripe for focused efforts to reduce the 

burden that heart disease poses to women and society in general. 

The workshop was organized jointly by the European Heart Network, the European Health 

Management Association and Bristol-Myers Squibb. This partnership, which builds upon key areas of 

work for all three organisations, is symbolic of the need to bridge across different sectors of health to 

achieve best results and demonstrates the potential of such collaborations. 

This report presents a synthesis of the workshop discussions. We hope that the messages it contains 

will be disseminated as widely as possible in order to stimulate further debate and lead to concrete 

actions to help secure healthy hearts for all European women. 

Workshop participants: Naomi Chambers 

Martina Dören 

Bengt Jonsson 

Peggy McGuire 

John O’Toole 

Silvia Priori 

Giovanni Sperti 

Anna van Poucke 

Susanne Volqvartz 




The Issues 

Facts and figures 

There is a widespread 

misconception that heart disease is 

mostly a male disease. Diseases of 

the heart and circulatory system, or 

cardiovascular disease (CVD) are 

the main cause of death in both 

men and women in Europe, causing 

more deaths than all cancers 

combined.[1] CVD includes 

coronary heart disease (CHD) and 

stroke. 

CVD is more frequent in men than 

in women below the age of 65, 

however the gap narrows after this 

age. With women living on average 

5–6 years longer than men, the 

clinical and economic burden that 

CVD poses to society is bound to 

increase. 

Source: European Cardiovascular 

Disease Statistics, 2005. Reprinted by 

kind permission from the European 

Heart Network and the British Heart 

Foundation. 

The figures, in fact, are staggering:* 

• Cardiovascular disease is the main cause of death in all countries of Europe. 

• CVD accounts for 46% of all deaths in women, as compared to 39% of all deaths in men in the EU. 

• Stroke kills more women than men, although more men have strokes. 

• More women die of CVD than of all cancers combined. 

• Of women who survive a first heart attack: 

42% die within one year following a heart attack, compared to 24% of men. 

46% will be disabled by heart failure within 6 years. This is two times the rate in men. 

More women will have a second heart attack or stroke compared to male survivors of heart 

attacks.[2] 

* Unless otherwise indicated, CVD statistics presented in this report are derived from the 2005 edition of 

European Cardiovascular Disease Statistics. Statistics are provided whenever possible for the EU-25, otherwise 

they refer to the European region as a whole. 




• One in three women with heart disease between the ages of 55–64 is disabled, and this rate goes 

up to 1 in 2 in women over the age of 75.[3] 

Death rates from CVD are falling in most Western European countries, however they are rising in 

many Central and Eastern European countries. Similar geographic differences exist in incidence 

rates. For example: 

• Death rates for women aged 35–74 living in Italy or the UK fell by 41% and 30% respectively 

between 1989–1999. In the Russian Federation, they rose by 25%. 

• The death rate for women is 19 times higher in the Ukraine for women aged 35–74 than it is in 

France (it is 10 times higher for men). 

• The incidence of coronary events* in women aged 35–64 is four times higher in Warsaw, Poland 

than in Catalonia, Spain.[4] 

In countries where death rates from CVD have been falling, the decline has been slower in women 

than in men. 

CVD in women: a neglected threat 

Source: European 

Cardiovascular Disease 

Statistics, 2005. 

Reprinted by kind 

permission from the 

European Heart 

Network and the British 

Heart Foundation. 

Most people, including women, are unaware of the importance of heart disease in women. Low 

awareness of the risk of heart disease is compounded by an emotional detachment from heart 

disease amongst women, with most women still much more worried about getting breast cancer. In a 

US survey, half the women interviewed knew that heart disease was the leading cause of death in 

women, but only 13% considered it as their greatest personal health risk.[5] Similar findings emerged 

in Denmark: fewer than 10% of women asked thought that cardiovascular disease was their greatest 

health threat whereas two-thirds of women believed that cancer was the largest threat. Surveys of 

* Coronary events are defined as a likely or definite heart attack. 




women in a number of other European countries are consistent with these findings. (Country survey 

results are published in the April 2002 edition of HeartMatters). 

Why this misconception? Heart disease appears later in life, so that most 50-year-olds may never 

have seen any women their age suffer a heart attack, whereas most women will have seen a relative 

or friend affected by breast cancer. This misconception is not helped by the fact that most physicians 

very rarely broach the topic of heart disease with their female patients. 

Low awareness amongst women is matched by low awareness within the medical profession about 

the prevalence and manifestations of heart disease in women. 

Most of the previous CVD research has been conducted on men, leaving a dearth of data on how 

prevention and treatment may differ for women. The lack of data on women, especially older women, 

leaves many questions unanswered. Indeed, women and older people of both sexes are often 

referred to as ‘the understudied majority’.[6] 

The enrollment of women in 

cardiovascular trials 

The enrollment of women in 

cardiovascular clinical trials came 

under scrutiny in the mid-1980s with 

the realization that less information 

about treatment was available on 

women with cardiovascular disease 

than on men. As a result, study 

findings are biased towards observed 

results in men, and conclusions that 

are drawn about appropriate doses, 

treatment practices and expected 

responses may not reflect the reality 

of treating female patients. Small 

numbers of women in trials may 

prevent proper subgroup analysis of 

treatment effects in women, or 

numbers may be too small to allow 

for any meaningful effects to be 

observed, leading to the erroneous 

conclusion that treatments are 

ineffective in women. 

A review of cardiovascular trials 

conducted in Europe between 

1986–1997 is presented here. 

Women are different 

Trial Enrolled 

patients 

% 

females 

Reference 

GISSI-1 11,711 25 Lancet 1986;1:397–402 

ISIS-2 17,187 23 Lancet 1988;2:349–60 

GISSI-2 12,490 20 Lancet 1990;336:65–71 

GISSI-3 18,023 22 Lancet 1994;343:1115–22 

4S 4,444 19 Lancet 1994;334:1383–89 

ISIS-4 58,050 26 Lancet 1995;345:669–85 

SMILE 1,556 27 NEJM 1995;332:80–85 

EMIAT 1,486 16 Lancet 1997;349:667–74 

GISSI-P 11,324 15 Lancet 1999;354:447–52 

CIBIS-2 2,647 19 Lancet 1999;353:9–13 

CHARM 7,601 31 Lancet 2003;362:759–66 

Source: presented by SG Priori at the Gastein workshop, 

October 2005. 

Clinical and epidemiological studies have shown that women are different from men with CVD. Their 

physiology, disease processes, clinical presentation and outcomes all differ. Therefore it is misleading 

to extrapolate results from male patients to women. Clinical decision making for women should be 

guided by data gathered in women. 




Some of these differences are outlined below: 

Predisposition to disease: Estrogen has a protective effect on women against heart disease before 

menopause, therefore CHD affects women about ten years later than men. Still, this does not mean 

that heart disease cannot start developing earlier in life, and that preventive steps earlier during the 

lifecourse are not effective at preventing later disease. 

Higher risk of death and disability: 

A woman who has a stroke or a 

heart attack (especially an older 

woman) is more likely to die than a 

man. Women also have a higher 

rate of re-attack and heart failure, 

leading to important disability. 

Different symptoms: Everyone is 

familiar with the crushing chest 

pain image of someone suffering a 

heart attack. Yet this is not 

necessarily the experience of 

women.[7] Instead, women may 

feel extremely tired, often for 

periods of one month preceding 

the attack. Ischemia may be more 

often silent in women.[8] 

Unrecognized myocardial infarction 

(heart attack) is greater in women 

than in men.[9] 

Most doctors are poorly trained to recognise these symptoms and medical textbooks fail to underline 

the different prevalence of male and female symptoms. Moreover, women are more likely to have comorbidities 

that may mask symptoms of heart disease. 

Poor evidence leads to poor clinical decisions 

As suggested above, most biomedical research continues to be based on the unstated assumption 

that women and men are physiologically similar in all respects apart from their reproductive systems. 

Other biological differences are ignored, as are the social/gender differences that have such a major 

impact on health. 

Poor evidence may lead to poor clinical decisions. Clinicians may be reluctant to offer women certain 

treatments where clear evidence of their effectiveness in women is lacking, inconclusive, or (possibly 

wrongly) negative. Studies continue to show that women are treated less aggressively than 

men.[10,11] Some clinicians may be discouraged from treating women, as when they do treat women 

with ‘male-based’ treatment regimens, women may not respond in the manner they expected. 

This vicious circle of ‘evidence breeds practice’ can only be broken by producing solid evidence, 

based on sufficiently large groups of women, of treatment effectiveness in women. 

The importance of good diagnosis 

Most common symptoms in women with a heart attack 

One month before heart 

attack (prodromal phase) 

During heart attack 

(acute phase) 

Unusual fatigue (71%) Shortness of breath (58%) 

Sleep disturbance (48%) Weakness (55%) 

Shortness of breath (42%) Unusual fatigue (43%) 

Indigestion (39%) Cold sweat (39%) 

Anxiety (36%) Dizziness (39%) 

Heart racing (27%) Nausea (36%) 

Arms weak or heavy (25%) Arms weak or heavy (35%) 

Adapted from: McSweeney et al. Circulation 2003;108:2619–23. 

The exercise stress test, commonly used to diagnose ischemic heart disease, may be less accurate 

in women.[12] In young women with a low likelihood of CHD, an exercise stress test may give a false 




positive result.[13] In contrast, routine exercise tests often fail to pick up single-vessel heart disease, 

which is more common in women than in men.[14] Because of these differences, physicians may 

avoid using these diagnostic tests in women. Thus a heart attack or stroke may not be detected in 

women until later, when it has already progressed to a more serious stage, leading to greater 

complications and poorer outcomes.[15] 

It is important to recognise that, in some areas, progress has been made in adapting practice 

standards to better serve women’s needs. For example, the creation of smaller stents and catheters 

has made a huge difference in allowing women to have access to key procedures such as 

angiography, angioplasty and coronary bypass surgery. 

CVD is mostly preventable 

One of the most striking features of cardiovascular disease is that most risk factors are known and 

are amenable to population-wide prevention approaches. Primary prevention is thus both possible 

and effective. This is evidenced by significant decreases in CVD mortality in several EU countries 

over the past 20 years. 

Risk factors include cholesterol, smoking, high blood pressure, obesity and physical inactivity. They 

are similar in both sexes but they may differ in relative importance. 

Smoking: Cigarette smoke is a major risk factor in all circulatory diseases. Smoking increases a 

woman’s risk of having a heart attack by a factor of 3. Women who smoke more than 40 cigarettes a 

day increase their risk of heart disease 20-fold. Even smoking 1–4 cigarettes per day doubles their 

risk of disease.[16] 

Source: European Cardiovascular Disease Statistics, 2005. Reprinted by kind permission from the European 

Heart Network and the British Heart Foundation. 




Women who smoke are twice as likely as male smokers to have a heart attack. If a woman smokes 

while taking the contraceptive pill, her risk of CHD can be increased substantially. 

Within two years of giving up smoking, women are able to decrease their risk of mortality by nearly 

25%. 

Hormonal changes, cholesterol and triglyceride levels: Before menopause, women are somewhat 

protected against heart disease by estrogen, which increases ‘good’ (HDL) and decreases ‘bad’ 

(LDL) cholesterol levels. This advantage disappears with menopause however, and cholesterol levels 

are higher in postmenopausal women than men at similar ages. The incidence of CHD increases 

dramatically in middle age. 

Evidence is growing that lowering blood cholesterol levels can reduce the incidence of major heart 

attacks in women with heart disease and improve survival in older patients. Yet guidelines on when 

and how to reduce cholesterol levels in healthy women have not yet been established. 

Diabetes: Diabetes increases the risk of heart disease more in women than it does in men. Women 

who have already had a heart attack have double the risk of a second attack if they are diabetic. 

Reasons for these gender differences are thought to include greater prevalence of risk factors such 

as obesity and hypertension in diabetic women. 

Obesity and high blood pressure: The benefits of treating severe hypertension have been 

demonstrated in both men and women, however evidence of long-term benefits of treating mild to 

moderate hypertension in women is still lacking due to low rates of inclusion of women in clinical 

trials. 

Lack of exercise: Most of the studies of the relationship between exercise and heart disease have 

been conducted on men, however there is growing evidence that low physical activity is also an 

important risk factor for women. Exercise is also thought to reduce some of the other risk factors for 

CHD such as obesity, high blood pressure and cholesterol. 

Stress: Stress is another important risk factor in women for cardiovascular disease. Women, 

particularly those juggling work with family duties, are thought to experience a ‘double stress’ 

(workplace plus home) compared to men. 

A considerable economic burden 

The sickness and disability associated with CVD pose a tremendous burden to women, health care 

systems and society in general. This burden may be measured in terms of medical costs of care, 

disability and lost productivity and the impact on the quality of life of women and their families. CVD 

accounts for nearly one-third of disability-adjusted years of life lost in the EU for both sexes 

combined.[17] 

CVD costs the EU approximately €169 billion per year. Around 62% of these costs are due to direct 

health care costs, 21% to productivity losses and 17% to the informal care of people with CVD.[1] 

Cost estimates of CVD by gender are scarce and much of the most recent data comes from the 

United States. A recent American study suggests that CVD costs society $227 billion per year in 

direct costs (medical costs of treatment), and $142 billion in indirect costs (lost productivity due to 

premature death and disability from disease).[18] 

When one looks at the excess costs per stroke, costs for women are consistently higher at all ages 

than for men. The presence of vascular complications increases per patient costs by a factor of 3.5. 




The challenges 


Raising the profile of heart disease in women must mean that women are encouraged to take their 

risk of cardiovascular disease seriously. Messages about heart disease must break through to 

women who may be struggling with the competing demands of children, ageing parents, and 

demanding careers. 

Physicians treating women – gynaecologists, general practitioners, internists, geriatricians and other 

specialists – have a key part to play in ensuring that women are made aware of cardiovascular care 

risk factors, symptoms and outcomes. 

Women need to receive appropriate and culturally-sensitive information about their risks. Information 

and communication channels that are specific to different groups of women, for example immigrant 

women, should be privileged. 

Information must be timely and account for possible changes in the evidence base. For example, the 

recent findings that postmenopausal use of hormone replacement therapy (HRT) may not decrease 

the relative risk of heart disease but may actually increase risk caused significant confusion amongst 

the millions of European women who use HRT. This situation brought to light the critical importance 

of providing women with up-to-date and comprehensive information to enable them to make the best 

decisions to protect their health.[19,20] 

Many risk factors for heart disease are rising among women. 

Smoking rates have declined more rapidly amongst men than amongst women in the past decade. 

Women are less likely to be successful at quitting smoking than men. In Finland, France, Norway 

and Spain, smoking rates have been stable or even increased in women in recent years. A worrying 

trend is the increase in smoking in younger women, especially in poor communities, in several 

European countries. 

Physical exercise rates 

are lower in young girls 

than they are in boys in 

many European 

countries.[21] Italian 

data suggest that 

obesity rates in women 

are either higher or 

equal to rates in men 

(Istituto Superiore di 

Sanita, 2003). 

Source: European 

Cardiovascular Disease 

Statistics, 2005. Reprinted 

by kind permission from 

the European Heart 

Network and the British 

Heart Foundation. 




Women can make changes to their lifestyles and habits to reduce their risk of heart disease. But one 

cannot simply assume that women will learn from campaigns targeted to males. Specific public 

health campaigns aimed at women are needed. 

Improving the evidence base 

Too many epidemiological studies and clinical trials continue to be done on male-dominated samples. 

As a result, there are still major gaps in our knowledge about the differences between disease 

processes in males and females. Both preventive and therapeutic strategies are too often applied to 

women when they have mainly been tested on men. 

The lack of data on women, especially older women, leaves many questions unanswered, such as: 

How female hormones affect cholesterol levels 

Whether aspirin is as effective for women as it appears to be for men 

When blood pressure medicines should be prescribed 

Which ones and what doses should be recommended 

How dietary recommendations might differ 

How to motivate lifestyle changes among women most effectively. 

There is an urgent need to conduct studies specifically designed to answer relevant questions for 

women and to determine what constitutes best practice. 

The starting point for collecting this evidence is in clinical research. Funding agencies may play a key 

role in challenging traditional exclusion criteria on the basis of gender in clinical trials.[22] In the 

United States for example, since 1993 the National Institutes of Health (NIH) Revitalization Act 

specifically requires the inclusion of women in every clinical trial involving a disorder that affects 

women. The objective is to: "ensure that the trial is designed and carried out in a manner sufficient to 

provide for a valid analysis of whether the variables being studied in the trial affect women [and men] 

differently." 

In EU funded studies and trials, proposals must aim for 

40% representation of each gender unless there is a 

good scientific reason to do otherwise. The requirement 

to balance gender representation in trials must, however, 

be addressed in conjunction with age. 

Because most clinical trials include small numbers of 

women, they may lack the statistical power to prove 

clinical benefits with any certainty in women. Yet costeffectiveness 

data rely on strong effectiveness data. 

Health economic analyses thus often have poor clinical 

material to go on to determine whether a treatment is 

cost-effective in women or not. This may have serious 

implications for resource allocation decisions in health 

care. Those making such decisions are more and more 

requiring clear demonstration of clinical and costeffectiveness 

to guide funding decisions. For example, 

economic studies have helped demonstrate that lipidlowering 

drugs and statins can be cost-effective for 

treating cardiovascular disease in women. 

The importance of gender-specific 

evidence for clinical guidelines 

Treatment and prevention decisions 

need to take into consideration genderspecific 

risk profiles by age. In the past, 

guidelines were usually based on 

absolute risk figures that did not 

account for the fact that women and 

men have different levels of risk at 

different ages. If treatment decisions 

were based on these intervention 

thresholds, many women and many 

young people would have been 

excluded from treatment. Recent 

European guidelines have modified 

their approach to assessing risk. As a 

result, more gender-specific 

recommendations are offered to guide 

practice.[23,24] 




Raising standards of care 

Management challenges for cardiovascular care cover the spectrum from primary prevention to 

delivery of high quality health services. Cardiovascular disease needs to be treated urgently and 

effectively in the acute setting. It also brings with it the requirements of a chronic condition. 

Continuous care that is patient-centred and allows full integration between primary, secondary and 

rehabilitation services is needed. 

Cardiac networks of care have been created in an attempt to break down institutional barriers 

between different clinicians (nurses, GPs, hospital general physicians, cardiologists, physiotherapists) 

who all play some part in the care of the cardiac patient. This collaborative approach to chronic 

disease management has been adopted in many countries. 

There have been concerted efforts in several European countries to raise the standards of 

cardiovascular care. In England, the National Service Framework (NSF) for coronary heart disease 

was developed to ensure consistent standards of care for CHD across the country. This ambitious 

strategic plan sets out a broad list of objectives to achieve better care. These include better 

prevention in high-risk groups, prompt care following heart attacks, better revascularisation services 

and improved rehabilitation. 

Do the above care strategies work for women? There is reason to believe that some of the current 

changes in service provision may not address the needs of female cardiac patients. For example, the 

drive to improve access by decreasing waiting times in the English NSF aims to allow more people to 

be treated more quickly. However, this increased flow of patients puts huge pressure on already 

strained staff. Time to communicate with the patient, to do detailed medical histories assessing comorbidities, 

may get lost. Women, particularly older women, often allow themselves to be processed 

in the passive patient role and may be particularly poorly served in such a system. 

Women typically do not allow themselves time to convalesce in the same way as men. Shorter 

hospital stays, if not coupled with appropriate rehabilitation services, will thus not allow them the 

needed recuperation time to return to full health.[25] Also, if adequate social services or community 

health services are not available, prevention and follow-up care may be inadequate. 

European level action 

Several European initiatives have played a critical role in raising political awareness of the 

importance of heart disease over the past decade. From 1998 to 2002, the EU co-funded the 

European Heart Health Initiative, which aimed to improve heart health promotion in the European 

region by building networks and exchanging experiences. During the Irish Presidency of the EU in 

2004, the EU Council of Ministers the EU Council of Ministers adopted conclusions on promoting 

cardiovascular health recognising that cardiovascular disease is the greatest killer of men and 

women in the European Union. Two high level Ministerial Conferences were organised in Cork in 

partnership with the European Commission, the European Heart Network, the European Society of 

Cardiology with the participation of the World Health Organisation and the United States Department 

of Health and Human Services, which focused attention on this issue. 

The EU has also played an important role in raising heart disease in women to the political agenda. 

In 1997, a European Commission report identified gender differences in the diagnosis and treatment 

of CVD and called for better woman-based evidence of treatment outcomes. The European Heart 

Network devoted a 2002 issue of Heart Matters [26] to the topic of cardiovascular disease in women. 

This issue sparked off a number of national campaigns aimed at fighting heart disease in women. 




The EU is also helping to build a stronger evidence base on heart disease through the EUROCISS 

Project (European Cardiovascular Indicators Surveillance Set). Initiated in 2000, the project aims to 

develop health indicators and recommendations for the monitoring of cardiovascular diseases. Results 

will permit cross-country comparisons and may help improve prevention and control of CVD.[27] 

Finally, the EU has a vital role to play in health promotion. The new Public Health Framework 

presents a unique opportunity for Europe to adopt a strategic focus on key priorities which are 

integrated and mutually reinforcing. The recent WHO Framework Convention on Tobacco Control will 

hopefully encourage further European policy developments aimed at setting high public health 

standards across all European countries. 

National level action 

European policies and programmes may provide a helpful 

lead in raising awareness, however they must be 

accompanied by highly visible national campaigns to reach 

and sensitise the female population. 

Grassroots initiatives aimed at promoting healthy hearts for 

women have been implemented in a number of European 

countries.* In addition, the introduction of bans on smoking in 

the workplace in several countries has the potential to lead to 

long-term improvements in the heart health of women. 

Tips for campaign planners 

Useful experience has already been gathered by several 

organisations campaigning about CVD among women. Here 

are the main lessons: 

• People will listen to the logical arguments only if their 

emotions are engaged first. 

• Campaigns should be created for a specific audience. 

This audience needs to be clearly defined. 

• Changing behaviour is difficult, so choosing the right tone 

is crucial. For instance the Danish Heart Foundation’s 

advertising campaign used humour, because women 

would have rejected an authoritarian ‘finger-pointing’ 

approach. 

• Using relevant celebrities can make a strong impact on 

the audience and also helps interest the media. 

• Awareness and credibility are increased if the campaign 

associates with organisations familiar to the audience (for 

example, the Danish Heart Foundation’s collaboration with 

major trade unions). 

* Further information on national campaigns is available from national 

heart foundation websites. A list of relevant websites is available on 

the European Heart Network website, www.ehnheart.org. 

Example of a national campaign: 

the Danish Heart Foundation 

Denmark has a very high 

percentage of women at work 

(71%). It also has one of the 

highest rates of smoking in Europe 

(around 30% in women aged 

35–65). 

In 2003, the Danish Heart 

Foundation launched a campaign 

to raise awareness of the risks of 

heart disease amongst Danish 

women. 

The campaign was underpinned by 

the slogan Mind yourself, woman! 

It was targeted at working mothers 

who are subject to the double 

stress of work and home. The aim 

was to encourage them to take 

control of their risk factors, namely 

stress, poor diet, lack of exercise 

and smoking. 

The April edition of the 

Foundation’s member magazine 

(circulation 80,000) was devoted to 

CVD in women. ‘Heart tips’ were 

provided on websites. Anyone 

could arrange for tips to be 

emailed to them daily. 

Collaboration with third parties, for 

example one of Denmark’s largest 

trade unions, had a very positive 

impact on awareness. Local 

committees organised a series of 

events, including a skipping 

session for the Members of 

Parliament health committee. 




• The campaign should engage policymakers to create awareness of the need for policy solutions. 

• Healthcare professionals, families and volunteers can all help make sure the benefits outlive the 

campaign – but only if the campaign has informed and motivated them. 

Conclusions 

Cardiovascular disease is the largest killer of women in Europe. Yet awareness of its importance 

remains dismally low, both amongst women themselves as well as amongst the medical profession. 

CVD is largely preventable. By altering their lifestyles, women can reduce their risk of CVD 

dramatically. 

Evidence of the effectiveness of preventive and therapeutic approaches to target CVD is still lacking 

in women. There is an urgent need to build strong evidence derived from women to guide future 

practice. 

Cardiovascular services for women need to be culturally accessible, patient-centred, evidence-based 

and responsive to patient needs. 

The challenges of addressing the needs of very diverse epidemiological, cultural and political 

contexts in the 25 member states must not be underestimated. Sensitivity to potential cultural 

differences across EU states is key if European policies and programmes are to be equally effective 

across the region. 

It is also important to recognise challenges in the implementation of health policies. Workforce 

shortages, insufficient resources, lack of integration between primary and secondary care all plague 

health care systems to a greater or lesser extent. Strategic plans to improve the management of 

cardiovascular disease in women need to address these hurdles in proposals going forward. 

This report has been intended as a ‘call to action’ to women, policy-makers, physicians and society in 

general. All have a role to raise awareness of the importance of cardiovascular disease in women 

and to reduce the burden it is posing on women and society in general. 

Calls to action 

To women 

• It is essential that women become better aware of the risks of cardiovascular disease. 

Cardiovascular disease is the major cause of death for women. More women die of CVD than of 

all cancers combined. 

• Risk factors for cardiovascular disease are known and most of cardiovascular disease is 

preventable. By taking control of their lifestyles and habits, women may reduce their risk of 

cardiovascular disease significantly. 

• Women should discuss possible risk factors with their physician. 

To clinicians 

• Physicians treating women – gynaecologists, general practitioners, internists, geriatricians and 

other specialists – have an essential part to play in ensuring that women are made aware of 

cardiovascular disease risk factors, symptoms and outcomes. 




• Physicians and medical students need training and education on gender and other diversity 

issues related to research, diagnosis, treatment, prevention and rehabilitation. It is for example 

counterproductive to have medical textbooks showing exclusively male heart disease patients. 

• All clinicians should recognise the importance of cardiovascular disease for women and raise 

awareness of its importance within the medical and social care community. 

• All clinicians should be attuned to the differences in pathophysiology in cardiovascular disease 

between men and women. They should ensure that their female patients receive gender-sensitive 

information and are presented with appropriate treatment options. 

• It is important for treating physicians to recognize the limitations of the existing evidence base on 

cardiovascular disease in women and the implications of these gaps for clinical practice. 

Whenever possible, they should aim to base clinical decisions for their female patients on direct 

findings in women. It may be misleading to extrapolate results from male patients to women. 

• A gender impact assessment should be part of all clinical programmes. For example, cardiac 

rehabilitation programmes should be specifically tailored to the needs of women, as their 

adherence to these programs is poor compared that of men. 

To the research community 

• The research community may help raise awareness of the urgent need to conduct studies 

specifically designed to answer relevant questions for women. More studies that explicitly search 

for innovative and better treatments for women are also needed. Only these findings will allow us 

to determine what constitutes best practice for women. 

• The research community needs to embrace and actively support more female scientists in 

research, clinical and public health programmes in order to avoid an unbalanced and malecentred 

view. 

• Funding agencies may play an important role in making funding of clinical studies conditional on 

appropriate recruitment of women. 

• Clinical guidelines should continue to strive to account for differences in presentation and 

response profiles between men and women in order to provide the most specific guidance 

possible to practicing clinicians. 

To public health officials 

• Every effort should be made to target public health campaign messages directly at women. Only 

gender-sensitive campaigns may help achieve the same decreases in heart disease in women as 

have been observed in men. 

• One cannot simply assume that women will learn from campaigns targeted to men. Every effort 

should be made to involve women in the design and delivery of these campaigns. 

To EU policymakers 

• The EU has a growing role to play in setting standards for prevention, health promotion, and care 

for women at risk of cardiovascular disease throughout the EU. 

• The EU also may help by supporting research efforts to build the information base and in creating 

a network to share and exchange best practice between countries. 




To national health policymakers and managers: 

• Ultimately, it is at the national health system level that dedicated efforts and strategies are 

needed. It is essential to recognise that raising the standards of care for women with CVD will 

undoubtedly have short-term cost implications, however long-term costs of disability and 

premature mortality may be significantly reduced 

• Redressing existing inequalities will thus require dedicated strategies and policies, significant 

training and education, and adequate resources. 

• Finally, for any strategy aimed at improving women’s heart health to be effective, its goals need to 

be clear, working practices need to be aligned with these goals and services need to be 

developed which fit with, are sensitive to and learn from women’s lives as they are actually lived. 

References 

1. European Cardiovascular Disease Statistics, 2005 edition. British Heart Foundation and European 

Heart Network. 

2. World Health Organisation. The Atlas of Heart Disease and Stroke. WHO. 2004. 

]www.who.int/cardiovascular_diseases/resources/atlas/en/] 

3. Wenger NK. Preventive coronary interventions for women. Med Sci Sports Exerc. 1996;28:3–6. 

4. European Cardiovascular Disease Statistics 2005, based on data from the MONICA (monitoring 

trends and determinants in cardiovascular disease) registers of coronary events in 16 European 

countries. 

5. Mosca L, Ferris A, Fabunmi R, Robertson RM; American Heart Association. Tracking women's 

awareness of heart disease: an American Heart Association national study. Circulation 

2004;109:573–39. 

6. Wenger NK. Cardiovascular disease in the elderly. Curr Probl Cardiol 1992;17:609–90. 

7. Douglas PS, Ginsburg GS. The evaluation of chest pain in women. N Engl J Med 

1996;334:1311–15. 

8. Stramba-Badiale M, Bonazzi O, Casadei G, et al. Prevalence of episodes of ST-segment 

depression among mild-to-moderate hypertensive patients in northern Italy: the Cardioscreening 

Study. J Hypertens 1998;16:681–88. 

9. Kannel WB, Dannenberg AL, Abbott RD. Unrecognized myocardial infarction and hypertension: 

the Framingham Study. Am Heart J 1985;109:581–85. 

10. Aguilar MD, Lazaro P, Fitch K, Luengo S. gender differences in clinical status at time of coronary 

revascularization in Spain. J Epidemiol Community Health 2002;56:555–59. 

11. Shaw M, Maxwell R, Kees K, Ho D, Oliver S, Ben-Shlomo Y, Ebrahim S. Gender and age 

inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better? 

Social Science & Medicine 2004; 59:2499–507. 

12. Sullivan AK, Holdright DR, Wright CA, Sparrow JL, Cunningham D, Fox KM. Chest pain in 

women: clinical, investigative, and prognostic features. BMJ 1994;308:883–86. 




13. Miller TD, Roger VL, Milavetz JJ, Hopfenspirger MR, Milavetz DL, Hodge DO, Gibbons RJ. 

Assessment of the exercise electrocardiogram in women versus men using tomographic myocardial 

perfusion imaging as the reference standard. Am J Cardiol 2001;87:868–73. 

14. Glaser R, Herrmann HC, Murphy SA, Demopoulos LA, DiBattiste PM, Cannon CP, Braunwald E. 

Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA 

2002;288:3124–49. 

15. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, Aylward P, Topol 

EJ, Califf RM. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. 

Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb 

Investigators. N Engl J Med 1999;341:226–32. 

16. Willett WC, Green A, Stampfer MJ, et al. Relative and absolute excess risks of coronary heart 

disease among women who smoke cigarettes. N Engl J Med 1987;317:1303–9. 

17. WHO Global Burden of Illness, 1990. [www.who.int] 

18. American Heart Foundation, 2004. ]www.americanheart.org] 

19. Writing Group for the Women´s Health Initiative Investigators: Risks and benefits of estrogen plus 

progestin in healthy postmenopausal women. Principal results from the Women´s Health Initiative 

Randomized Controlled Trial. JAMA 2002;288:321–33. 

20. Manson JE, Hsia J, Johnson KC et al. Estrogen plus progestin and the risk of coronary heart 

disease. N Engl J Med 2003;349:523–34. 

21. European Heart Network. Children and young people – the importance of physical activity. 

December 2001. [www.ehnheart.org/files/phyactivity-084635A.pdf] 

22. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The 

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in 

high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium 

channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart 

Attack Trial (ALLHAT). JAMA 2002;288:2981–97. 

23. European Society of Cardiology. Guidelines for Cardiovascular Disease Prevention in Clinical 

Practice, 2003. [www.escardio.org/knowledge/guidelines/CVD_Prevention_in_Clinical_Practice.htm] 

24. Conroy RM, Pyorala K, Fitzgerlad AP, et al. on behalf of the SCORE project group. Estimation of 

ten-year risk of fatal cardiovascular diease in Europe: the SCORE project. Eur Heart J 

2003;24:987–1003. 

25. Brett J, personal communication, 2004. 

26. Heart Matters. Quarterly Bulletin of the European Heart Network. April 2002. 

[www.ehnheart.org/files/HM%205%20final-142113A.pdf] 

27. European Cardiovascular Indicators Surveillance Set (EUROCISS) Working Group. Coronary and 

cerebrovascular population-based registers in Europe: are morbidity indicators comparable? Results 

from the EUROCISS Project. Eur J Public Health 2003;13(3 Suppl):55–60. 




Health economics 

Bengt Jönsson 

Burden of CVD 

US data for the 2004 report direct health care cost of USD 227 billion and indirect costs of USD 142 

billion. A Swedish study of CHD, which represents about 60% of cost of CVD shows a total cost of 

SEK 178 million per 100,000 inhabitants, divided into SEK 82 million direct costs and SEK 96 million 

indirect cost. However, there is no comprehensive study available for Europe. 

Another way of looking at cost of CVD is to estimate the extra life time costs for the incidence. 

Birnbaum et al has studied life time medical cost for women due to CVD in the US. Total life time 

cost of CVD is USD 423,000 in 2002 prices. 

For strokes we have similar data from Sweden. The life time cost of a stroke is between EUR 40,000 

and 76,000 dependent on age. Costs are significantly higher for women than men. 

Cost drivers 

Both direct and indirect costs are important in CVD. A closer look at the direct health care costs 

reveal that hospitalisation still is the major cost driver both for CHD and for stroke. However, for 

strokes social service costs are very important as well, while indirect costs are of less importance 

due to the age distribution. 

Intervention and cost-effectiveness 

Over the last decades a number of new technologies have been introduced for prevention, treatment 

and rehabilitation of heart disease. I will focus on health economic aspects and in particular the 

evidence for cost-effectiveness. 

I will present three examples, illustrating important aspects of cost-effectiveness for women. The first 

example concerns primary prevention with lipid lower drugs, and the importance to adjust these 

criteria according to gender. Women have a lower risk, but when an event happens, the 

consequences in terms of loss of quality-adjusted life expectancy are greater. Thus the intervention 

threshold should be lower for women than men. A second example is from secondary prevention, 

using results from the CURE trial. Clinical trials usually do not include enough patients for a separate 

analysis of men and women. However, modelling can be used for studying the effect on women. It is 

shown that clopidogrel within and after acute coronary syndrome is a cost-effective intervention both 

for men and women, with and without PCI. The third example is from lipid lowering in secondary 

prevention, where the cost-effectiveness has been questioned for women. However, a differentiated 

analysis where cost-effectiveness is studied in relation to gender and total cholesterol at start, shows 

that this intervention is very cost-effective, also for young women with low cholesterol levels. 

Conclusion 

Studies on the cost of the disease, as well as the cost-effectiveness of interventions from a gender 

perspective can help us to provide guidance on how to use limited resources in an optimal way for 

the improvement of women’s health in Europe. 



Workshop 3a 

Private health insurance 

in OECD countries 




Summary 

Francesca Colombo 

Introduction 

Health spending in OECD countries averages more than 8% of gross domestic product (GDP) and 

the share is rising. Overall, some three-quarters of that spending is publicly financed. Private health 

insurance accounts, on average, for only a quarter of private-sector financing, although there is great 

cross-country variation. In a third of the OECD member countries at least 30% of the population has 

private health insurance, while market size is negligible in nearly as many countries. Private health 

insurance also plays a variety of roles, ranging from primary coverage for particular population 

groups to a supporting role for public systems. 

Policy attitudes towards private health insurance also vary. Some governments do not see private 

health insurance as an important or desirable component of their health systems. Others consider it 

to be a pillar of the health system. Governments look to private health insurance to supplement 

public financing, or in some cases to replace it, for a variety of reasons. It may simply be a matter of 

finding an alternative source of financing to increase the capacity of the health system, or a means to 

achieve other health policy goals, such as greater individual responsibility for health-care funding. 

Private health insurance can help governments attain health system performance goals, but can also 

put them at risk. The effect depends, in part, on the role of private health insurance, in terms of 

market size and function with respect to public systems. In countries where private health insurance 

plays a prominent role, it can be credited with injecting resources into health systems and helping to 

make them more responsive. However, it has also given rise to considerable equity and cost control 

challenges in most of those same countries. 

This Policy Brief looks at trends in private health insurance in OECD countries and at the 

opportunities and challenges created by these markets. It also depicts useful practices that can help 

policy makers employ private resources to help them achieve health policy goals. 

What is the role of private health insurance in OECD countries? 

In the United States, the Netherlands and Germany, private health insurance is a source of primary 

coverage for population groups without access to public health cover. Under the US system, in which 

public coverage through Medicare and Medicaid is restricted to the elderly, disabled and certain poor 

groups, 72% of the population has some form of private health insurance. In the Netherlands, nearly 

a third of the population – those in the upper-income bracket – is excluded from publicly funded 

insurance; almost all of those excluded buy private primary cover. Germany, on the other hand, is the 

only OECD country allowing individuals above an income threshold to opt out of social health 

insurance. 

In Australia, Ireland, New Zealand and the United Kingdom, where privately funded providers operate 

in parallel to the public delivery system, private health insurance duplicates existing public universal 

coverage, offering a private alternative. Nearly half of the Australian and Irish populations purchase a 

private health insurance policy, making these the largest duplicate markets across the OECD. 




Private health insurance also complements financing from public 

programmes in many OECD countries by covering cost sharing 

under those arrangements. This type of coverage predominates 

in France, where complementary insurance reaches over 90% of 

the population. In the United States, individuals eligible for 

Medicare can buy policies covering co-payments or other 

service gaps in the public programme. 

Finally, in many OECD countries private health insurance 

supplements public systems by financing goods and services 

that are excluded from public coverage. Private health insurance 

is purchased by 65% of the population in Canada, where the 

supplementary role is the sole permitted function of private 

health insurance in most provinces, while in the Netherlands 

nearly all of the population with social health insurance 

purchases supplementary insurance. In Switzerland, 80% of the 

population supplements basic mandatory health coverage with a 

voluntary private health insurance policy. 

The variety of roles and market sizes of private health insurance in OECD countries (see Table 1 on 

the next page) arises from several factors. Many countries with large markets have a tradition of 

private health financing and insurance markets. Statutory health coverage and delivery systems 

affect which services, providers and population groups private health insurance covers, and 

government attitudes towards private health insurance markets shape their structure and dimension. 

The presence of employer-based private health insurance often contributes to explain high levels of 

private coverage (as in the United States, Canada, and France). Consumer desire to obtain more 

and faster care, or the level of satisfaction with publicly funded services also influences demand for 

private health insurance. 

Does private health insurance improve access to care and cover? 

Types of private health 

insurance 

Private health insurance is 

used at different levels, and for 

different reasons, in individual 

OECD countries. 

In some countries it is the 

primary source of health 

coverage for at least part of the 

populations; in others it 

duplicates the public system, 

offering a private alternative; 

and finally it acts as a 

complement or supplement to 

public programmes. 

The contribution of private health insurance to improving access to health coverage and health care 

has varied depending on how large a private market has developed and how broad a pool of risks it 

covers. 

For example, private health insurance markets have not developed enough to provide significant 

financial protection in Korea, Mexico, Greece or Turkey, despite large gaps in the population or 

services covered by public systems. This could be the result of several factors, ranging from lack of a 

history of health insurance markets to premium affordability considerations. 

Even where private markets have developed, access to coverage remains a key challenge. Where 

private health insurance is under little or light regulation, higher-risk individuals have often faced 

difficulty in obtaining policies at an affordable price. Several OECD countries have introduced 

measures to promote availability and affordability of insurance, which apply either to the entire 

private health insurance market or to that part of it servicing high-risk groups. 

Clearly, when public cover is not comprehensive or universal, private health insurance has enhanced 

access to care. But such access is often inequitable, largely because private health insurance is 

typically purchased by high-income groups. 

In duplicate systems, for example, private health insurance provides a level of care, choice and 

speed of access above that offered by public systems, to those who can afford to pay for it. Privately 




Table 1 

PHI (% of total 

health expenditure) 

Population Types of private coverage 

covered by PHI (%) 

Australia 7.3 

44.9 

40.3 

Duplicate, Complementary, 

Supplementary 

Austria 7.2 

0.1 

31.8 

Primary (substitute) 

Complementary, Supplementary 

Belgium not available 57.5 Primary (principal), Complementary, Supplementary 

Canada 11.4 65* Supplementary 

Czech Republic 0* negligible Supplementary 

Denmark 1.6 28 (1998) Complementary, Supplementary 

Finland 2.6 10 Duplicate, Complementary, Supplementary 

France 12.7 92 Complementary, Supplementary 

Germany 12.6 

18.2 of which: 

9.1 

9.1 

Primary (substitute) 

Supplementary, Complementary 

Greece not available 10 Duplicate, Supplementary 

Hungary 0.2 negligible Supplementary 

Iceland 0* negligible Supplementary 

Ireland 7.6 43.8 Duplicate, Complementary, Supplementary 

Italy 0.9 15.6 (1999) Duplicate, Complementary, Supplementary 

Japan 0.3 negligible Not available 

Korea not available not available Supplementary 

Luxembourg 1.6 2.4 Complementary, Supplementary 

New Zealand 6.3 35 Duplicate, Complementary, Supplementary 

Norway 0* negligible Not available 

Mexico 2.5 (2001) 2.8 Duplicate, Supplementary 

Netherlands 15.2 

92 of which: 

28 

64* 

Primary (principal) 

Supplementary 

Poland not available negligible Supplementary 

Portugal 1.5 (1997) 14.8 Duplicate, Complementary, Supplementary 

Slovak Republic 0* negligible Supplementary 

Spain 3.9 

13 of which 

2.7 

10.3 

Primary (substitute, principal) 

Duplicate, Supplementary 

Sweden not available negligible Complementary, Supplementary 

Switzerland 10.5 80 Supplementary 

Turkey 0.7 (1994) < 2 Complementary, Supplementary 

United Kingdom 3.3 (1996) 10 Duplicate, Supplementary 

United States 35.1 71.9 Primary (principal), Supplementary, Complementary 

Notes: Negligible indicates a proportion covered of less than 1%; PHI = Private health insurance; * = estimate 

Source: OECD. Private Health Insurance in OECD countries, 2004. 




insured patients may benefit, in particular, by obtaining shorter waiting times for elective surgery. But 

there is no clear evidence that waiting times are also reduced in the public sector, the only choice for 

those on lower incomes. 

There are also equity issues arising from the fact that in some countries the private health-care 

sector pays providers more than they could earn in the public system. While this encourages high 

service volumes and productivity in the private sector, the quality and quantity of publicly financed 

services might suffer as a consequence, especially when providers’ responsibility and obligations to 

public patients are not clearly defined and monitored. To avoid such problems, policy makers in some 

systems have introduced regulations limiting the possibility for privately insured persons to enjoy a 

superior level of care and choice, as in the case of the Netherlands. This minimises the risk of 

creating two levels of health care according to insurance status and, therefore, ability to pay. 

Does it create more choice and responsiveness? 

Private health insurance has enhanced consumer choice and the responsiveness of health systems 

in many OECD countries. First, the opportunity to buy private health insurance in itself offers 

consumers an additional level of choice with respect to financing health-care services and providers 

on an out-of-pocket basis. Second, private health insurance has improved individuals’ choice over 

health providers and timing of care in most countries with duplicate markets – although the scope of 

this added choice depends upon the freedom of choice already existing within public systems. Third, 

most private health insurance markets offer a wide array of products to consumers, allowing them to 

tailor their risk and product preferences. 

Clearly, for consumers to exercise meaningful choice, insurers’ marketing and product information 

materials need to be clear and enable comparisons across the market. Consumers have complained 

about the quality of product information at the point of sale in some countries. Governments or 

private organisations have intervened by disseminating comparative information on the quality, 

features and cost of health plans in some countries, such as the United States and Switzerland. 

But an abundance of product choices can make it harder for higher-risk patients to find cover, to the 

extent it results in segregation of the market by risk level. To avoid the problem of vulnerable groups 

being priced out of the private health insurance market, as has occurred in some OECD countries, 

some policy makers have limited the scope for insurers’ flexibility and innovation. For example, they 

have regulated the minimum benefits that insurers must cover, required insurance products to be 

standardised, or limited the extent to which insurers can refuse cover and rate premiums on the 

basis of individual risk. 

Does private health insurance promote high-quality care? 

Private health insurance has had only a minimal impact on the quality of care in most OECD 

countries, since private insurers have not usually engaged in significant efforts to influence the 

quality of the services they finance. The lack of effort is due to a combination of factors, ranging from 

lack of regulatory and financial incentives for insurers, to a desire not to restrict individual choice, as 

well as resistance from health-care providers to the introduction of a new source of influence on 

decisions over appropriateness of care. 

The United States has been the only OECD country where some private insurers, known as 

managed care plans, have been substantially involved in efforts to influence some aspects of care 

delivery. Despite indications of some effectiveness, the overall evidence of the impact on quality of 

care is mixed: such plans do not appear to have fundamentally changed clinical processes. Payment 

incentives that do not consistently reward plans’ or employers’ efforts to improve quality and 




inadequate quality-measurement and reporting systems, explain the still small and non-systematic 

impact of private health insurance on quality improvements in the United States. 

Has it helped relieve cost pressures? 

Policy makers often look to private health insurance markets as an alternative or additional source of 

funding for publicly financed health systems, especially when these budgets are stretched to 

capacity. Yet health systems in OECD countries continue to be predominantly financed from public 

sources, which account, on average, for 72% of total health expenditure, compared to 6.3% for 

private health insurance and 19% for out-of-pocket payments. Only in the United States does private 

health insurance exceed a third of total health expenditure, at 35%, while it goes above 10% only in 

the Netherlands, Canada, France, Germany and Switzerland (Figure 1). 

Figure 1: Health expenditure by source of finance, 2000 

100% 

Public expenditure on health Private health insurance All other private funds Out-of-pocket payments 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

15 

35 

44 

9 

15 

63 

United States 

Netherlands 

10 

13 

76 

France 

11 

13 

75 

Germany 

16 

11 

71 

Canada 

33 

11 

56 

Switzerland 

14 

8 

73 

Ireland 

19 

7 

69 

Australia 

19 

7 

69 

Austria 

Source: OECD Health Data, 2003, 2nd Edition. 

15 

78 

New Zealand 

24 

72 

Whatever the role played in a health system, private health insurance has added to total health 

expenditure. Most OECD countries apply less government control over private sector activities and 

prices, compared to public programmes and providers. Private insurers tend to have less bargaining 

power over the price and quantity of care as compared with public systems, particularly single-payer 

ones. Countries that have multiple sources of primary coverage, including those with significant 

private health insurance market size, tend to be those with the highest total health spending levels 

per capita, such as the United States, Switzerland, Germany and France. 


Global Health Challenges: European approaches and responsibilities 378 

20 

75 

8 

88 

16 

83 

23 

Spain 

Finland 

Luxembourg 

Denmark 

Italy 

Mexico 

Japan 

Hungary 

Iceland 

Czech Republic 

Note: Countries are ranked by decreasing size of private health insurance. 

73 

52 

48 

17 

78 

21 

76 

16 

84 

9 

91 

11 

89 

Slovak Republic 

14 

85 

Norway


Has private health insurance shifted cost from public systems? 

There are a number of reasons why private health insurance has not significantly reduced public 

financing burdens. For one thing, people with private insurance often continue to rely upon publicly 

financed hospital services in duplicate markets. Privately financed hospitals have often focussed on a 

limited range of elective services, leaving the responsibility for more expensive services or 

populations to public programmes. 

Second, in OECD countries that have restricted eligibility for public insurance to lower-income and 

vulnerable groups, leaving the rest to buy primary private health insurance (the United States, the 

Netherlands, Germany), public spending on health as a percentage of GDP is not lower than that of 

many countries that provide universal public coverage (Figure 2). This can be partly explained by the 

concentration of health-care cost among a small fraction of the population that is generally publicly 

insured – such as the elderly, chronically ill, and long-term disabled. 

Third, de-listing of services from public coverage, another strategy to shift cost onto the private 

sector, has generally remained confined to less expensive services, which may be paid for out-ofpocket 

or through supplementary private health insurance policies. 

In some cases, private health insurance has actually added to public expenditure on health or public 

costs generally. Where private health insurance covers cost sharing on public coverage systems, as 

in France, the resulting increases in use of services raise the cost of publicly financed health 

systems. In addition, countries that grant significant public subsidies to private health insurance, as 

Australia and the United States, have seen a reduction in government revenue or an increase in 

public cost. 

Figure 2: Public and private health spending as a share of GDP and expenditure financed 

by private health insurance, 2000 

% 

40 

35 

30 

25 

20 

15 

Public expenditure on health (% GDP) Private expenditure on health (% GDP) 

7.9 7.8 

7.1 6.9 6.5 6.5 6.5 6.1 6 6 5.9 5.8 

10 

7.3 

6.2 

5.5 5.4 5.3 5.1 5.1 5 4.9 4.7 

5.9 

5 

4.7 

2.9 

2.6 2.3 

2.7 2.8 

3.2 

2.7 

1.5 

2.2 

2.4 

1.8 1.7 

2.1 

1.6 1.7 

2.3 

1.5 

1.7 

0.6 1.1 

0.6 

0.6 

0 

Norway 

Czech Republic 

Denmark 

France 

Iceland 

Germany 

Canada 

Source: OECD Health Data, 2003, 2nd Edition. 

Spain 

Austria 

Netherlands 

United States 

Switzerland 

Italy 

Japan 

Australia 

New Zealand 

Private health insurance (% of total expenditure on health) 

Finland 

Hungary 

Slovak Republic 

OECD Average 

Mexico 

Ireland 

Luxembourg 




Does private health insurance make health systems more efficient? 

While private health insurance is often viewed as a tool to enhance efficiency, the evidence shows it 

has made only a small contribution so far. Several reasons explain this performance. Insurers need 

to sustain high administrative costs in order to attract and retain clients, provide them with a diversity 

of insurance plans, and negotiate multiple contractual relationships with providers. Furthermore, in 

several OECD countries, insurers have had few incentives to manage care cost-effectively, due to a 

combination of desire not to restrict individual choice, providers’ resistance, and the cost of 

implementing such action. 

Difficulties in extracting efficiency improvements from private health insurance markets can also 

come from the way in which insurers compete. In several OECD countries, insurers are confronted 

with limited competitive pressures as there is little consumer mobility across insurers. It is attractive 

for insurers to employ cost-shifting and selection of risk as a means of insurer competition and 

protection against adverse selection, rather then improving the cost-effectiveness of care provided to 

clients. Finally, the lack of ‘vibrant’ price and quality competition among providers inhibits market 

forces in insurance markets, for example if providers exercise dominant market power, leading them 

to demand high prices for health services and shielding them from insurers’ pressure to improve 

quality or cost-effectiveness of care. 

How can policy makers use private health insurance to improve performance? 

A system based on competing primary insurers can improve responsiveness and consumer choice, 

but at increased cost. Where private health insurance is the primary source of coverage for certain 

population groups, it may be particularly challenging to assure adequate access to coverage for 

vulnerable populations. Regulations to address market failures and promote equity have costs, in 

terms of government resources and diminished insurer flexibility to innovate. 

Duplicate private health insurance markets can serve as a lever to improve systems’ responsiveness 

when policy makers consider it appropriate to ration public health expenditure according to 

individuals’ willingness to pay. Yet this generally results in differences in access to care and coverage 

according to insurance status. The degree of differential access that occurs, and the extent to which 

these access variations are considered equity challenges vary by country. In addition, duplicate 

private health insurance has not significantly reduced public health expenditure. 

In the presence of significant cost sharing within public systems, complementary private health 

insurance helps ensure access to needed care. However, full private coverage of such cost sharing 

encourages insured individuals and providers to increase utilisation. Unless some cost sharing is 

retained to encourage individual cost awareness, private health insurance hinders efforts to control 

public systems’ outlays. 

Finally, supplementary coverage provides individuals with an opportunity to buy financial protection 

against risks associated with services not covered by public programmes. Removing public sector 

coverage of some health services helps reduce public expenditure. However when utilisation of 

supplementary services is linked to publicly financed services, this increases public costs. As private 

health insurance markets generally have less comprehensive reach than does public coverage, 

decisions to de-list services need also to weigh the desired reductions in public sector cost against 

the equity implications of lack of public coverage. 

Policy makers have a number of tools at their disposal to address these challenges. 

• Access-related standards help to promote insurance coverage for high-risk persons and may be 

particularly useful in primary private health insurance markets. The need for these interventions 




often depends on the comprehensiveness of the benefits they apply to, and the extent to which 

the costs of any high-risk coverage are cross-subsidised by other private insurees or by other 

financing sources. If publicly funded systems provide adequate access to needed health services, 

policy makers may question the need for such interventions in their markets. 

• Although private health insurance can create disparities in access to health care between those 

with and those without private cover, policy makers can intervene by regulating the roles that 

private insurance is allowed to have; regulating price differentials between publicly and privately 

financed medical practice; specifying providers’ obligation to public patients and monitoring 

compliance with those obligations. 

• Maintaining at least some modest cost sharing in public systems that cannot be insured against 

helps to minimise undesired cost consequences of complementary private health insurance. 

• Policy makers can maximise effective choice within private health insurance markets by fostering 

readily understood comparative information and product disclosure requirements. Some limits on 

benefit packages may be appropriate, particularly if products are sold to vulnerable population 

groups. Yet, benefit standardisation reduces insurers’ ability to innovate and tailor products to 

individuals’ demands. 

• Policy makers can maximise cost shifting between the public and private sector by encouraging 

private insurees not to rely on public systems for privately covered services. They also need to 

assess whether subsidies towards private markets are self-financing and appropriate by weighing 

carefully their cost and benefit. Applying cost-control measures within the overall health system, 

including the private sector, improves the ability to control cost within private markets. 

• Incentives or regulatory requirements might facilitate efforts to improve cost-effectiveness of care. 

Examples include removing insurers’ obligations to contract with all providers, or providing 

incentives for insurers to be involved in preventative care or care management. Improved 

consumer information could facilitate effective competition among insurers. Systems to 

compensate insurers with a worse risk structure can help reduce insurers’ incentives to select 

good risks, thus promoting equitable risk pooling. However, they can also reduce or remove 

incentives for insurers’ efficiency. 

Bibliography 

Private Health Insurance in OECD Countries, OECD, 2004. ISBN: 9264015639. 

Towards High-Performing Health Systems, OECD, 2004. ISBN: 9264015558. 

Towards High-Performing Health Systems –Policy Studies, OECD, 2004. ISBN: 9264015590. 

Colombo F, Tapay N. Private Health Insurance in OECD Countries: The Benefits and Costs for 

Individuals and Health Systems. OECD Health Working Papers No.15. 

[www.oecd.org/els/health/workingpapers] 

BuchmuellerTC, Couffinhal A. Private Health Insurance in France. OECD Health Working Papers No. 

12, 2004. [www.oecd.org/els/health/workingpapers] 

Colombo F, Tapay N. The Slovak Insurance System and the Potential Role for Private Health 

Insurance. Policy Challenges. OECD Health Working Papers No. 11, 2004. 

[www.oecd.org/els/health/workingpapers] 




Colombo F, Tapay N. Private Health Insurance in Ireland. A Case Study. OECD Health Working 

Papers No. 10, 2004. ]www.oecd.org/els/health/workingpapers] 

Colombo F, Tapay N. Private Health Insurance in Australia. A Case Study. OECD Health Working 

Papers No. 8, 2003. ]www.oecd.org/els/health/workingpapers] 

Colombo F, Tapay N. Private Health Insurance in the Netherlands. A Case Study. OECD Health 

Working Papers No. 18, 2003. [www.oecd.org/els/health/workingpapers] 

More information on private health insurance is available at: www.oecd.org/health, by clicking on 

‘OECD Health Project’ and then on the ‘OECD Study on Private Health Insurance’. 



Workshop 4a 

Survey of Health, Ageing 

and Retirement in Europe 

(SHARE) 




��Oliver Lipps Combining interdisciplinary information on 385 

ageing problems in Europe (abstract) 

��Rudolf Winter-Ebmer Health and health care ccross European countries 386 

(abstract) 

Page 




Combining interdisciplinary information on ageing problems in 

Europe 

Oliver Lipps 

Abstract 

Population ageing is one of the largest social and economic challenges of the 21st century in 

Europe. However, even basic information about the economic, social, and health situation of the 

elderly is often still missing. The EU-sponsored ‘Survey of Health, Ageing and Retirement in Europe’ 

(SHARE) aims to create a pan-European interdisciplinary panel data set covering persons aged 50 

and over. The collected data include information on economics, physical and mental health (including 

‘objective’ measures from physical tests), and social aspects. Project participants are currently 

eleven countries ranging from Scandinavia (Denmark, Sweden), Western and Central Europe 

(Austria, Belgium, Germany, France, The Netherlands, Switzerland) to the Mediterranean (Greece, 

Italy, Spain). To ensure strict comparability the survey has followed a common set-up across all 

countries. 

In the workshop, we detail the background of the project, and stress its scientific potential as well as 

its policy relevance. We describe the development process of SHARE in the eleven participating 

countries. Due to the cross-national, longitudinal and multi-disciplinary nature of the project, both, the 

development of the instrument and the actual data collection, have been major organisational tasks 

characterised by an exceptionally high degree of complexity. Last, we present first results, mainly 

from the fieldwork process. 




Health and health care across European countries 

Rudolf Winter-Ebmer 

Abstract 

Comparable data on health and health care across European countries is difficult to get. The Survey 

on Health, Ageing and Retirement in Europe (SHARE) provides such information in a representative 

and comparable way for citizens above 50 years of age. In this presentation I will focus on 

preliminary results from the first wave of the survey. Whereas self-reported general health questions 

as well as those for long-standing illnesses and disabilities often have problems with subjective 

assessments, we provide also other – more objective – health measures: grip strength and walking 

speed, which should be more comparable across countries. Together with information on health care 

and financial and family situation, these health data can be used to assess socioeconomic health 

risks as well as coping strategies in different social groups. 



Workshop 5a 

Improving health literacy 

in the European Union: 

Towards a Europe of informed and 

active citizens 




��Karl Krajic Summary report 389 

��Ilona Kickbusch Annex and figures 397 

Page 




Summary report 

Karl Krajic 

Introduction 

The World Health Organization (WHO) defines health literacy as “the cognitive and social skills and 

ability of individuals to gain access to, understand and use, information in ways which promote and 

maintain good health.” An individual who is health literate has the knowledge, skills and confidence 

to manage his or her own health on a daily basis. This includes making healthy choices and being 

able to navigate the health care system in order to make the best use of health services. This also 

means being empowered to actively communicate health needs and participate with health 

professionals in the process of improving health. Empowerment, an educational process designed to 

help patients develop the knowledge, skills, attitudes and a degree of self-awareness necessary to 

effectively assume responsibility for their health-related decisions, is a key element of health literacy. 

The notion of health literacy extends beyond the health care system into everyday life. Health literate 

individuals have the knowledge and ability to make healthy choices and adopt healthy lifestyles. They 

are able to actively address determinants of health, either individually or through community action. 

Health literacy is becoming increasingly important for social, economic and health development – it is 

an essential form of literacy in modern societies. 

The aim of the workshop that took place during the European Health Forum in Bad Gastein on 8 

October 2004 was to underline the importance of health literacy as a key component and integrative 

element of a modern European health policy and health information strategy. 

The workshop’s panel brought together experts of various key perspectives with respect to health 

literacy: 

• Citizens, who need to navigate health information and health care systems. 

• health care professionals, who need to interact with informed and health literate patients. 

• Health insurers, who need to interface with informed and health literate consumers. 

• Policy makers, who wish to empower individuals and communities to take decisions that improve 

health. 

• Academics, who wish to gain a better understanding of the determinants of health and the 

interface between literacy and health. 

The panel discussed why health literacy is important; what knowledge and experience with respect to 

health literacy exist (in the different disciplines represented in the panel); and how health literacy can 

be improved. Inputs from the panel stimulated a lively discussion which underlined that health literacy 

is an important issue which should be moved to the centre of health policy in Europe, both at national 

and at EU level. 




Executive summary and conclusions 

Aim of the workshop 

The aim of the workshop was to underline the importance of health literacy as a key component and 

integrative element of a modern European health policy and health information strategy, including 

European initiatives on life-long learning. 

Definition of health literacy 

The World Health Organisation defines health literacy as “the cognitive and social skills and ability of 

individuals to gain access to, understand and use, information in ways which promote and maintain 

good health.” 

Health literacy and current policy initiatives 

Health literacy is in line with EU health initiatives, such as the health information strand in the 

European Public Health Programme. Health literacy could also contribute to other European policy 

areas, as it has an impact not only on quality of life but also on wealth and development. 

Economic aspects 

Health literacy has a strong economic aspect. A low level of health literacy can, for example, reduce 

effectiveness and efficiency of health care interventions, lead to insufficient or wrong use of the 

health care system and increase the likelihood of unhealthy lifestyles. 

Different perspectives, Common conclusions 

There are different perspectives and approaches with respect to health literacy. However, there seem 

to be common points and conclusions: 

• Research seems to confirm a strong relationship between health literacy and health outcomes. 

However, a better understanding of this relationship needs to be developed. 

• More research into health literacy is needed (in particular to establish measurement systems). 

• Health literacy should be included as a priority in relevant policy areas, such as health, social 

affairs and education, at EU and national level. 

• Efforts in relation to health literacy should include a strong focus on population groups vulnerable 

to social exclusion (e.g. migrants). 

• Health literacy should include an alliance of different stakeholders. Awareness on health literacy 

should be raised among policy-makers. 

Summary of workshop contributions 

What is health literacy and why is it Important? Jürgen Pelikan 

Professor Jürgen Pelikan, who chaired the workshop, analysed health literacy from a health science, 

public health and sociology perspective as a key determinant of health behaviour. He stressed that 

health will become even more important to individuals and to society in the future due to macrotrends 

such as globalisation and individualization. 




Professor Pelikan outlined some arguments explaining why health literacy is of special interest to 

stakeholders involved in European health policy. 

They included the arguments, that health literacy: 

• can be measured; 

• can be directly influenced, and; 

• affects health care, public health and society at large. 

Health literacy is a crucial factor in most health care interventions (for example, prescription of 

medicines), co-determining their outcome and effectiveness and the efficiency of health care 

systems. 

In most European countries health literacy does not seem to be as well understood and as high on 

the health policy agenda as needed. 

Contribution of Ilona Kickbusch 

Dr Kickbusch gave the introduction on the topic of health literacy. As an international expert, she 

addressed the key questions and issues in relation to this topic. 

Definition of health literacy The World Health Organisation defines health literacy as; “the cognitive 

and social skills and ability of individuals to gain access to, understand and use information in ways 

which promote and maintain good health.” 

European health society Health literacy skills are important in a complex European society in which 

health is increasingly considered important. Health literacy is relevant for all EU citizens, it is of high 

relevance, for migrants both from inside and outside the European Union, and in the EU’s immediate 

environment (for example, the growing AIDS epidemic in Russia has a potential impact on health in 

Europe). 

Relevant EU policy initiatives Potential links can be found between health literacy and existing EU 

health initiatives, such as the health information strand in the European Public Health Programme 

and the EU’s Information Society and e-health activities. Health literacy could also contribute to other 

European policy areas, as it has an impact not only on the quality of life but also on wealth and 

social development. Unfortunately some important EU policy areas, such as education and lifelong 

learning, which do not make any reference to health literacy. 

Key aspects of health literacy Health literacy is more than simply a new label for health information 

or education. Literacy includes ‘applying knowledge’. Health literacy is an empowerment concept, 

referring to an active process and implies health improvement and maintenance. It does not only 

concern healthy behaviour and lifestyle, but also co-operation in health care and citizen and patient 

rights, both of which are of critical importance in health literacy. 

Development of health literacy Health literacy can be developed not only through the health care 

system, but also through structures such as educational systems, the mass media, patient 

organizations and self-help groups. 

Health promotion Health literacy can be used to measure the outcome of health promotion activities. 

Economic aspects Health literacy has a strong economic aspect. A low level of health literacy can, 

in some cases lead to the wrong use of the health care system, reduce effectiveness and efficiency 

of health care interventions or increase the likelihood of unhealthy lifestyles. 




Summary of the debate 

Differences: health literacy and health information and education 

The difference between health literacy and traditional health information and education needs to be 

better clarified. The following factors distinguish health literacy from traditional health information and 

education concepts: 

• Health education is a technology, an intervention. 

• Health literacy is an intermediate health promotion outcome. 

• Health literacy can be considered ‘social and human capital’ and not the result of one single 

intervention (for example, health education), but of many processes. 

Different perspectives 

Political perspective: health literacy seems to focus empowerment activities on changes of individual 

skills. The need to address health determinants must be highlighted and the aspect of ‘rights’ should 

be taken into account. 

Scientific perspective: there should be clear arguments why there is a need for a new concept and 

why this should be researched. 

Panel Discussion 

A user’s perspective – Peggy Maguire 

From the perspective of the user, the following aspects are of particular relevance: 

• In order to take responsibility for their own health and to be able to make confident and healthy 

lifestyle choices, people need access to knowledge, skills and tools. 

• In case of sickness, people need to be able to navigate increasingly complex health care 

systems, to understand medical advice and to actively participate in processes creating health. 

• Health information and education should cover the entire lifespan: from children and teenagers to 

the elderly. Health information and education should be part of the ‘lifelong learning process’. 

• Health literacy can be a ‘hidden problem’ as it is often not recognised by policy-makers and health 

care providers. 

The Cancer Information Project of the European Institute of Women’s Health is one example of a 

‘users’ perspective approach’ aiming to provide information relevant for action. Recommendations 

based on experiences resulting from the Cancer Information Project are: 

• More (multidisciplinary) research into health literacy is needed (funds should be made available 

for this). 

• Creative approaches to communicate health information should be explored, using print, 

electronic materials and media. 

• Simple user-friendly information should be used. 

• All stakeholders should be involved. 




A health policy perspective – Sunjai Gupta 

Dr Gupta underlined the multidimensionality of health literacy, including: 

• Understanding and acting upon information: the capacity of individuals to look after their health in 

partnership with health professionals. This approach is very similar to ‘self-efficacy’ and relevant, 

for example, for successful self-management of chronic diseases. 

• Empowerment of people in order to enable them to make the right choices and to self-regulate 

lifestyle and behaviour (as outlined in the UK public health White Paper ‘Choosing Health?’ issued 

in 2004). 

• Acting on wider determinants of health (for example, community development). 

• Health literacy as an all-embracing concept which encompasses successfully navigating the 

health system, primary prevention and dealing with the wider determinants of health. In this 

respect, health literacy is about having skills for health and for life in general. 

The ‘Skilled for Health’ project was launched in the UK in January 2003, aiming to improve health 

literacy amongst the more deprived sections of the population. The project showed great willingness 

on behalf of the groups involved to share experiences. The upcoming UK Presidency of the EU will 

be an opportunity to further develop and exchange ideas on health literacy as empowering 

individuals and reducing health inequalities is among the UK’s key priorities in the area of health 

during its Presidency term. 

A health insurer’s perspective – Ann Broekhoven 

Why health insurers should be concerned about low (health) literacy: 

• General literacy levels are much lower than we usually think: one out of four people in Ireland 

commands a low literacy level and is not able to read information on medicinal products. It seems 

that in too many cases the (written) information available is not culturally adequate. 

• Health policy initiatives in Ireland have tried to address the issue: a series of projects were 

initiated aiming to develop adequate written materials. 

• There are genuine concerns with respect to direct interaction between health care professionals 

and their patients: professionals have a general tendency not to take into account any difficulties 

the ‘client’ may have to understand the information communicated. 

• Professionals generally seem to work in their own ‘system’, trying to keep up with constant 

changes, dealing with difficult problems and situations such as communicating bad news. 

However, some professionals have acknowledged that they have to invest in health literacy as a 

key determinant of health. 

• Health insurers are in a unique position to promote best practice by means of introducing 

incentives for health care providers to deliver high quality and cost effective care. In this respect, 

providers could be stimulated to include elements related to health literacy in items such as 

clinical protocols, quality standards, service level agreements and customer charters. 

A clinician’s and clinical researcher’s perspective – Michael Pignone 

There are still many challenges in health literacy research. On the basis of extensive literature 




review, Dr Pignone reported: 

• So far, there are no adequate measures for the broad concept of health literacy, for using it as an 

outcome variable in research. 

• Most of the research in the US focuses on functional literacy and on reading ability. There are 

strong relationships between low literacy and negative health outcomes. However, it is difficult to 

clarify or analyse confounding variables such as education. In addition, it needs to be recognised 

that the relationship between health knowledge and health outcomes is at best indirect. 

• Only few studies have tried to evaluate health effects of (narrow) literacy interventions. 

• Disease management studies indicate that health outcomes are in particular negative if low 

literacy is combined with a bad quality system that does not work properly. Under these conditions 

people with high literacy seem to get by, while those with low literacy do not. People with low 

literacy seem to profit most from an improvement of the system. 

• The question of whether self-efficacy as a core concept serves the same purposes as health 

literacy, still needs to be clarified. 

• In general there seems to be a considerable need for more research on health literacy. Europe 

could exploit its wealth of different systems in conducting this research. 

A health promotion/health science perspective – Doris E Gillis 

The following experience from Canada was shared: 

• Under the heading ‘health and literacy’ a considerable amount of research, policy and resource 

development has taken place over the last years in Canada. 

• Research underscores the correlation between low literacy levels and poor health outcome. 

• National health policy has put the issue on the agenda with the establishment of a national 

literacy and health office and a series of activities (e.g. conferences, etc.). 

• Currently, a national agenda is being developed through the Literacy and Health Research 

project. 

• Action related to health and literacy is not restricted to research and policy-making at a national 

level: research projects and other activities have been initiated at local level (for example, in Nova 

Scotia). 

• One of the outcomes of the Literacy and Health Research project is a broad, political definition of 

health literacy, defining the concept as “an action-oriented framework” including issues related to 

items such as access to services, the application of health information, informed health decisions, 

advocacy for well-being and control over health determinants. 

The following conclusions and recommendations can be drawn from the Canadian experiences: 

• There is a need for further research in order to clarify the concept under question and to build 

evidence. 

• There should be education programmes for practitioners (in order to improve quality of practice). 




• Programmes should be developed that address health literacy for specific population groups. 

• Awareness on health literacy should be raised among health policy makers. 

• Inter-organisational and inter-sectoral co-operation should be strengthened. 

Summary of debate 

Research vs. social development approach 

Several contributions to the discussion focused on the health literacy concept. From a scientific and 

research perspective, there seem to be arguments for a narrow, clear and measurable concept that 

would enable the development of common instruments, comparisons of measurements and the 

development of theories. However, from a social development perspective, a broad ‘umbrella 

concept’ containing visionary, as well as goal-oriented, elements could be preferred. 

Political perspective 

From a political perspective, the following points were raised: 

• Health literacy is an essential tool for the empowerment of patients by increasing literacy levels 

and by enabling patients to put knowledge into practice. 

• Health literacy is especially important for marginalized population groups. However, it can be 

difficult to reach these groups. 

• Health literacy should involve different policy areas and stakeholders, (for example, health and 

other policy areas, the media, and the pharmaceutical industry): health literacy as a ‘composite 

approach’. 

• A broad concept of health literacy will be needed in order to form alliances and to build networks 

and systems. 

• It will be important to be careful when using the term ‘literacy’, given related sensitivities (nobody 

wants to be considered illiterate). 

Research perspective 

From a research perspective, the following points were raised: 

• Problems of measurement (literacy measured by an English language instrument). 

• Literacy should not be measured by measuring knowledge. 

• Research in India shows a positive relationship between heart disease and literacy. The question 

is how this relationship can be explained. 

• A possible outcome of health literacy could be the increase of life expectancy. Treatment 

adherence (compliance) could perhaps be an intermediate indicator for health care. 

• There could be a positive role for health care companies and health care providers that invest in 

health literacy. 

• Research needs to identify and evaluate the components of the composite health literacy 




approach (for example, literacy, knowledge, self-esteem and self-efficacy). 

Suggestions for actions at EU level 

• Patients would like to see action with respect to health literacy. One practical action could be the 

publication of health literacy guidelines on websites. 

• EU health and research programmes should prioritise problems with an important patient 

empowerment aspect and a strong potential impact on life expectancy, such as obesity. 

• Efforts in relation to health literacy should include a strong focus on population groups vulnerable 

to social exclusion (for example, migrants). 

• The European Commission’s departments (Directorates General) dealing with relevant policy 

areas such as health, education and social affairs should collaborate in order to improve health 

literacy in Europe. 

• Further clarification of the meaning of health literacy in Europe is needed, also given cultural 

differences in meaning in Europe. In order to achieve this, research and discussion between 

different stakeholders should be stimulated. 




Annex 

Ilona Kickbusch 

Introduction 

Advancements in public health have transformed Europe. The member states of the European Union 

(EU) for the most part have become, or are on their way to becoming, ‘health societies’, defined by 

six dimensions: 

• A high life expectancy and ageing populations 

• An expansive health and medical care system 

• A rapidly growing private health market 

• Health as a dominant theme in social and political discourse 

• Health as a major personal goal in life 

• Health as a right of citizenship 

Health is a co-produced good – and in a health society, access to health information and utilization of 

health knowledge play a crucial role for the fulfillment of personal and societal expectations and for 

enabling citizens to make healthy choices. Within the EU this is expressed in two major policy 

initiatives: 

• the Public Health Framework Programme,[1] with the aim to provide an integrated approach to 

protecting and promoting health, puts a special emphasis on the dissemination of information and 

knowledge; and 

• the initiative on the Information Society includes as one of its key strategic areas the development 

of new e-Health possibilities “for almost every aspect of health care, from making medical care 

systems more powerful to providing better health information to everyone.”[2] 

Both of these policy initiatives put the active European citizen central to their deliberations on health 

with the intent to empower communities, consumers and patients. Indeed it is proposed to put all EU 

policies in the service of good health – as recently expressed by Commissioner David Byrne – as an 

effort to bring Europe closer to its citizens, improve the quality of life and help bridge gaps of inequity 

and participation. Access to health information is on a par with access to health care: it is considered 

a right of citizenship. In a Europe of the future, “Everybody has easy and prompt access to affordable, 

high quality health care – whoever and wherever they are…people will have no trouble finding clear 

and reliable information on how to be in good health and about diseases and treatment options.” [3, 

p.10] European Ministers have asserted that the needs of EU citizens must be the centre of attention 

in the development of high quality health-related information services and that the widespread 

availability of high quality health information creates the potential for citizen empowerment.[4] 

One way to capture this new central policy component that combines health knowledge with health 

action is the concept of health literacy. Health literacy will need to become a key literacy in European 

society. “Literacy is part and parcel of the pursuit of freedom, itself a central tenet of 

development…”[5, p. 209] Health literacy is at least as important and economically relevant as basic 

literacy, digital literacy and information society literacy (which are the three types of literacy 




emphasized by the European Commission’s policy area on Lifelong Learning in ‘Making a European 

Area of Lifelong Learning a Reality’.[6]). 

What is health literacy? 

The World Health Organization (WHO) has defined health literacy as “the cognitive and social skills 

and ability of individuals to gain access to, understand and use information in ways which promote 

and maintain good health.”[7, p. 10] An individual who is health literate has the knowledge, skills and 

confidence to manage health on a daily basis. This includes being able to know when to enter the 

health care system and how to navigate through it in order to make the best use of health services. It 

means understanding doctor advice and also being empowered to actively participate with health 

professionals in the process of creating health. Empowerment, an educational process designed to 

help patients develop the knowledge, skills, attitudes and degree of self-awareness necessary to 

effectively assume responsibility for their health-related decisions,[8] is a key element of health 

literacy. “To have the capacity to exercise greater control over their health, people need information, 

knowledge and understanding. This gives confidence and a will to assert control.” [9, p. 43] Health 

literacy also includes understanding one’s right in relation to health and the health care system, and 

it enables patients to understand and act in their own interest. 

The notion of health literacy also extends beyond the health system. Health literate individuals have 

the knowledge and ability to make healthy choices and adopt healthy lifestyles. They employ health 

skills, which are a subset of their life skills. A recent report by the National Consumer Council in the 

UK summarizes the key skills of health literacy as (1) navigating health care systems, (2) engaging in 

self-care and (3) participating in decision-making – and doing all of these with self-confidence.[9] 

Those who are health literate are also able to take an active role in addressing determinants of 

health. Health literacy is becoming increasingly important for social, economic and health 

development.[10] 

Three domains of health literacy, as put forward by Don Nutbeam, include functional, interactive and 

critical.[11] (See Figure 1.[12]) First, functional health literacy refers to the basic skills of reading and 

Figure 1: Health literacy framework 

Level of health literacy individual role 

Critical 

health 

literacy 

Interactive 

health 

literacy 

Functional 

health 

literacy 

advanced 

health 

knowledge 

functional 

literacy 

critical thinking 

and 

analysis 

Empowerment 

social support 

and networks 

basic health 

knowledge 

PROACTIVE 

ACTIVE 

PASSIVE 




writing that allow an individual to function effectively in regards to health, such as ability to read basic 

health education materials on health risks or how to use the health system. Second, interactive 

health literacy encompasses more advanced cognitive, literacy and social skills that can be utilized to 

participate in health activities, to understand different forms of communication of health messages 

and to apply health information to changing circumstances. And, finally, critical health literacy refers 

to the more advanced cognitive and social skills, which can be used to critically analyze health 

information, to improve individual and community capacity, to act on social and economic 

determinants of health, and to understand the political and economic dimensions of health. 

A framework for health literacy, developed by the Committee on Health Literacy at the Institute of 

Medicine, shows the three major points of intervention in the health literacy framework: educational 

systems, health systems, and culture and society (see Figure 2).[13] According to the framework, 

these three systems may ultimately contribute to health outcomes and costs. This figure also shows 

clearly that societal investments in health literacy will need to be made in all three systems. For 

example, culture and society investments for health literacy can be made in social marketing and 

advertisements of health products, while in the education system, investing in schools and 

institutions of adult education can promote health literacy. 

Figure 2: Potential points of intervention in the health literacy framework 

Health literacy is undoubtedly reliant on basic literacy skills and cognitive development. Poor literacy 

not only hinders health literacy but can also limit an individual’s personal, social and cultural 

development. [7] However, low health literacy does not necessarily mean low literacy. Even people 

with advanced literacy skills can experience difficulty in obtaining, understanding and using health 

information. A person who functions well in the home or work environment can still have insufficient 

literacy in the health care realm.[14] This is one of the reasons for the rapid development of self-help 

groups and patients’ organizations. 

As health expands in modern societies, the role of the individual in health becomes more significant 

and diverse. In the health marketplace, the individual becomes a consumer; while in the health 

system, the individual becomes a patient. The individual is also a voter on health issues (and indeed 

health policy issues are gaining increasing importance in deciding elections in OECD countries) and 




a social actor in health movements. In these various contexts, health literacy takes on different 

meanings. One constant factor, however, is what sociologists call the reflexivity of modern social life - 

that social practices (in this case health practices) are continually reexamined and revised in light of 

new information. What is healthy today is unhealthy tomorrow; treatments and medications are 

continually being improved and expanded. The organization of the health system is changing 

regularly and the rights of access are being constantly redefined. Therefore health literacy is an 

active process; citizens have to continually learn new information and un-learn outdated information 

in order to maintain good health and act as informed patients. Empowerment of citizens to participate 

actively and confidently in this process is critical to population health. 

Health literacy in the context of health education 

Health literacy is a distinguishable concept from health knowledge, health education and health 

promotion. The transfer of health information is fundamental but not sufficient to improving health 

literacy in a population. As mentioned above, health literacy includes helping individuals develop the 

Figure 3: Categories of health activities with selected examples 

Health activities Focus Examples of Materials Examples of Tasks 

Health promotion Enhance and 

maintain 

health 

Health protection Safeguard 

health of 

individuals 

and 

communities 

Disease 

prevention 

Health care and 

maintenance 

Systems 

navigation 

Take 

preventive 

measures 

and engage 

in early 

detection 

Seek care 

and form a 

partnership 

with health 

providers 

Access 

needed 

services 

Understand 

rights 

Articles in newspapers and magazines, 

booklets, brochures 

Charts, graphs, lists 

Food and product labels 

Articles in newspapers and magazines 

Postings for health and safety warnings 

Air and water quality reports 

Referendums 

News alerts (TV, radio, newspapers) 

Postings for inoculations and screenings 

Letters re: test results 

Graphs, charts 

Health history forms 

Medicine labels 

Discharge instructions 

Education booklets and brochures 

Maps 

Application forms 

Statements of rights and responsibilities, 

informed consent 

Health benefit packages 

Purchase food 

Plan exercise regimen 

Decide among product options 

Use products 



Vote 

Determine risk 

Engage in screening or diagnostic 

tests 

Follow up 

Describe and measure symptoms 

Follow directions on medicine 

labels 

Calculate timing for medicine 

Locate facilities 

Apply for benefits 

Offer informed consent


skills and confidence to act on that knowledge and the ability to work with and support others. Health 

education improves health literacy by creating opportunities for learning about healthy behaviour. 

However, the top-down strategies of health education interventions of the past did not result in 

substantial or sustainable behaviour change and therefore have had little impact on reducing the 

health gap between different social and economic groups.[11] Effective health education in the 

context of a health promotion approach (as outlined in the Ottawa Charter[15]) provides health 

knowledge, facilitates the development of life skills and provides opportunities for learning that are 

intended to improve health literacy. 

Literacy is the pathway between education and health. Health literacy emerged as a model to show 

the linkages between health promotion interventions, the determinants of health and the range of 

outcomes from such interventions. Health literacy is now understood as a health promotion 

outcome.[16] The centre for Global Assessment provides a useful categorization of health activities 

as they relate to strategies of health promotion, health protection, disease prevention, health care 

and maintenance and systems navigation (see Figure 3).[17] This categorization also underlines the 

important point that as relevant as health literacy is as a health promotion outcome, disease 

management, systems navigation, and consumer behaviour are also very important in this context. 

Finally, within the universe of health information we need to consider three crucial dimensions, as 

outlined by the United States (US) Department of Health and Human Services[18]: 

Figure 4: Universie of health information 

UNIVERSE OF HEALTH INFORMATION 

Personal Provider 

Personal health dimension, which 

supports management of individual 

wellness and health care decisionmaking; 

Provider dimension, which 

encompasses information to 

enhance the quality and 

effectiveness of health care; and 

Community dimension, which 

includes a broad range of 

information, including populationbased 

health data and resources, 

necessary to improve health. 

Each dimension represents key stakeholders with regard to health literacy but (as Figure 4 

illustrates) while each dimension has information needs that are distinct [18], they also clearly 

overlap in the context of everyday life. 

Why health literacy needs to be a priority in the European Union 

Citizens expectations and goals 

European citizens want health information, choice and empowerment.[19] People’s appetite for 

information is often greater than physicians have acknowledged until now, as evidenced by the 

rapidity with which the internet has become a major force in providing health information. Public 

health organizations, health insurance companies, pharmaceutical companies, patient organizations 

and others are putting more and more health information on the web. The UK National Health 

Service, for example, has established a national electronic library for health. The internet has 

empowered patients to discuss with health professionals in new ways and allowed them to gain 




competence to manage major health conditions. Yet, people in greatest need of information about 

preventable or treatable conditions are the least likely to have access to the information. [9] While 

professionals of the UK National Health Service have universal internet access via the health 

service’s wide-area network, patients in this system are not afforded the same access to internetbased 

health care.[20] With all the potential and real progress comes new danger and inequality in 

the digital health divide. “Variation in access to information is ultimately disempowering: it reduces 

people’s ability to act promptly and engage in self-care, and it erodes self-confidence and access to 

services impacting negatively on health.”[9, p. 28] 

Ageing society 

Ageing is a predominant issue that will shape the health of many Europeans in the coming years. 

According to the WHO, in 2002, Europe had the greatest number of countries with the highest 

proportion of individuals over age 60 of countries with more than 10 million inhabitants. Eight out of 

the top ten were Member States of the EU, and it is projected that in 2025 the ranking will largely 

stay the same. In Europe, the old-age dependency ratio (that is, the total population aged 60 and 

over divided by the total population aged 15–60) will increase from 0.36 in 2002 to 0.56 in 2025.[21] 

The elderly have the greatest health literacy needs due to their high prevalence of chronic diseases, 

yet they are disproportionately represented among the health illiterate.[13, 22] Preventive strategies 

can in fact improve the health of the ageing population by bringing benefits to major health conditions 

like obesity, diabetes, cardiovascular disease and osteoporosis. Such measures can help both to 

improve the quality of life of older people as well as contribute to the control of health care costs in 

the EU.[23] The European government’s responsibility in supporting health literacy programs for 

healthy ageing is one way to positively address the demographic challenges in the new EU. While a 

focus on older people is clearly one of the needs for strengthening health literacy in Europe, this 

must clearly be done within a wider strategy of lifelong learning and an understanding that ageing is 

a life long process – the basis for which is laid early in life. 

Complexities in an expansive medical system 

In the context of an expansive health and medical care system, Europeans are increasingly 

confronted with complex decisions regarding their health. Maintaining health or living with disease 

both require high health literacy and constant decision-making. Nearly every choice is a health 

choice. Health systems are becoming more complicated to navigate, informed consent documents 

are often confusing to patients[13] and treatment options are growing as technology advances. 

Individuals have to weigh different prescription drug options and adhere to complex regimens. Selfmanagement 

of health and shared decision-making with health professionals are becoming more 

common. Self-management education includes teaching patients with chronic and long-term 

conditions problem-solving skills, developing their confidence to improve quality of life and working in 

partnership with health care professionals. Also, according to the National Consumer Council, most 

patients prefer shared decision-making with health professionals versus strictly professional-based 

decision-making. These processes are reliant on patients’ ability to understand their health condition 

and manage it.[9] 

Increasing information in the health marketplace 

As the health marketplace expands, more and more health information and products influence 

Europeans in making health decisions. According to the Eurobarometer, health-related information is 

sought after on the internet, television, print (newspapers and journals), as well as from traditional 

medical and health organizations.[24] (See Figure 5.[12]) A ‘wellness revolution’ is occurring, 

evidenced by increased marketing of wellness products and services including nutritional products 

(such as supplements), organic food, fitness products and services (yoga and Pilates), voluntary 




FIgure 5: Health literacy and the market – consumers and the information deluge 

friends 

and 

family 

popular 

media 

medicine (including cosmetic surgery and lifestyle drugs), alternative health care (such as 

acupuncture) and resources on wellness (particularly in the media and information sector) and 

wellness insurance.[25] In the United States alone, the sales of the wellness industry have already 

reached approximately US$200 billion and that it is set to achieve sales of US$1 trillion within ten 

years, thus matching the health care industry.[26] 

However, unreliable sources, fraudulent claims and conflicting information can create problems for 

even the most literate citizens. There is a need to create knowledgeable consumers who can 

exercise choice in a highly unregulated health and wellness market. Individuals therefore need 

reliable channels of health information as well as the cognitive ability to sift through all of the 

information in order to make informed decisions. In his reflection process on a new EU health 

strategy, David Byrne maintained, “European citizens need reliable and user-friendly information 

about how to stay in good health and the effects of lifestyle on health. When they fall ill, they need 

authoritative information about their condition and treatment options to help them take decisions. 

Enabling citizens to make the right choices is indispensable.”[3] 

Health gaps in the EU 

TV 

radio 

government 

health 

orgainsations 

health 

internet news 

media 

literacy filter 

The 

consumer 

health 

care 

provider 

health 

associations 

health 

insurance 

organisations 

self-help 

books 

peerreviewed 

literature 

The expansion of the EU has resulted in major health gaps between countries. Western European 

countries enjoy better health and longer life expectancy than the less wealthy countries of Central 




and Eastern Europe.[27] Among the 25 Member States, life expectancy for men ranges from 64 to 

77 years. There is a five-fold difference between EU countries in terms of incidence of lung cancer 

and a 17-fold difference when it comes to tuberculosis.[3] As choices are expanded in the European 

health society, this health gap becomes increasingly obvious throughout the region. The EU has, as 

one of its goals, the achievement of an equitable health status across Member States. But health 

gaps within EU Member States exist as well. In the Netherlands, for instance, in 2001, bettereducated 

and wealthier individuals experienced on average four additional years of life and 12 

additional years of good health than those who were less educated and poorer.[28] The promotion of 

a health literate Europe can help to reduce health gaps both between and within Member States. 

Movement of people, goods and services 

Movement of people, goods and services also creates a need for improved health literacy. Today, all 

West European countries have a positive migration balance, and several of the new EU Member 

States in Central Europe currently follow the same pattern. According to data collected between 

2000-01, approximately 18.7 million legal foreign residents lived in the 15 ‘old’ EU Member States 

(out of a total 381 million inhabitants). (Today, the European Union, or EU 25, has 455 million 

inhabitants.) Of the 18.7 million legal foreign residents, fewer than 6 million people were EU citizens 

living in another EU Member State; 13 million were third country nationals.[29] As people migrate in 

Europe, individuals from diverse cultures enter new health systems. Culture largely shapes 

perceptions of illness and health, which then influence people’s experience in the health care 

system.[13] Miscommunication between physicians and migrants is not uncommon, and health 

messaging that doesn’t take culture into consideration can miss its mark. The movement of goods 

and services throughout the EU also has implications for the health literacy of Europeans. Articles 

28–30 of the European Commission Treaty established the principle of free movement of goods 

among Member States. Individuals need to be informed about the health effects of different products 

that are flowing into their communities, such as health products and medicines purchased on the 

internet. And the health care system needs to be more user-oriented. 

Effects of poor health literacy 

Insufficient levels of health literacy can lead to inefficiencies in the health care system. While 

empirical data on the effects of low health literacy in Europe are limited, research from the US centre 

for Health Care Strategies concluded that individuals with low health literacy are less likely to: (1) 

understand written and oral information from health professionals, (2) act upon necessary procedure 

and directions (such as medications and appointments) and (3) be able to navigate the health 

system to obtain necessary services.[9] A recent Institute of Medicine report shows that individuals 

with limited health literacy are more likely to be hospitalized and use emergency services.[13] 

Furthermore, according to Institute of Medicine, people who are health illiterate are less likely to use 

preventive services, have less knowledge of disease management and health promoting behaviours, 

and report poorer health status. A 2004 report by the Agency for health care Quality and Research 

noted that the 90 million Americans, or nearly half of the United States population, who have difficulty 

understanding and acting upon health information are less likely to get potentially life saving tests 

(mammograms, Pap smears), flu and pneumonia vaccines, and take their children for child care 

visits.[30] Low health literacy costs the US up to US$73 billion every year.[31] 

Looking to the future 

Policy 

• Europe has the potential to be an international leader in shaping policies that promote health and 

health literacy. Health, first and foremost, needs to be at the centre of EU policy making.[3] The 




two key dimensions of an EU health strategy include addressing the determinants of health and 

strengthening citizens’ health literacy. Citizens’ needs and rights must be the focus of this 

strategy. Health literacy needs to be part of all major EU health initiatives and could be 

incorporated into national systems performance targets. 

• Policy makers need to ensure the provision of reliable health information through the 

establishment of quality criteria for health-related portals of information. Yet, it is also essential 

that quality health information come from not from one source but a variety of reliable sources. 

The EU could create guidelines and programmes for specific populations in Europe that are high 

risk for health illiteracy, such as migrants, the poor and the elderly. 

• Since health knowledge comes from so many sources, a larger strategy is needed to generate 

health literacy throughout society. The EU needs to systematically develop a health information 

and literacy infrastructure at the regional level. This could include the establishment of new 

resources and roles among health professionals, such as the use of decision aids, support 

workers and knowledge brokers.[9] 

• Improved health literacy also requires European policymakers and leaders outside of the health 

sector to be aware of the key elements that contribute to health illiteracy.[32] New alliances 

between health and education sectors- at the local, national and regional levels can help reach 

the goal of a health literate Europe.[11] 

Learning 

• Health literacy needs to become an integral part of the health system as well as a key component 

of modern literacy (in schools, adult education, etc.). Incorporating health knowledge and skills 

into school curricula would help establish a foundation of health literacy in early life. 

• Integrating health literacy into the European Commission’s policy area of Lifelong Learning is very 

important. In November 2001, the Commission adopted Communication on Making a European 

Area of Lifelong Learning a Reality, yet the document did not include any mention of health 

literacy. Lifelong learning is a core element of the mission of the EU; it is central to 

competitiveness, employability, social inclusion, active citizenship and personal development.[6] 

Health literacy needs to be a key component of this strategy. 

e-Health 

• e-Health can be a useful tool in developing health literacy. (e-Health refers to the use of modern 

information and communication technologies to meet needs of citizens, patients, health care 

professionals, health care providers, as well as policy makers.[4]) With new communication 

technologies, Europeans can become more involved in their health decisions and treatment, and 

appropriate access to such technologies can help guarantee a health literate public.[32] EU 

policies can help to bring information and communication technology to the disadvantaged 

population. 

• The ‘e-Health Action Plan’ of the EU, which aims to be in place by the end of 2005, is a crucial 

step in the pursuit of a health literate Europe, and its implementation should be fully supported by 

all Ministers. The plan includes electronic health cards, development of health information 

networks and online provision of health services (including information on healthy living and 

illness prevention, electronic health records and e-reimbursement).[33] In May 2003, the 

European Commission, in collaboration with the Greek Presidency, held a high level conference in 

Brussels on e-Health during which the Ministers expressed their commitment to the development 




of national and regional e-Health plans in the e-Health Ministerial Declaration. The Declaration 

outlines ways in which Ministers can (1) promote quality of and enhance efficiency in health care 

through e-Health applications, (2) facilitate citizen involvement through access to high quality 

information, and (3) implement and share best practices of e-Health.[4] 

Health and patient advocacy organizations 

• Support for patients’ organizations is an important step in promoting health literacy. Such 

organizations that promote patients’ rights and advocate for improved health can be a reliable 

source of health information. European health societies are reliant on the active participation of 

patients’ organizations, health literate consumers and social movements; this is necessary to 

advance the health literacy platform throughout the EU. Patients’ groups will gain increasing 

importance in shaping the future of the health society, as the key value that remains is the 

empowerment of the citizen. 

• Professional associations, such as the European Medical Association, also have potential to 

shape health literacy across the EU, particularly in better training of health professionals. The 

American Medical Association, for example, is creating an initiative to combat health disparities by 

focusing on patient-centred communication. The initiative, which focuses in part on health literacy, 

will develop practical self-assessment toolkits for health care organizations that address patientcentred 

communication for vulnerable populations.[34] 

Culture 

• Health literacy programs and messages need to be rooted in the context of culture.[13] Peter 

Koehn calls on health care professionals to develop ‘transnational competence’ in providing care 

to migrants.[35] Transnational competence, which encompasses analytic, emotional, creative, 

communicative and functional skills that facilitate effective communication between the clinician 

and patient, has the potential to reduce inequities in health care within countries. Such skills could 

include clinician/patients’ understanding and respect of each other’s personal beliefs and 

practices regarding the causes, treatment and prevention of illness; ability to express/encourage 

expression of uncertainties, doubts, health-related worries and questions; and relating in a way 

that builds trust. It is also imperative that health literacy initiatives combat social stigma 

associated with illiteracy that can hinder people from seeking health advice or care. 

Ageing population 

• The EU has a clear role to play in promoting health literacy among those of advanced age. In 

addition to implementing ‘age friendly’ policies, health literacy initiatives could be created to 

mitigate the adverse consequences of health illiteracy among the ageing population. Focusing on 

functional health literacy capacity over the life course would help to ensure that future generations 

of older people are health literate. The WHO Active Ageing Initiative supports efforts to use health 

literacy as a tool to promote active ageing throughout Europe. The initiative emphasizes 

autonomy and independence, interdependent solidarity, disability-free life expectancy and 

improved quality of life.[21] 

Research 

• The health literacy research agenda in the EU needs to be significantly strengthened. Public and 

private funds should be allocated to health literacy research. New measures of health literacy 

need to be established, as current health literacy measures are largely limited to reading skills. A 

set of indicators or scales should be developed for the three domains of health literacy (that is, 




functional, interactive and critical). 

• Once measures are established, tools can be developed to determine baseline health literacy 

data in the EU. Comparative assessment of health literacy can be conducted throughout the EU. 

Differences in levels of health literacy in relation to gender, population and age groups, education 

and income can be measured over time.[10] 

• The EU would benefit from the establishment of a health literacy research program. Available 

research supports only limited conclusions about causality. An empirical evidence base for health 

literacy- including the costs associated with health illiteracy as well as the health outcomes of a 

health literate Europe- needs to be established. Research should focus, for example, on the cost 

of low health literacy in Europe and the link between general literacy and health literacy. Surveys 

on basic adult literacy could include health components. 

• The creation of a European network or centre on health literacy would help to codify the health 

literacy information that is generated in the research as well as act as a resource for individuals 

and organizations to networking, information transfer and skill building. A European health literacy 

conference, held by this network/centre or another organization, could help share best practices 

among the public health community. 

Acknowledgements 

The author would like to thank Lea Payne for her contribution to this paper. 

References 

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European Communities, 23 September 2002. 

2. e-Health. European Commission’s website on Information Society 

[http://europa.eu.int/information_society/eeurope/2005/all_about/ehealth/text_en.htm, accessed 24 

September 2004] 

3. Byrne D. Enabling Good Health for All: A reflection process for a new EU Health Strategy. 

European Commissioner for Health and Consumer Protection, 15 July 2004. 

4. eHealth Ministerial Declaration. e-Health 2003 High Level Conference of the European 

Commission, 22 May 2003. 

5. United Nations Educational, Scientific and Cultural Organization, Literacy as Freedom. Paris: 

UNESCO, 2003. 

6. European Commission, Making a European Area of Lifelong Learning a Reality. Commission of 

the European Communities, 2001. 

7. World Health Organization, Health Promotion Glossary. WHO, 1998. 

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in Israel. Health Promotion International 2001;16(1):87–94. 

9. Sihota S, Lennard L. Health Literacy: Being Able to Make the Most of Health. London: National 

Consumer Council, June 2004. 




10. Kickbusch I. Health literacy: addressing the health and education divide. Health Promotion 

International 2001;16(3):289–97. 

11. Nutbeam D. Health literacy as public health goal: a challenge for contemporary health education 

and communication strategies into the 21st century. Health Promotion International 

2000;15(3):259–67. 

12. Kickbusch I, Navario P. Improving Health Literacy Among Older Europeans. Pfizer Health 

Literacy Roundtable, Brussels, 12 June 2003, unpublished. 

13. Nielsen-Bohlman L, Panzer AM, Kindig DA. (eds). Health Literacy: A Prescription to End 

Confusion. Washington DC: National Academy of Sciences, 2003. 

14. Sullivan E. Health Literacy. Albuquerque: University of New Mexico Health Sciences centre 

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September 2004 

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Health Council in Noordwjk on 10 September 2004. 

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the wellness revolution. Health Promotion International 2003;8(4):275–78. 

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New York: John Wiley and Sons, 2002. 




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September 2004] 

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January 2003. 

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Transnational Competence. EcoHealth 2004;1(1):69–85. 



Workshop 5b 

Towards a European 

global health strategy 




��John Wyn Owen Chairman’s introduction 412 

��Graham Lister Europe’s current engagement with global health issues: 414 

A case for developing a European strategy 

��John Martin Text not available 

��Ted Schrecker Text not available 

��Martin McKee Text not available 

��Alan Ingram Summary report 423 

Page 




Chairman’s introduction 

John Wyn Owen 

This workshop draws on the discussions in the plenary sessions on the very first day and earlier 

today when we had presentations from Julio Frenck, Roel Bekker, Ilona Kickbusch, culminating in the 

EU Commissioner, David Byrne, giving his keynote address on Global Health Global Caring. This 

workshop draws on these plenary sessions to consider possible practical elements in a European 

global health strategy, recognising the increasing interdependence between Europe and the world, 

the scale of global health challenges and how Europe can marshal its unique resources to meet 

them in a more focussed and concerted way. The workshop will contribute to the formulation of policy 

proposals to feed into consultation with European institutions, governments and other stakeholders 

during 2005. 

In opening this session I would like to share with you some of the rationale that the Nuffield Trust has 

adopted in promoting the concept of a United Kingdom strategy for global health. We marshalled the 

arguments for the development of a cross-sector strategy and they also explain why a European 

strategy should be considered. The rationale for a global health strategy flows from the scale of 

threat to human security and economic stability posed by the spread of global diseases and 

pathogens, and that they require concerted policy and action. Globalisation resulting in the 

movement of people, goods and ideas means that European health is critically linked to global health 

measures and health resources. In this as in other spheres domestic and foreign policy interests are 

interdependent. Our dependence on health professionals from outwith Europe and the range of 

ethnic groups with specific health needs in Europe underline this fact. Health improvement or in 

some countries the prevention of further decline is not only important for humanitarian reasons but is 

also recognised to be an essential basis for economic and social development while aid funding and 

expertise is essential, professional and community links are also vital to support global health. 

Trade and foreign direct investment and the policies and conditions applying to them are basic 

determinants of global health. There are health issues relating to the corporate social responsibility of 

multinational companies and specific issues concerning the supply and marketing of drugs and other 

medical resources. 

Policies for global health cannot be determined by government alone. Concerted policy and action is 

required not only with other countries and international agencies but with multinational companies 

and specifically pharmaceutical companies, non-governmental organisations and health 

professionals. 

Measures to sustain health embody common values across cultural and geographic barriers. Policies 

and actions on global health can therefore provide a bridge to peace for countries and communities 

and failure to address health needs can lead to further alienation and despair fostering failed states 

and cities. 

The promotion of global health can be a positive form of engagement with the global community, help 

to mitigate some of the negative aspects of globalisation and make a crucial contribution to both 

human development and global security. 

Europe has a unique set of resources and connections that should be harnessed in a coordinated 

and focussed way in order to make the most effective possible contribution to these various urgent 




and vital tasks which I have just mentioned. Many of those working in the health service are strongly 

motivated by humanitarian instincts and a desire to help others, giving recognition to the work done 

by many in responding to global health issues would be very motivating. 

Finally the increasing use of public private partnership arrangements to deliver global health 

programmes suggests a further rationale for better strategic planning. 

Our discussions today will be led by Graham Lister from the Nuffield Trust, Ted Schrecker from the 

University of Saskatchewan Canada, John Martin from WHO Office at the European Union, and 

Professor Martin McKee, Professor of European Public Health at the London School of Hygiene and 

Tropical Medicine. 

Before I close I would like to remind you that the sessions on the opening day and these two 

sessions today were part of an idea developed in particular by Louise Sarch of the National Heart 

Forum in the UK. She died tragically at a very young age and I believe that taking these issues of 

global health forward was very much central to her being and I believe that as we move towards a 

European global health strategy in the Gastein context that we will associate it with the memory of 

Louise Sarch. 




Europe’s current engagement with global health issues: a case for 

developing a European strategy 

Graham Lister 

Introduction 

I am delighted to be able to respond to the lead set by Commissioner Byrne in his address to the 

Forum [1] calling for “health to be set at the heart of EU economic, social and foreign policy” and 

Professor Kickbush’s address [2] in which she called for the creation of a ‘European Council for 

Global Health’. As John Wyn Owen pointed out in introducing this session, “Global health represents 

the greatest moral challenge to our generation and the greatest threat to the health and security of 

future generations of Europeans and our fellow global citizens”. 

In this paper I discuss Europe’s current engagement with global health issues and make a case for 

developing a European strategy for global health, through a process of engagement with European 

institutions, member state governments, international business interests, health professional bodies 

and civic society groups. In arguing for such a process I note the many different areas of policy and 

action that contribute to global health, that require such cross sector international support and action. 

To develop a European strategy for global health, we at the Nuffield Trust, together with Professor 

Kickbusch, are consulting with colleagues from the European Foundation Centre, which represents 

some 500 foundations across Europe, to create a European Council for Global Health. The 

Foundations are uniquely placed to support such a process since they can form bridges between 

action at EU level and action in member states and with developing countries and can bring together 

business interests and civil society to address the full range of the determinants of global health. 

Background 

The Nuffield Trust has undertaken a series of policy reviews of global health since 1998. We 

convened the first major UK conference on this theme, helped to initiate the Centre on Global 

Change and Health at the London School of Hygiene and Tropical Medicine and established the UK 

Partnership for Global Health (see www.ukglobalhealth.org ) which brings together international 

agencies, government departments, the private sector, NGOs and professional and academic 

representatives to raise awareness and stimulate action. This led to a number of further initiatives 

including those concerning: 

• Making globalisation work for the poor (input to UK white paper) 

• Global Health Award: Corporate social responsibility and global health 

• Information and knowledge for global health 

• Globalisation, women’s development and health 

• European Union foreign and health policy (eurohealth, 2002) 

• Pathfinder UK strategy for global health 

• International health as a global public good (UNDP paper) 

• Support for global health networks across the EU and Commonwealth 

• Global health and foreign and security policy 




We have therefore taken steps together with our colleagues from the European Foundation Centre to 

develop dialogue on global health issues. At the European Foundation Conference in Athens earlier 

this year, foundations agreed to support the ‘Europe in the World’ initiative to double aid contributions 

outside Europe and address global health issues. Meetings and networks have been established on 

‘Health Research to meet the Millennium Development Goals’, together with the Global Forum for 

Health Research and ‘How European foundations can help the fight against HIV/AIDS’. 

More recently we have supported the dialogue ‘European health policy an international perspective’ 

with Robert Madeline and ‘European Responses to the HIV/AIDS pandemic: the role of foundations 

and civil society’ with Commissioner Poul Nielson at the European Policy Centre. At the European 

Health Forum Gastein we organised the theme ‘Global Challenges: European approaches and 

responsibilities’. 

We applaud Commissioner Byrne’s call for a broad based EU strategy putting health at the centre of 

economic, social and foreign policy built through partnerships. Our proposals are intended to take up 

this challenge in respect of global health and to offer our help in pursuing this goal. 

Global health 

We define global health as those threats to and opportunities to improve population health that 

transcend borders, cultures and /or generations [3] and which require international cooperation for 

their resolution.[4] Such threats are relevant to developing and developed countries and include the 

impact of infectious diseases, such as HIV/AIDS, TB, Malaria, SARS, Influenza and the misuse of 

antibiotics as well as non communicable diseases such as depression, heart disease and cancer 

arising from changes in cultures due to the impact of international marketing of products and 

lifestyles. Threats to global health may arise from long term environmental damage such as global 

warming and the impact on social and economic determinants of health such as employment and 

inequality. We also take account of threats posed by chemical, nuclear and biological terrorism, 

which in part arise from the clash of cultures and growing inequality. Opportunities to improve global 

health include the development of new health solutions, such as affordable prevention and treatment, 

investment in preventive health and improved health systems delivery, improved surveillance of 

health threats and means of sharing health knowledge. 

Developments in global health in wealthy regions such as Europe take place against the background 

of three revolutions in public health: the control of infectious disease through protective measures 

and medicines, the control of non-communicable disease through behaviour modification, and the 

empowerment of individuals, communities and societies in promoting health.[5] These revolutions 

have been facilitated by rapid expansions in wealth, improvements in public infrastructure, and 

progress in science, medicine and the pharmaceutical industry. This has made possible a 

demographic transition from high fertility and high mortality to low fertility and low mortality, 

accompanied by increases in life expectancy and a shift in the burden of disease from infectious 

diseases to non-communicable diseases. While Europeans can now live with HIV/AIDS, as a result 

of preventive measures and drug therapies, Europeans remain vulnerable to new and re-emerging 

infectious diseases, the SARS outbreak gave a warning of this. A lethal form of influenza could bring 

a major pandemic. There have been over 30 such new and re-emerging disease threats in the last 

20 years, including MRSA and VMRSA. Our vulnerability is increased by the misuse of antibiotics in 

both the rich world and the poor. We are also experiencing an epidemic of lifestyle related conditions 

such as obesity, smoking and alcoholism and a continuing growth in mental illness. These conditions 

are global health threats arising in part from a failure to control the excesses of international 

companies that manipulate public perceptions through sophisticated mass marketing. 

Middle income countries are improving in economic performance as a result of globalisation, at the 




same time they are opening market opportunities for products and lifestyles which damage health. As 

a result the burden of disease is shifting towards non-communicable diseases and mental health 

issues. They are starting to experience patterns in health that are similar to those in rich countries, 

while at the same time continuing to struggle to deal with communicable diseases, leading to a 

double burden.[6] This double burden is increasingly observed even within the poorest regions, 

illustrated strikingly in patterns of obesity and underweight, with extremes at both ends of the 

spectrum being found. Middle and low income countries have also experienced a rapid growth in 

mental health problems, arising at least in part from the loss of traditional cultures and values as a 

result of the impact of western cultural dominance and marketing.[7] 

In poor countries most people remain excluded from the health revolutions of the 19th and 20th 

centuries, with communicable diseases remaining a pervasive threat to health and barrier to 

development.[8] This is especially the case in sub-Saharan Africa, the only world region where 

communicable disease still accounts for the majority of deaths. Poor people face numerous health 

risks on a daily basis; while poor countries experience 90% of the burden of disease, only 10% of 

research effort is devoted to their needs and 1% of total health resources; the richest 20% of the 

world population spend over $1,500 per head on health, the poorest 20% spend less than $15 per 

head. Of the 1.2 billion poorest people 70% are women, who not only face risks to their own health 

but are the principal carers for their children. Children comprise 10% of the world’s population, yet 

bear 40% of the global burden of disease. Over 5 million die each year, mostly in poor countries.[9] 

Failure to take action on the threats and opportunities posed by global health represents the most 

terrible loss of human potential, it is leading to a 20% reduction in the economic performance of 

some African countries and three heads of state have said that their countries could become 

ungovernable. The HIV/AIDS pandemic threatens the stability and security of Africa and South Asia 

with terrible consequences for the world economy and global security.[10] Amartya Sen recently 

pointed out that the argument that many terrorists are not poor, would similarly overlook the links 

between the troubles of Northern Ireland and failure to respond to the potato famine of 1845–50.[11] 

Europeans have a common understanding of the consequences of failure to address the challenges 

of history, born of bitter experience. 

EU policies relevant to global health 

Global health can be seen as a cross cutting theme of many aspects of EU policy and action in 

respect of: 

• Trade and intellectual property rights 

• Development aid 

• Knowledge sharing and migration of health workers 

• Environmental protection 

• Foreign and security policy 

We note key policies these fields and suggest the need for further action. 

Trade and intellectual property rights 

The imbalance in terms of trade between European and developing countries is a factor which 

underlies poverty, which is the major determinant of health in developing countries. The EU has 

supported action through the WTO to complete the Doha round of trade talks aimed at reducing the 

impact of agricultural subsidies and has promised further action on this issue. But it remains the fact 

that EU agricultural subsidies are seven times the level of aid and every €300 of subsidy is estimated 




to reduce poor country farmer income by €60.[12] 

The EU has pressed for and achieved agreement on trade related aspects of intellectual property 

rights (TRIPS) to provide access to generic versions of essential medicines. However, this 

agreement is limited to ‘emergency’ situations and has not yet been translated into substantial 

support for the delivery of essential medicines. 

Europe has led the way on the Framework Convention on Tobacco Control, a new approach to 

controlling trade in products harmful to health, but again action has been slow to follow. And it 

remains to be seen whether similar action can be taken in respect of alcohol and food with high salt, 

sugar and fat content. 

We suggest there is a need to apply Health Impact Assessment, as required for internal EU 

economic and social policies, to external trade policies, drawing on the example of the Swedish 

National Institute of Public Health’s evaluation of the health impacts of the Common Agricultural 

Policy.[13] 

European based multinationals are major investors in developing countries, through direct 

subsidiaries, joint ventures and networks of local suppliers. This is beneficial in creating employment 

and prosperity. Such companies can also have a major impact on health through the treatment of 

their employees, the communities in which their operations are based and local customers. It would 

be helpful to recognise and support best practice by European based multinationals, in much the 

same way that environmental policies are recognised by shareholders and customers. We suggest 

that a European approach to corporate social responsibility for global health could be beneficial both 

to companies and global health. 

International investment has a particular impact on women’s development and health, for example 

there are 27 million jobs in export processing 90% of which are taken by women and women are also 

the main workforce in most other industries outsourced to developing countries. While this creates 

opportunities it also creates problems in that women may be regarded as wage slaves with lack of 

rights at work or at home. Since women are also the prime providers of family health this is leading 

to breakdown in family health. This requires EU action in partnership with the private sector to 

strengthen women’s development for health. 

Development aid 

The EU and its member states provide 55% of total official development assistance (ODA) and over 

65% of grant ODA. Europe has increased its aid levels in recent years after two decades of decline 

and has also taken steps towards debt reduction. These represent considerable achievements but 

Europe is still less than half way towards meeting the target of 0.7% of GDP for ODA set in 1969 and 

there is a need to ensure that more aid is focussed on countries with the greatest need. Currently 

less than 45% of European Development Funds go to the poorest countries and too much of 

European aid is tied to conditions including the use of resources from donor countries and the 

opening of markets such as health care to private investment. As there is an ongoing review of EU 

development policy it is timely to re-examine this. 

EU countries also played a leading role in establishing and funding the Global Fund for HIV/AIDS, 

Tuberculosis and Malaria. European aid has played a vital role in filling the gap left by the withdrawal 

of US funding from reproductive and women’s health organisations. It has also been helpful in 

providing cross-sector support for health systems at a time when more and more funding is focussed 

on disease specific programmes such as HIV/AIDS. This approach to aid reflects European values of 

health as a human right. It would be helpful to see such values expressed more forcefully as a 




counterweight to current US administration policies in this field. 

At present while recipient countries are pressed to coordinate their use of aid donor countries create 

immense problems by failing to coordinate their efforts. Furthermore the trend towards disease 

specific ‘vertical’ interventions can often mean that resources are drawn from other aspects of health 

system management. There is a need to improve the coordination of European multilateral, bilateral 

and NGO aid in the field of health around the needs and capabilities of recipient countries. 

Support for health systems in developing countries also requires cooperation between health 

professionals, academics and research based companies in Europe and developing countries, for 

example, the partnership between Malaria Vaccine Initiative, GlaxoSmithkline, Centro de 

Investigação em Saude da Manhiça and the Mozambique Ministry of Health, recently announced the 

trial of a new malaria vaccine for children.[14] It is hoped that the creation of the ‘European and 

Developing Country Clinical Trial Partnership’ will lead to further successful partnerships. A strategy 

to build on and support such partnerships would be very helpful. 

EU bodies make a substantial contribution to global health through engagement with surveillance 

networks, provision of expertise and advice and expanding cooperation with the WHO. Given the 

current crisis in global health caused by the HIV/AIDS pandemic and other factors it is essential both 

to further strengthen the governance role of the WHO and to establish the means to provide further 

support for its functions, recognising that the WHO can lead with others but cannot by itself solve 

global health issues. It is also essential to ensure that WTO, IMF and other agencies examine the 

potential impact of their actions on health. The development of the European Centre for Disease 

Prevention and Control, support for the International Health Regulations and the development of 

support networks are all urgent tasks for the EU Commission. 

It is important to recognise that a great deal of investment in health in developing countries, for 

example to halt the spread of HIV/AIDS and TB, to prevent the misuse of antibiotics and to improve 

the surveillance of new and re-emerging diseases are a global public good which ultimately protects 

our own health. We suggest that investment in global public goods for health should be evaluated as 

such, we suggest that an additional European target should be set for such investment. 

Knowledge sharing and the migration of health workers 

European based pharmaceutical companies, Universities and research centres are major sources of 

research and development for health. This represents a major opportunity to contribute to global 

health, yet only 10% of research and development is directed towards the health needs of 

developing countries. The EU has taken steps to provide funding for orphan drugs directed towards 

uneconomic markets and the recent Priority Medicines programme may provide further support. 

Some EU countries also provide tax and other incentives for research on the diseases of the 

developing world and advance purchase funds and other market mechanisms may help. It would be 

useful to establish clear EU policy in this field to promote a positive investment environment for 

pharmaceutical companies while directing more research towards global health targets. The idea of a 

European Institute for Health along the lines of the US National Institute for Health, but probably as a 

network of existing bodies, is one we would endorse, we have recently called for the creation of such 

a body for the UK. 

EU policies have stressed the importance of developing e-health within Europe and of supporting 

actions to bridge the so-called digital divide between Europe and the developing world, particularly 

Africa, where access to and use of information and communications technology for health remains 

extremely limited. Many bodies in Europe are very willing to share knowledge for health with 

developing countries. However, the key constraint lies in the lack of capacity to identify health 




knowledge and information needs from the recipient country’s perspective and lack of information 

and communications technology. The crisis in health systems in many developing countries requires 

urgent research into new ways of delivering health and care services using health knowledge in non 

traditional ways. This requires support for a global network for research on health solutions that can 

be supported and partnered by European centres but must include developing countries 

Currently efforts to support health systems in developing countries are undermined by the flow of 

health professionals from poor countries to the EU. The UK has been the greatest importer of 

doctors and nurses due to its failure to train enough staff for its own needs and the widespread use 

of English. However other states including Scandinavian countries and the Netherlands also attract 

staff from developing countries. While a number of recent studies have suggested that movement of 

professionals is unlikely to present a problem,[15] discussions with colleagues at the Gastein 

Conference suggest that since the opening of borders there is now a worrying trend in the movement 

of health professionals from lower to higher income countries. 

This problem requires action to ensure that the EU as a whole trains enough health professionals to 

meet its needs and where staff are attracted from other countries, action is taken to compensate for 

the cost of training and damage to the local health economy. Evidence from the UK, which has tried 

to establish agreements on ethical recruitment, suggest that by itself this is not a sufficient answer to 

this complex issue. At our recent meeting with Robert Madeline at the European Policy Centre we 

offered to lead an urgent review of options for EU policy and action in this field. 

Environmental protection 

As advocates for action on global health we share common concerns with those focussed on 

environmental issues and have much to learn from their success in raising the awareness of civic 

society, industry and policy makers. For example most multinational companies have policies for 

environmental protection but relatively few consider their impact on global health. The European 

Union has developed programmes of policy and actions in respect of environmental protection since 

1973, at European Parliament level a committee brings together concerns on the environment, public 

health and consumer protection. In a European strategy it will be important to set global health 

concerns in the context of sustainable development. 

Foreign and security policy 

While hard military power - defensive alliances and the supply of arms – can be seen as the 

currencies of cold war diplomacy, foreign policy in the era of globalisation depends on the exercise of 

soft power [16] – the power to influence – achieved through exchanges in fields such as trade, social 

solidarity, support for human rights and democracy. This is reflected in EU foreign and security 

policies, which also focus on EU development and humanitarian aid and actions on as global public 

goods such as health and environmental protection as defining features of the Europe Union in the 

world. The EU has for some years been examining the development of a common policy regarding 

the subsidy of arms export, the logical conclusion of its emerging foreign policy would be to replace 

such subsidies with support for global public goods, this would require action through the WTO on 

US arms subsidy. 

Recent studies have shown that global health and environmental issues pose a far greater threat to 

lives than conflict. Even in conflict situations losses arising from disease far outweigh the direct 

casualties of warfare.[17] It is therefore appropriate to redirect efforts to protect human security 

towards threats to health. Common European security and defence policy is focussed on the 

development of a rapid reaction force for peacekeeping and crisis intervention. Many such crises will 

arise from and/or give rise to serious health threats. This requires the ability to deploy teams able to 




provide emergency health support in difficult circumstances. Health can be a bridge to peace 

because it evokes values shared across cultures even across a divide of hatred. 

Global health challenges create shared EU concerns for health security arising from imported 

infections whether deliberate or accidental. There is an urgent need to review and standardise port 

health functions across the EU, and to share intelligence on possible threats. From a wider 

perspective the possibility of areas of Africa and Asia declining into ungovernable, failed states as a 

result of HIV/AIDS is the most serious threat to global security. 

The case for a European strategy for global health 

As we have noted in the previous section the EU Commission and Parliament have often recognised 

the importance of global health within the context of policies in other fields, such as development aid, 

foreign policy, security or EU health protection. This sometimes means that conflicting goals have to 

be resolved. For example, there is an argument that aid should be focussed on the poorest 

countries, but many immediate threats to European health arise from health conditions in our near 

neighbours. Defining global health as a policy objective in its own right may help to resolve such 

issues particularly if the concept of global public goods is introduced as a mechanism for funding 

alongside development aid. 

Commitment to the Millennium Development Goals and the coming review of progress during 2005 

provides an opportunity to assert EU policies in relation to global health, since it is already clear that 

the goals many of which directly or indirectly relate to health are unlikely to be met. It is therefore 

timely both to review EU aid policies and to examine EU strategies for global health. 

This process could help define and reflect European shared values for health: as a secular human 

right, including women’s rights to reproductive health choice, as an issue of solidarity both within 

Europe and in the world and an issue on which human values transcend political divides. A clear 

presentation of such values as the basis for a European strategy for global health would both provide 

moral leadership to the world and could prove a source of common identity for Europeans. While 

these may seem unexceptional values, they are distinctly different to those espoused by the current 

US Administration, which has expressed its strategy for global health in the goals of the State 

Department, the global health strategy produced by CDC and in Millennium Challenge Account aid 

programmes and PEPFAR. Professor Sachs,[18] while paying tribute to EU policies, has suggested 

that the EU could better “punch its weight” in the debate on such issues if it were to set out its own 

global health strategy. 

While the EU has responded to a succession of issues concerning global health, a strategy would 

provide an important point from which to look forward to foresee threats and opportunities. It would 

provide a basis for dialogue with developing countries on the factors which determine their health 

and the actions that can improve their health status. 

Many aspects of global health require local and national action as well as EU support and leadership, 

however, for the issues identified in the preceding section we suggest EU wide leadership is 

essential to enable a coordinated response. This is particularly important in trade related aspects of 

global health. We hope to see further developments of national programmes for global health 

stimulated by the leadership provided by the EU. 

Global health issues cannot be solved by the actions of international agencies and national 

governments alone, it is essential to engage with the private sector, health professionals the 

academic world and with civil society. Many such organisations are already committed to global 

health programmes, indeed a visit to any developing country will reveal a great array of different 




agencies at work. A European global health strategic planning process would help improve 

communications and coordination of effort, which is sorely needed. 

A European Council for Global Health 

At the European Health Forum Gastein, Professor Ilona Kickbusch called for the formation of a 

European Council for Global Health to bring together national and international agencies across 

Europe to research and promote action on global health issues. We support this proposal and have 

called a meeting with our colleagues from the European Foundation Centre and Professor Kickbusch 

for the 3 November to create the Council. 

The Council could play an important role, working in partnership with the EU Commission. It could 

draw on a wider network of interested parties working through national level networks such as the 

UK Partnership for Global Health, the Irish Forum for Global Health, similar groups in Germany, The 

Netherlands and France, and elsewhere and with Europe wide representatives of patient 

organisations, business interests and professional groups. 

The Council might also establish contact with regional or other organisations in developing countries 

concerning global health issues, some such groupings already exist for example the Commonwealth 

Health Minister’s Meeting. 

The European Foundations Centre and the 500 European Foundations are in a unique position to 

support this development through its Europe in the World Programme, since they can form a bridge 

between the EU and civil society throughout the member countries and can dialogue with industry 

health professionals and international organisations. 

As a first step the European Council for Global Health could work in partnership with the Commission 

to establish values and goals for a European strategy for global health. This would require 

widespread involvement and open engagement with all interested parties. 

This might then stimulate a programme of research and action on current and future issues 

concerning global health. Thus our aim is not simply to produce a statement of strategic intent and 

direction but to build a programme of action with the Commission, national governments, the private 

sector, NGOs, health professionals academic centres and foundations. 

At this stage we are consulting on the precise role, functions, organisation and operations of the 

Council, including its name. We welcome the chance to discuss this further with the incoming 

Commissioner for Health and Consumer Affairs. 

Finally we would like to take the opportunity to thank the outgoing Commissioner David Byrne for the 

enthusiasm, energy and leadership he has shown on global health issues. 

References 

1. Byrne D. Address to the Plenary Session of the European Health Foundation, Gastein October 

2004 

2. Kickbusch I. Europe’s Role :Partners in World Health. Gastein, October 2004 

3. Lee K. Globalisation and Health Policy. A Review of the Literature and Proposed Research and 

Policy Agenda. London: London School of Hygiene and Tropical Medicine, August 1998. 

4. Institute of Medicine. America’s Vital Interest in Global Health, National Academy Press, 1997. 




5. Kickbusch I. The future value of health. Perspectives in Health, 2001. 

[www.paho.org/English/DPI/Number14_article5_3.htm] 

6. WHO. World Health Report 2002: Reducing Risk, Promoting Healthy Life, 2002. 

[www.who.int/whr/2002/en/] 

7. Institute of Medicine. Neurological, Psychiatric and Developmental Disorders: Meeting the 

Challenge in the Developing World. Washington DC: National Academy Press, 2001. 

8. Brundtland GH. Speech to conference on ‘Global Health, Poverty and Development’, 19–22 June 

1999. [www.globalhealth.org/view_top.php3?id=91] 

9. WHO statement on World Health Day, 7 April 2003. 

[www.who.int/mediacentre/releases/2003/pr28/en/] 

10. Feachem R. World fails to grasp AIDS threat. Pakistan Daily Times. 30 October 2004. 

[www.dailytimes.com.pk/default.asp?page=story_15-12-2002_pg9_7] 

11. Sen A. IHMEC/Lancet Annual Global Health Lecture: Health and Security. University College 

London, 12 October 2004. 

12. Stern N. Dynamic development innovation and inclusion. Munich Lectures in Economics series, 

CES in conjunction with MIT Press. 

[http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:20076448~menuPK:34463~pa 

gePK:34370~piPK:34424~theSitePK:4607,00.html] 

13. Elinder LS. Public Health Aspects of the EU Common Agricultural Policy Swedish Institute of 

Health, April 2003. [http://www.who.int/hia/examples/agriculture/whohia035/en/] 

14. Lister G. Malaria Trial Success [item 656 at www.ukglobalhealth.org] 

15. Nicholas S. The challenges of the free movement of health professionals. Zajac M. Free 

movement of health professionals: the Polish experience. Jakubowski E, Hess R. The market for 

physicians. Buchan J. Not from our own backyard? The United Kingdom, Europe and international 

recruitment of nurses. In: McKee M, MacLehose L, Nolte E. Health Policy and European Union 

Enlargement. London: Open University Press, 2004. 

16. Nye J. Soft power the means to success in world politics, Public Affairs Cambridge MA: Perseus 

Books Group, 2004. 

17. Gordon DF, Noah D, Fidas G. The Global Infectious Disease Threat and its Implications for the 

United States. US National Intelligence Council, 2000. 

[www.cia.gov/cia/reports/nie/report/nie99-17d.html] 

18. Lister G. The Netherlands VWS Examines Global Health Issues, [item 564 at 

www.ukglobalhealth.org] 




Summary report 

Alan Ingram 

This workshop drew on discussions in the plenary sessions to consider possible practical elements in 

a European global health strategy, recognizing the increasing interdependence between Europe and 

the world, the scale of global health challenges, and how Europe can marshal its unique resources to 

meet them in more focused and concerted ways. The workshop was intended to contribute to the 

formulation of policy proposals to feed into consultation with European institutions, governments and 

other stakeholders during 2005. 

Introduction 

A number of themes relating to European approaches and responsibilities emerged during plenary 

sessions: 

• The pace and complexity of globalisation mean that its health dimensions have to be continually 

revisited; 

• Besides microbes, ideas, lifestyles, policies and corporate strategies also travel globally, with 

profound implications for health and health policy; 

• There are many links between the local and the global; local experience can feed back into the 

global debate; 

• Europe’s role in developing its own health systems has provided a global model, and European 

countries have helped to finance success stories in international health; 

• Three elements for renewal: exchange of information; evidence on what works and what doesn’t; 

empathy with diversity and building on common values. 

• Poverty-related health threats as the greatest burden of health insecurity; 

• Complementarity of roles in global governance 

• Health impact assessment and health’s intersectoral role; 

• Europe’s role as an example others want to follow, and its special responsibility in social affairs; 

• Solidarity and a new global social contract on health – the success of a humane globalisation will 

depend on how the excluded are treated; 

• As much as Europe is doing, it’s not enough. 

• Global health is about more than Official Development Assistance. 

Chairing the session, John Wyn Owen noted opportunities to submit proposals on global health to 

EU institutions and to engage European foundations. The idea of global health strategies has been 

supported by the Nuffield Trust in the UK and other countries as being particularly important in the 

context of globalisation. 




Graham Lister 

Dr Lister argued that a strategy is certainly required; it is time for Europe to stand up and be counted 

and to demonstrate its solidarity, and there is sufficient in common between member states for an EU 

strategy to make sense. Global health should be seen as more than aid; it can be considered a 

global public good. The case for a European Global Health Strategy needed to be grounded in the 

perspective of fairness, in, trade, access to medicines, R&D, knowledge exchange, aid and a range 

of other policy areas. A European Council for Global Health could play a useful role in focusing the 

minds of policy makers. 

John Martin 

Dr Martin presented a view from Brussels, and echoed the statement of the WHO Director General 

that today’s global health situation raises urgent questions about justice. The excessive concern with 

security, which often means only our security, is troubling. What is needed is security plus justice. 

The agenda is complex; issues must not be picked off individually. This requires a meaningful 

strategy. 

A strategy would give substance to the idea of solidarity, reinforce the cause of health within the EU, 

and reinforce the role of the EU in multilateral institutions. A lot is going on already, but there is a 

long to do list, including: introducing health into regional cooperation strategies and the new 

Neighbourhood initiative; following up on trade and health issues; increasing awareness of human 

rights issues; and monitoring the priority medicines agenda. 

A visible debate in Brussels is urgently required in order to maintain interest and to level an 

unbalanced playing field: few of the twenty thousand lobbyists there are campaigning for public 

health. 

Ted Schrecker 

Professor Schrecker, drawing on the Canadian experience, hoped that the concept of solidarity, 

considered beyond the pale in North America, was not out of date in Europe. The idea of a strategy 

was to be strongly endorsed. 

Care was urged in the use of key concepts. The idea of global public goods has limitations; it has a 

precise meaning in economics which often excludes health, and issues of distribution are often 

overlooked. The linking of health and security should be resisted because the prevailing security 

agenda is so narrow; securitization risks the creation of stigmatised ‘Others’. Investing in health is 

almost certainly good development policy, but there is a risk that investment will be targeted to 

achieve the greatest return rather than meet the greatest need. And what is good economics at the 

firm or industry level may not be good for the public in general. Finally, health as a human right 

poses formidable challenges of imagination and implementation in the poorest countries. Taking the 

G8 countries as a focus, rich countries have failed to deliver fully their promises on global health and 

development, and still have a long way to go. 

Martin McKee 

Professor of European Public Health, London School of Hygiene and Tropical Medicine 

Professor McKee outlined three areas where a European Global Health Strategy could make a 

difference. 

First, the situation in the wider European neighbourhood, particularly the former Soviet Union, 




excluding Estonia, Latvia and Lithuania is urgent. Life expectancy is falling, yet assistance is trivial. 

Investment is required in North Africa and the Middle East, and the EU should make sure that the 

European CDC’s remit does not stop at EU borders. 

Second, the countries of the Western Balkans face much unfinished business; health gaps are 

growing and a range of threats to health exist: a tobacco epidemic, drug use, trafficking, prostitution 

and violence, plus tuberculosis and HIV/AIDS. 

Finally, Europe can provide a necessary counterpoint to the exceptionalism of the Bush 

administration on sound science, multilateralism, international law, protection of vulnerable 

populations and foreign policy that goes beyond narrow self interest. Europe can also fill gaps in 

reproductive health and untying EU aid. 

Discussion 

In discussion, participants highlighted a range of important issues: 

• Influencing recalcitrant governments to act on health through public accountability; 

• Engaging diplomats and lawyers in action for health; 

• Picking the right alliances, with industrial lobbies funding fake science; 

• How to engage philanthropy in shared visions of what needs to be done; 

• Keeping mental health on the agenda; 

• Involving civil society; 

• Taking gendered perspectives; 

• Although strategy may only come from crisis, the vision must be developed now, and this will 

place pressure on policy makers; 

• Developing a clear and consistent EU voice; 

• The power of Europe taking a global lead. 

Conclusions 

It was clear from the presentations and discussion that strong support exists for the idea of a 

European Global Health Strategy and that the proposed European Council for Global Health could 

provide a focus in developing it. Participants were clear on what needs to be done and who needs to 

do it. It is vital to fostering visible debate and accountability in Brussels. It was observed that the 

people in the room represented the coalition of the willing – the challenge is to persuade the 

unwilling to change. 



Workshop 6a 

HIV/AIDS in Europe: 

Economic and demographic 

challenges for health systems and 

disenfranchised populations 




��Gabriel Ghitescu Bringing children new hope: 428 

Melinda Hanisch The value of partnerships in fighting 

Jeffrey Sturchio HIV/AIDS in Romania 

��Magdalene Rosenmöller Summary report 436 

Page 




Bringing children new hope: the value of partnerships in fighting 

HIV/AIDS in Romania 

Gabriel Ghitescu, Melinda Hanisch and Jeffrey Sturchio 

The Romanian government and Merck* have worked together since 1997 to increase access to 

treatment for thousands of children and adults living with HIV/AIDS in Romania. Through this 

exceptional partnership, the number of patients with access to therapy has increased dramatically. In 

January 2002 the government announced that it had achieved its stated goal to provide antiretroviral 

therapy to 100% of patients in need of treatment, making Romania one of the few countries able to 

provide this level of care.[1] Romania’s commitment to fighting the epidemic, its determination to 

implement a comprehensive approach to the problem and its willingness to partner with the private 

sector make it a model for other countries fighting HIV and AIDS under similar circumstances. 

Merck’s contributions to the fight against HIV and AIDS 

As a leading research-based pharmaceutical company, Merck has a strong commitment to improving 

access to HIV/AIDS care and treatment throughout the world. Our primary role is to continue 

research and development into new life-saving treatments. In this connection, Merck Research 

Laboratories scientists have made important discoveries, such as understanding the role of the 

protease enzyme in the HIV life cycle and establishing the structure of the protease enzyme, which 

contributed to the development of the first protease inhibitors. In the 1990s, Merck scientists 

discovered and developed two novel medicines, CRIXIVAN (indinavir sulphate) and STOCRIN 

(efavirenz), which have played a pivotal role in the development of international standards of 

treatment for people with HIV/AIDS.[2,3] Merck is conducting clinical trials on an integrase inhibitor 

candidate and also has a major program of continuing research to develop a well-tolerated and 

effective HIV vaccine. 

Merck also has a role to play in fostering infrastructure development and facilitating access to 

HIV/AIDS treatment and care. Our commitment to public/private partnerships is recognized in many 

areas of the world, particularly where countries are suffering greatly from the ravages of the 

HIV/AIDS epidemic with limited resources of their own to cope. In addition to the partnership with 

Romania described here, Merck has undertaken several other initiatives to help increase access to 

treatment and care, including the Enhancing Care Initiative (in collaboration with the Harvard AIDS 

Institute) and the African Comprehensive HIV/AIDS Partnership (together with the Government of 

Botswana and the Bill & Melinda Gates Foundation). Merck also participates in the joint UN-industry 

Accelerating Access Initiative, with UNAIDS, WHO, the World Bank, UNICEF, UNFPA, and six other 

pharmaceutical companies. In addition to these initiatives, Merck is making its antiretroviral 

medicines available to the poorest countries and those hardest hit by the HIV/AIDS epidemic at 

prices at which the company does not profit.[4–7] 

Merck believes that a sustainable response to the HIV/AIDS epidemic depends not just on delivering 

* Merck & Co., Inc., Whitehouse Station, New Jersey, USA, is a leading research-driven pharmaceutical 

products and services company. Merck discovers, develops, manufactures and markets a broad range of 

innovative products to improve human and animal health, directly and through its joint ventures. Outside North 

America, the company operates in most countries under the name Merck Sharp & Dohme (MSD). 




effective medicines, but also on strong political commitment to a consistent and comprehensive 

strategy that includes improvements in health care infrastructure and appropriate funding that will 

enhance the quality, delivery and outcomes of care for HIV/AIDS patients. Public/private partnerships 

can facilitate and accelerate change by using targeted resources to make a difference. We believe 

Merck’s partnership with the Romanian government to expand access to HIV/AIDS treatment is an 

important example of how public/private partnerships can be used to great effect. 

Romania’s HIV crisis 

Almost 15 years ago, the world was shocked to discover that during the Ceausescu regime 

thousands of children in Romania, most of them orphans or abandoned, had been infected with 

HIV/AIDS. In the1990s, Romania was home to 60% of Europe’s pediatric AIDS cases.[8–10] Tragic 

images of young children dying of AIDS dominated the news in Romania and around the world. 

Romania’s HIV/AIDS problem differs from that in many other countries in the world, in that it is 

overwhelmingly a youth-based epidemic. When the problem was first discovered the majority of 

patients were children; in 1998 there were approximately 6,000 children and adolescents infected vs. 

approximately 1,000 adults. Today, even as many of these children have grown, AIDS in Romania is 

still a youth-based epidemic, with approximately two-thirds of patients – more than 5,000 people – 

under 18 years of age.[11] 

The Ceaucescu regime left Romania’s medical establishment ill-equipped to deal with the epidemic. 

While by 1997 all antiretroviral (ARV) drugs available worldwide were registered in Romania, access 

to treatment was constrained by several obstacles. Health professionals had little understanding of 

HIV, which inhibited diagnosis, and no uniform treatment standards existed, so physicians had no 

clear guidance regarding optimal treatment regimes or international standards of therapy. Patients 

were seen at local infectious disease hospitals, most of which had no capacity to monitor HIV 

infection in patients. From a public health perspective, there was no clear picture of the epidemiology 

of the epidemic in Romania, and no way to track individual cases. Further, there was a lack of 

necessary resources for treatment. As a result of these combined factors, in 1997, of some 6,200 

HIV-positive patients, only about 2,000 were treated (32%), of whom only 30 (1.5%) were on highlyactive 

antiretroviral therapy (HAART) in accordance with international guidelines.[11] 

Foundation for success – the National AIDS Programme 

In 1997, the government took decisive action to address the country’s chief obstacles in fighting the 

epidemic. A newly established National AIDS Committee, housed under the Ministry of Health, 

developed a national AIDS programme that was supported at the highest levels of government. In 

addition to prevention strategies, the plan contained three strategic elements aimed at improving 

access to treatment and care: first, a computerized network for case reporting and follow-up, which 

would also give a clear picture of epidemiology and allow doctors and public health experts to plan 

accurately for needed services; second, the development and implementation of the first national 

treatment guidelines; and third, the development of the necessary infrastructure for monitoring 

patients’ disease progression and evaluation of treatment strategies.[12] This was an impressive and 

ambitious initiative, but the Ministry of Health lacked the resources to sustain the program entirely. 

The government approached Merck with a proposal for a public/private partnership in implementing 

the program. 

Merck’s response 

The Romanian government’s approach to increasing access to treatment was wholly consistent with 

Merck’s views on the need to seek comprehensive solutions and the power of public/private 




partnerships in expanding access to HIV/AIDS treatment and care. Further, the government had 

demonstrated a clear commitment to fighting the epidemic, which had a unique character in Romania 

due to the overwhelming number of children infected. Thus, the Company saw an opportunity to 

target its resources to help effect real change for people living with HIV/AIDS in Romania. 

Over the past seven years, Merck has worked in partnership with the Government of Romania to 

support the implementation of the government’s national AIDS strategy at every stage, donating 

approximately $1.5 million toward projects aimed at improving the health care infrastructure for 

HIV/AIDS. In 1998, Merck supported the printing and distribution of the country's first national 

treatment guidelines for HIV/AIDS, which encouraged uniformity of treatment standards across the 

country. Next, also in 1998, a $40,000 donation from Merck facilitated the construction and 

implementation of a national AIDS database, which gave health authorities their first detailed picture 

of the scope of the disease in Romania, and allowed for individual case tracking and follow-up. 

In 1999, Merck donated $1 million to the National AIDS Committee to establish a network of seven 

regional AIDS treatment centres 

linking the 40 local infectious 

disease clinics throughout the 

country.[13] These centres were 

equipped with state-of-the-art 

technology for testing CD4 count 

and viral load. This made it 

possible for doctors to monitor the 

disease status of individual 

patients and to gauge the 

effectiveness of their treatment. 

Thus, the installation of these 

centres in one step raised the 

standard of care for all patients 

with HIV/AIDS to international 

levels. In the same year, on 

International AIDS Day, the 

National AIDS Committee 

awarded Merck Sharp & Dohme 

the Diploma of Excellence for its 

work in the fight against HIV/AIDS 

in Romania. 

Figure 1: Diploma of Excellence bestowed on MSD by Dr 

Adrian Streinu-Cercel, President of National AIDS 

Committee, 1 December 1999 

In 2002, Per Wold-Olsen, Merck’s 

President of Europe, Middle East 

& Africa, and former US Secretary 

of State Madeleine Albright visited Romania for a series of meetings with then President Iliescu, then 

Prime Minister Nastase and other top Romanian officials. At that time Mr Wold-Olsen announced 

additional contributions for Romania’s HIV/AIDS program, including $230,000 to finance purchase of 

additional CD4 tests for all monitored patients for one year; $20,000 to set up the national AIDS 

database within the Ministry of Health; and technical assistance in procurement management, which 

would reduce costs by up to $5 million while allowing for the treatment of 500 additional patients 

expected to require treatment over the following year.[14] 




Figure 2: AIDS budget and numbers of treated patients, 1997–2004 

Million USD 

40 

35 

30 

25 

20 

15 

10 

5 

0 

treated patients 

2.1 

1.9 

2.7 

5.5 

2.4 

8.5 

3.0 

Financial factors leading to increased access 

13 

1997 1998 1999 2000 2001 2002 2003 2004 

Source: Romanian National AIDS Committee 

000s patients 

In addition to the National AIDS programme, the Romanian government further demonstrated its 

commitment to solving the access problem by steadily increasing the treatment budget from $2.7 

million in 1997 to $32 million in 2004 – more than a ten-fold increase. The rise in budget 

commitments tracks with the steady increase in treated patients throughout that period, from about 

1,900 to approximately 5,700 (see Figure 2). 

In March 2001, Merck announced that it was unconditionally lowering prices for its AIDS medications, 

CRIXIVAN and STOCRIN, to levels where it makes no profit in the world’s poorest countries and 

those hardest hit by the epidemic.* These prices were also extended to the government of Romania 

because of its strong political commitment to fighting the epidemic, especially its commitment to 

provide universal access to HAART. Merck’s action helped the government significantly to increase 

the number of patients currently being treated.[15] Merck was the first company in Romania to provide 

such unconditional and significant price reductions in Romania. Later that year, at the time of the UN 

General Assembly Special Session on HIV/AIDS (UNGASS), the government obtained commitments 

from other companies for future price reductions under the UN Accelerating Access Initiative. 

* As a guideline to identify developing countries to which these differential prices for CRIXIVAN and STOCRIN 

apply, Merck uses the generally accepted United Nations Development Programme’s Human Development 

Index (HDI). The HDI measures the overall development of countries with an indicator combining life 

expectancy, educational attainment and standard of living (in GDP per capita). Countries are classified as having 

high, medium or low human development. In addition, Merck adjusts for the severity of the HIV epidemic in 

specific countries (as measured by adult prevalence rates reported by UNAIDS). In addition to providing the 

lowest prices to countries in the low HDI category, these prices also apply to countries in the medium HDI 

category with an adult HIV prevalence of 1% or greater. More information on Merck’s HIV pricing policy can be 

found at www.merck.com/about/cr/policies_performance/social/medicines_developing.html. 



4.4 

21 

4.6 

25 

4.9 

30 

5.7 

32 

6 

5 

4 

3 

2 

1 

0


Government actions in 2001: a new level of commitment 

In early 2001, the newly-elected government of President Ion Iliescu and Prime Minister Adrian 

Nastase set itself the goal of providing 100% access to international standards of ARV treatment by 

the end of 2001, and moved aggressively to make that happen, announcing several new legislative 

measures to facilitate the fight against AIDS. These included cutting import taxes and VAT on AIDS 

medications, and increasing the budget for treatment by more than 60% (from $13 million in 2000 to 

$21 million in 2001), with a supplemental allocation for children. The Parliament also adopted a 

decree ensuring the rights of children with HIV/AIDS, including right to treatment. 

The government took the fight against AIDS to a new level in 2001 by establishing a high-level 

Intersectoral Committee on HIV/AIDS. Co-chaired by UNOPA, the main Romanian HIV/AIDS 

patients’ organization, the Committee was a clear effort to reach out to all relevant public and private 

players, including the Ministries of Health, Education, Finance and International Affairs, the national 

insurance house, UNICEF, UNAIDS, and representative of industry and local NGOs. The purpose of 

the Committee was to ensure cooperation among ministries and between the public and private 

sectors on issues of HIV/AIDS treatment and care, prevention, education and social rights, and to 

ensure coordination and timely implementation of relevant government initiatives. The Committee 

was instrumental in obtaining a $39 million grant from the Global Fund to Fight AIDS, TB and Malaria 

to improve prevention of HIV/AIDS and tuberculosis.[16] 

HIV in Romania today: the power of partnerships 

In January 2002, the government announced it had achieved its goal of being able to provide HAART 

to all HIV/AIDS patients who need it according to international guidelines.[17] Then Minister of Health 

Dr Daniela Bartos and Dr Adrian Streinu-Cercel, President of the National AIDS Committee, publicly 

recognized Merck and the public/private partnership as a critical success factor in helping to achieve 

universal treatment access. The success of the partnership was further highlighted at a joint briefing 

during the May 2002 United Nations General Assembly Special Session (UNGASS) on Children.[18] 

The government’s accomplishments in expanding access to HIV/AIDS treatment and care could not 

be more impressive. While in 1997, only five out of every thousand diagnosed patients received ARV 

therapy, today all patients who need antiretroviral treatment under international guidelines – almost 

6000 individuals – receive such treatment. Of those, approximately 94% are on triple combination 

therapy, while the remaining 6% are being treated successfully on other regimes.[11] This rate of 

treatment is directly comparable to those found in most industrialized countries.[19] 

Lessons learned 

The Romanian government’s success in expanding access to international standards of treatment for 

all HIV/AIDS patients, including thousands of children, has drawn attention in the international 

media,[9] and international experts have cited it as a possible model for other countries fighting the 

epidemic under similar circumstances. For example, Dr Peter Piot, Executive Director of UNAIDS, 

has said: “…one of the lessons of Romania (is) that (improving access to treatment) can be done. If 

the political will is there, and if a good partnership is found with manufacturers of drugs like Merck, 

with the medical community, with patient groups, it’s possible.“[20] 

In this connection, several lessons can be drawn from this experience: 

Political commitment of the government is a must. The Romanian government demonstrated a great 

deal of courage in acknowledging the tragedy of HIV/AIDS infection in their country. The 

establishment of the National AIDS Committee, the development and step-by-step implementation of 




a clear strategy through the national AIDS program, and steadily increasing the budget allocation for 

treatment all required a high degree of political will. The program could not have been developed, nor 

sustained through two successive governments, without it. 

National capacity can be built. The success of the government’s comprehensive strategy depended 

on building a health care infrastructure that was equipped both professionally and materially to 

improve diagnosis, treatment and care. The promulgation of the first national HIV/AIDS treatment 

guidelines and the establishment of a network of state of the art regional AIDS treatment centres 

helped to substantially raise the level of care available to patients in Romania. 

Engagement of all sectors of national society and the /global community are necessary. The 

government’s outreach to patient groups, and its establishment of the Intersectoral Committee, with 

its involvement of all major public and private stakeholders, helped to galvanize the country’s 

commitment to dealing with HIV/AIDS not only as a public health problem, but also as a social and 

economic issue. The public/private partnership with Merck has been recognized by the government 

as critical to their success. 

Safe and secure distribution systems can be implemented. Romania has over 20 distributors for 

HIV/AIDS drugs and medical equipment. In recent years the procurement system has been 

streamlined; in 2002 a national tender was implemented to designate one party to supply all 

HIV/AIDS treatment centres. This served to stabilize the distribution of HIV/AIDS drugs in the country 

and greatly reduced the potential for fluctuations in drug acquisition, which had been a particular 

problem at the local level. 

Prices have come down significantly – but this alone is not enough, and third-party financial support 

is needed. Merck’s action to cut the prices unilaterally on its HIV/AIDS medications enabled the 

government to move closer toward its 100% treatment goal. Still, universal access in Romania could 

not have been achieved without the government’s actions to increase the budget commitment for 

HIV/AIDS treatment 10 times over seven years, or without efforts to procure additional support from 

outside sources such as donations, sponsorships and the Global Fund. 

Support for continued investment in research and development by the pharmaceutical industry is 

critical. Romania has achieved universal treatment while maintaining intellectual property laws that 

are fully compatible with its obligations as a WTO member under TRIPS. This proves that upholding 

of international standards of intellectual property protection does not constitute a barrier per se to 

treatment access. 

Bringing children new hope 

Working together, the Romanian government and Merck have enabled access to treatment for all 

people living with HIV/AIDS in Romania, including thousands of children and adolescents. 

Public/private partnerships like the one between the Romanian government and Merck, which 

combine public sector support with targeted private sector resources, can effectively increase the 

number of people who have access to international standards of care. The Romanian case 

demonstrates that, when the right policies are in place, and with commitment, action, and 

partnership, significant progress is possible in improving access to treatment for patients living with 

HIV/AIDS. 




References 

1. Romanian National AIDS Committee/Ministry of Health and Family press release, Ministry of 

Health and Family announces that today all HIV/AIDS patients that need treatment have access now 

to antiretroviral therapy, 31 January 2002. 

2. Galambos L. War against HIV, American Heritage of Invention & Technology 

2000;15(Spring):56–63. 

3. Galambos L, Eliot Sewell J. Confronting AIDS: Science and Business Cross a Unique Frontier 

Whitehouse Station, NJ: Merck & Co., Inc., 1998. 

4. The Enhancing Care Initiative: AIDS Care Teams in Action, 1998–2004. Boston, Massachusetts: 

Harvard School of Public Health, 2004. 

5. Collaborating to Improve HIV/AIDS Care and Treatment in Resource-Scarce Settings: How to 

Form and Sustain Effective AIDS Care Teams Boston, Massachusetts: Harvard School of Public 

Health, 2004. 

6. Distlerath LM, MacDonald G. The African Comprehensive AIDS Partnerships – a new role for 

multinational corporations in global health policy, Yale Journal of Health Policy, Law and Ethics 

2004:IV(1):147–56. 

7. Watson PA (ed). The Front Line in the War Against HIV/AIDS in Botswana: Case Studies from the 

African Comprehensive HIV/AIDS Partnerships (ACHAP) Gaborone, Botswana: African 

Comprehensive AIDS Partnerships, 2004. 

More information on Merck’s initiatives on access to medicines in the developing world can be found 

at http://www.merck.com/about/cr/policies_performance/social/medicines_developing.html. 

8. www.usembassy.ro/USAID/hiv2.htm 

9. McNeil D. Romania declares victory in fight against AIDS, New York Times, 11 February 2004, 

p A1. 

10. Hamers FF, Downs, AM. HIV in central and eastern Europe, The Lancet 2003;361:1037. 

11. Data from Romanian National AIDS Committee. 

12. Romanian National AIDS Committee, National AIDS Programme, 1997–2000. 

13. Romanian National AIDS Committee press release, Romania Announces New Step in National 

AIDS Programme, Bucharest, Romania, 2 July 1999. 

14. Government of Romania press release, Meeting of Romanian Prime Minister Adrian Nastase with 

Madeleine K. Albright, Former US Secretary of State, Michael Guest, US Ambassador to Romania, 

and Per Wold-Olsen, President, Europe, Middle East & Africa, Merck & Co., Inc., USA. Bucharest, 

Romania, 25 November 2002. 

15. MSD Romania press release, Merck Sharp & Dohme to help speed access to HIV treatment in 

Romania through significant price reductions for CRIXIVAN and STOCRIN, Bucharest, Romania, 12 

March 2001. 




16. www.theglobalfund.org/search/portfolio.aspx?countryID=ROM 

17. Romanian National AIDS Committee/Ministry of Health and Family press release, Ministry of 

Health and Family announces that today all HIV/AIDS patients that need treatment have access now 

to antiretroviral therapy, Bucharest, Romania, 31 January 2002. 

18. Permanent Mission of Romania to the United Nations, press release, Partnership Brings Hope to 

Romania’s Children, New York, 9 May 2002. 

19. Data from the World Health Organization’s 3 x 5 initiative, March 2004. 

[www.who.int/3by5/en/coverage_march2004.jpg] 

20. A Reason for Joy, joint video presentation by Merck and Government of Romania, ©2003 by 

Merck & Co. Inc., USA. 




Summary Report 

Magdalene Rosenmöller 

The HIV/AIDS challenge: impact and consequences for socioeconomic development in 

Europe 

Following the tradition at the European Health Forum Gastein, this Saturday morning’s Special 

Interest Session was jointly organized by the World Bank and the European Commission. This year’s 

focus was on the HIV/AIDS epidemic in Europe, following on from the Dublin Agenda and the Vilnius 

conference, with particular attention paid to the challenges for health systems and vulnerable groups. 

HIV/AIDS in the wider European neighbourhood: trends and findings from recent World Bank studies 

– J Godinho and T Novotny 

Although frequently underestimated, the HIV/AIDS epidemic is a serious threat for Eastern Europe 

and Central Asia. Different World Bank programmes have addressed the epidemic not just in terms 

of health, but also as a development issue, with the realization of the extraordinary opportunity to 

prevent explosive growth by sufficiently early intervention. 

MDGs, AIDS and youth: what does the future hold for economic and social development? – 

J Baudouy 

The HIV/AIDS epidemic, which is favoured by arms and drug trafficking and increasing migratory 

movements, affects young people above all. There are a range of socioeconomic implications 

resulting from the high costs of treatment, loss of productivity/social capital and a rising dependency 

ratio. Interesting case studies exist from countries such as Moldova, where programmes target 

particularly vulnerable groups. Other actions include improving information about the function of 

public health, increasing the opportunities for youths to participate in the knowledge economy and 

decriminalizing risk-related behaviour. More information at: www.worldbank.org/eca/aids 

The AIDS epidemic – impact of on policy making: a case study from Russia – S Sharp 

Economic models can help in the difficult task of better appreciating the impact of the epidemic. The 

different models: UNDP (macroeconomic analysis); World Bank (more practical); and ILO (more 

sectoral), serve different purposes and use different criteria, but they show similar scenarios: a 

decline in population and GDP. The Imperial College model, the most comprehensive and integrative 

model available, focuses on micro-economics. Modelling in Russia has led to an increase in 

resources and has helped make advances in the issue in terms of advocacy, by moving away from 

an emotive to an objective language, providing a clear structure as a basis for debate, engaging 

potential opponents, and gaining attention in policy analysis. More information at: 

www.undp.org/rbec/ 

UNAIDS – national and international roles in policy making – L Loures 

UNAIDS, working in synergy with the World Bank and GTFAM in Central Asia, faces the important 

problem of scarce resources, the impact from trade agreements and the global context. UNAIDS is 

an important regional authority, allowing for the sharing of success stories and forging alliances and 

cooperation across regions, both South/South and North/South. More information at: www.unaids.org 




The Global Fund and its outreach to the disenfranchised – U Weber 

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an independent public–private 

partnership with the aim of disbursing funds geared towards the disenfranchised. So far a total of 

over $4 billion in four funding rounds has been allocated to 128 countries, of which 22 are in Europe. 

A major challenge is to find the right balance between the key priorities of sustainability, ownership, 

speed, and accountability. The extent of the epidemic and its explosive development requires a very 

speedy implementation – but this is often over-ambitious. Other constraints are cumbersome 

procedures, lack of management and institutional capacity and a low capacity in civil society. 

Targeting vulnerable groups is difficult, with the additional hindrance of the power struggle that 

accompanies the distribution of funds. More information at: www.theglobalfund.org/en/ 

Addressing the challenge: local and global responses to serve disenfranchised populations 

and foster exchange and experience 

Making services work for poor people: examples of public-private partnerships – Pinel 

An interesting example of a successful public-private partnership comes from Romania. In the light of 

high infection rates, particularly among children, insufficient infrastructure, poorly prepared 

professionals and a very low level of access to treatment, the Romanian government approached 

MSD in 1997 with a call for help. The national AIDS Committee was established within the MoH, 

supported by MSD with the development of national HIV/AIDS treatment guidelines, donations to the 

construction of the national AIDS database, and the establishment of the national network of 

treatment centres, test kits, and technical assistance. Increased access to treatment was achieved 

on the one hand by a rise in the allocation in the state budget, and by the lowering of prices by MSD 

on the other. The new goal of 100% TTT set out in 2000 was achieved in 2002. Success factors in 

this experience included political commitment to the programme, the building of national capacity, the 

engagement of all sectors, safe and secure distribution systems, the lowering of treatment prices with 

the concomitant financial participation of other players. More information at: 

www.merck.com/about/cr/policies_performance/social/romania_network.html 

How countries cope with AIDS: a case study from Moldova – V Soltan 

The case study from Moldova showed that it is possible to successfully address the AIDS epidemic. 

Moldova underwent an important increase in AIDS at the end of the 1990s, accentuated by a context 

of difficult economic conditions and insufficient surveillance capacities. The National Programme, set 

up in 2001, represented a joint effort by the government, civil society and others, and received grant 

funding from the World Bank, GFTAM and USAID. It resulted in a 100% availability of ART, the 

setting up of a national monitoring and surveillance system and the necessary laboratory equipment 

and training of professionals. Other activities were addressed to vulnerable groups in collaboration 

with the Soros Foundation, to uniformed services (with UNDP), to prisons, and other NGO projects. 

While the HIV prevalence rate continued to increase, reduction has been seen particularly with 

injecting drug users (IDU). This is mainly due to the effectiveness of education and harm reduction 

activities. Future challenges lie with other vulnerable groups particularly CSWs and youths at risk. 

More information at: http://hivinsite.ucsf.edu/global?page=cr03-md-00 

The role of NGOs: combating AIDS and reducing drug-related harm in Central and Eastern Europe 

and Central Asia – Illiuta 

NGOs play a particularly important role in combating AIDS and reducing related damage in Central 

and Eastern Europe and Central Asia. The mission of CEEHRN, the CEE Harm Reduction Network 

is to support, develop and advocate harm reduction strategies. Founded in 1997, the organization 




now has 211 members in 25 countries. Activities include a website, a database on best practices, 

toolkits, partnership networking, training and organization of conferences. The main problems in 

these regions are the high and increasing numbers of people living with HIV/AIDS, of whom very few 

have access to ARV, due to the high prices, the weak medical infrastructure, the discrimination and 

stigma related to the epidemic, and poor adherence to the treatment. NGOs are best placed to 

induce change by advocating making HIV a political priority, informing policy makers about the needs 

of civil society, providing information to PLWHA, supporting the development of national strategies 

and guidelines, helping to provide services to the affected communities, offering training to medical 

professionals and supporting the development of treatment services. The CEEHRN experience has 

shown that a correct response is a mix of services addressing the needs of the vulnerable 

population. More information at: www.ceehrn.org 

Addressing the AIDS challenge through networking – Françoise Hamers 

In Europe, a number of different communicable diseases networks assure surveillance. EuroHIV, the 

surveillance network for HIV/AIDS, acts in 52 countries in the European region. This surveillance 

started in 1984, and was the first Europe-wide surveillance system. Hosted at the Veille Sanitaire 

(France) since 1999, it is funded by the European Union and collaborates with WHO and UNAIDS. 

Its main role is early detection, confirmation of trends, and outlining the broader epidemiological 

situation. Surveillance in Europe shows different pictures: in the west, there is a mature, 

concentrated epidemic, increasing in migrants and homo/bisexual men. In Eastern Europe and 

Central Asia, the epidemic is predominantly among injecting drug users, and is emerging among 

heterosexuals. In Central Europe, the epidemic is quite low, but the risk of spreading is present in all 

countries. European surveillance and international comparisons provide a very positive force for 

action; furthermore, data are important for advocacy and have the catalyzing role of improving 

national surveillance systems. Difficulties include the differences in national systems, which hinder 

comparison (but at the same time provide richness), the frailty of the funding mechanisms, and the 

cumbersomeness of European administrative procedures. But these are offset by a strong political 

commitment to the fight against HIV/AIDS and the recent creation of the European Centre for 

Disease Prevention and Control (ECDC). Future challenges include the successful integration of 

European surveillance networks into the ECDC, collaboration with the new member states and the 

neighbouring countries in strengthening the link between surveillance and prevention, the promotion 

of new laboratory technologies and the implementation of behavioural surveillance. More information 

at: www.eurohiv.org 

Reaching marginalized groups via national programmes – E Klinkert 

The Netherlands, holder of the EU presidency in 2004, has a very strong programme of development 

cooperation particularly geared towards marginalized groups. The Dutch government allocates 0.8% 

of GNP to development, which is implemented in a decentralised way, with a particular focus on 

poverty alleviation, including HIV/AIDS. Marginalized groups include poor people (women, youths 

and children), sick people, PLWHA, migrants, drug users, sexual minorities and the homeless. 

SWAP, the sector-wide approach, includes HIV/AIDS activities in the support of basic health services, 

including reproductive health. But for this multi-sectoral issue, the challenge is to reach marginalized 

groups, as political commitment is limited, sexual rights are usually absent and the issue is tainted 

with stigma and discrimination. The many stakeholders are usually poorly coordinated, while AIDS is 

eroding whatever little capacity is present. The three Cs (commitment, coordination and capacity) 

guide work with governments and civil society. Close cooperation with NGOs and civil society is 

important, as they are usually part of the solution. More information at: www.minbuza.nl 




European HIV/AIDS strategies. The EU Centre for Disease Prevention and Control 

The European Union has a long history of HIV/AIDS policies, with this issue being the focus of public 

health activities since the 1980s, with the establishment of a network of experts and the Community 

network on surveillance and control of communicable diseases. The EU development cooperation 

framework places HIV/AIDS in the context of poverty reduction, and the EU research programme 

committed itself to supporting the Development Clinical Trial Partnership. The alarming incidence of 

HIV in Eastern Europe and the neighbouring counties is addressed under the public health 

programme and other horizontal instruments. The Dublin and Vilnius conferences have shown that 

there is a need for a new HIV/AIDS prevention policy. The epidemic affects all areas, not only health, 

and so there is a need for a coordinated and integrated approach within the EU and its surrounding 

regions. The aim of the EU action is to offer a synthesis of best practices, elaborating basic priorities 

and suggesting operational action points by the end of 2005. The main areas for action are the 

prevention of new infections, the reduction of the negative impact of the epidemic, the mobilisation of 

resources, and better coordination. The action plan includes an EU-wide information campaign, 

involvement of youth, a focus on vulnerable groups and sustainable health systems. The 

development of epidemiological surveillance systems in partnership with neighbouring countries and 

the exchange of best practice leadership and advocacy are crucial. More information at: 

www.europa.eu.int/comm/health/index_en.htm 

Discussion 

In the subsequent discussion a number of issues were raised. In particular, it was found that the 

seriousness of the situation calls for very speedy action. The pattern of the situation is changing: the 

growth rate among IDUs is stagnating, while heterosexual transmission cases are increasing. Gay 

men are one of the most vulnerable groups, as stigma and discrimination are high in the region. 

Surveillance and economic models continue to be very useful tools, even though issues of data 

collection and protection need to be solved in many countries. For the access to and pricing of drugs, 

it is important not only to take account of producer prices, but also of the mark-ups by the distribution 

channels and the custom duties of recipient countries. Here collaboration between the industry and 

government is paramount. With HIV/AIDS as a pan-European problem, the European Union is 

assuming its responsibility in the fight against the epidemic. 

The lack of institutional capacity in the countries in question is often a big drawback in the fight 

against HIV/AIDS. The implementation and/or scaling up of projects and programmes is highly 

dependent on local capacities. Training of professionals is extremely necessary. Being at the 

forefront, nurses are particularly exposed, and their problems are usually not taken into account. One 

problem was treated very openly in the discussion: corruption, often due to lack of institutional 

capacity and managerial skills, unclear definitions of procedures and monitoring systems, while low 

incomes might tempt some to mismanagement. Action needs to include training, good monitoring 

systems and very prompt action in case of irregularities. 

Conclusions 

A whole series of take-home lessons came out of the session: in such an alarming situation, the 

speed of implementation of projects is determined by the epidemic. Models are very useful, they are 

objective, bring forward advocacy and lead to better responses. Cooperation is essential: all actors 

need to be involved and public private partnerships have advantages. It is important to see that it is 

not only a health matter, but a general, multi-sectoral issue in need of an integrative strategy. 

Increased collaboration and exchange of experiences and best practices, as in the present session, 

were welcomed by all organizations and participants. 



Lunch Workshop L1 

Towards a health 

competent consumer: 

EU policy action for improved health 

information 




��Rodney Elgie Health information: the patient’s perspective (abstract) 442 

��Christine Marking Information to patients and EU policy initiatives 444 

��Peter Singleton The second ‘Informed Patient’ report: 451 

‘An EU Framework for Action’ 

Page 




Health information: the patient’s perspective 

Rodney Elgie 

Abstract 

Health costs are rising and will continue to do so with the advent of new medicines, new surgical 

techniques and new diagnostic procedures. Consumers have come to expect not only a better quality 

of life, but a longer life and one without disability where ever possible. Yet there are serious doubts 

as to whether illnesses are being detected early enough, or if the optimum treatment is prescribed 

when the correct diagnosis is made, or if the correct treatment regime is implemented whether the 

consumer is fully compliant. Governments within the EU appear to deliberately withdraw from 

promoting good health linked to appropriate preventative measures. There is little immediate political 

mileage in the notion of prevention. It requires a long-term strategy and substantial investment of all 

manner of resources. This is an alien concept to governments that enjoy a life span of four years or 

less and thus need immediate impact and voter appeal. From the consumer's perspective, if 

governments think good health is expensive, then try putting a cost to poor health. The figure will 

certainly be far more frightening. 

Information on its own has limited value. For example, in the UK, successive governments have 

spent millions of Euros on providing information about the dangers of smoking, often accompanied 

by quite graphic captions. However, the number of teenage girls taking up smoking has actually 

increased over the past ten years. Clearly, information does not change lifestyles or behaviour per 

se. The teenage girl seeks to emulate the slim-line figure of her favourite pop idol, film star or model: 

lung cancer is viewed as affecting people in their forties and fifties. When you are fifteen that is a 

lifetime away and by then there will probably be cures for all types of cancer in any event. We have 

encountered the same unfortunate experience with sexually transmitted disease and unwanted 

pregnancies in the UK over the past decade, so it is safe to assume that information relating to safe 

sex has been an abject failure. It is likely to prove true for obesity as well, despite current information 

programmes on healthy eating and healthy lifestyles. 

We now need a radical overhaul in the way health is delivered in the EU. We have witnessed 

substantial changes in societal needs over the past century. In the first half of the twentieth century 

the emphasis was on the control of infectious diseases such as polio and TB. The focus then 

switched to episodic care in the second half of the last century with the concentration on acute 

episodes such as heart attacks. For the first half of this century we need to look at chronic care, 

especially in those countries with a low GDP. Chronic conditions represent the greatest challenge to 

all European states today. If we are to begin to cope financially, the trick must be to do more with the 

same level of resources. How might that be achieved? By the reduction in current levels of waste 

occasioned by under-, over-, mis- and non-diagnosis accompanied all too often by over-, under- or 

inappropriate prescribing. That is not to say the physician is wholly to blame. Equal liability and fault 

rests with the consumer through poor compliance. It matters not which word is used to describe 

these phenomena – compliance, adherence, alliance or concordance – the fact remains that all too 

many patients fail, for whatever reason, to take their medicine in the most effective way. 

What is needed is education and knowledge to go hand in hand with information, so that the 

information provided is fully understood along with the rationale behind it. As we move away from the 

old notion of diagnosis and treat to predict and prevent, education will be at the forefront. We need to 

view health as an investment, not a cost. Ill health at its most extreme, such as the Black Death 




epidemic in the 14th century and the AIDS epidemic in the 20th century, wreaked economic havoc in 

those countries that were affected the most. Educated consumers will not only consume medicines in 

a more effective fashion. They will seek early intervention and early diagnosis. We practice 

preventative measures in the area of dentistry so why not implement a similar practice for physical 

and mental well-being? Why do men value their cars more highly than their own bodies? They are 

educated about engines and the need for carrying out timely servicing and repairs on their vehicle. 

They are not educated or knowledgeable about their own bodies and the benefits accruing from an 

annual check up booked at the same time as their car service! A more health competent consumer is 

someone who, through education combined with information, appreciates why they adopt certain 

practices and avoid others, accepts a degree of responsibility for the management of his or her own 

state of good health, for example, through diet, exercise and general lifestyle, and develops a 

productive partnership with the health professionals charged with the delivery of cost effective health 

care. 




Information to patients and EU policy initiatives 

Christine Marking 

This paper provides a brief overview of the most relevant current EU policy developments which 

could provide opportunities (‘policy entry points’) to progress better provision of quality health 

information to patients and consumers. 

European Commission 

G10 

The ‘G10 Medicines High Level Group on Innovation and the Provision of Medicines’ was established 

in March 2001. The aim was to bring together key EU decision-makers to discuss the issues relevant 

to achieving the right balance of health objectives and industry competitiveness in Europe. A report 

[1] was produced containing 14 recommendations, including a specific recommendation on 

information to patients. The Commission has responded to these recommendations by means of a 

Communication [2] outlining practical steps for the implementation of the recommendations. 

Recommendations on Enhanced Information and Patient Information Leaflets: 

• Establishing an information and knowledge system: a European Health Portal; 

• Explore a range of approaches to provide a realistic and practical framework for the provision of 

information on prescription and non-prescription medicines; 

• Prohibition on advertising of prescription medicines to the public will continue; 

• Reflect on establishing a ‘Public Private Partnership’ to advise and monitor the quality of existing 

information and produce guidelines; 

• Re-ordering of the information in the patient information leaflet to improve their comprehensibility; 

• Introducing of mandatory readability testing of leaflets; 

• EMEA undertaking a project, with patient organisations, to consider new ways of ensuring that 

information on medicines takes more account of patient needs. 

Within this context, DGs SANCO and Enterprise are exploring the establishment of public-private 

partnerships in relation to medicine information provision. A working group, composed of 

representatives of all stakeholders, will probably be set up to progress the issue. 

Review of the EU pharmaceutical legislation 

In March 2004, EU Industry Ministers formally approved the European Parliament’s position on the 

Review of EU pharmaceutical legislation (FML). Member States will now have 18 months to adopt 

the Directives (approximately by October 2005). 

While key aspects mostly relate to ‘technical’ issues such as the Centralised Procedure, the 

composition of the EMEA Management Board and new terms for data protection, information to 

patients became a hotly debated issue during the deliberation processes. The Commission’s original 




proposal to allow industry to directly provide information on prescription medicines to consumers in 

three disease areas was rejected by the European Parliament, and intense debates, involving all 

health stakeholders, took place on what the next steps should be. As a result, the European 

Parliament has requested the Commission to come forward with a thorough analysis of the situation 

relating to the provision of medicines information as well as recommendations for next steps. This 

will need to be completed before the end of 2007. 

Public Health Framework Programme 

In March 2003 the EU's new Public Health Action Programme [3] was launched, which will run 

between 2003 and 2008. The aim is to embody an integrated approach towards protecting and 

improving health in the EU. 

The programme will support and encourage activities such as networks, coordinated responses to 

health challenges, sharing of experience, training and dissemination of information and knowledge. 

As part of this integrated approach, links with other EU programmes and actions will be created. The 

programme will focus on three key priorities in a ‘horizontal’ (i.e. integrated) way: 

• Improving health information and knowledge 

• Ensuring rapid reaction to health threats 

• Addressing health determinants through health promotion 

The programme is implemented on the basis of annual work programmes, setting out the priorities 

under the three strands of the programme. These programmes are agreed between the Commission 

and the programme’s advisory committee, consisting of high-level representatives of the Member 

States’ health authorities. Calls for proposals are issued on the basis of these work programmes, 

inviting governmental bodies, academic institutes and European NGOs to apply for EU project 

funding. 

The 2004 work programme on health information focuses on a number of interesting issues such as 

the establishment of a EU public health portal, e-Health and health impact assessment. 

Health information portal 

The Commission is in the process of exploring the possibilities of putting in place a health information 

portal, as part of the Public Health Framework Programme and the e-Health initiative (cooperation 

between DG Sanco and DG InfSoc). 

European Health Forum Working Group on health information 

The EU Health Forum serves as an information and consultation mechanism to ensure that the aims 

of the Community’s health strategy are made clear to the public and respond to their concerns. It 

aims to provide an opportunity to representative organisations of patients, health professionals and 

other stakeholders, such as health service providers, to make contributions to health policy 

development, its implementation and the setting of priorities for action. 

The EU Health Forum is composed of two complementary elements: an Open Forum as a platform 

for general exchange of information and for a discussion with a broader range of groups and 

interested parties, and a Health Policy Forum with a consistent set of member organisations, for the 

discussion of key policy areas. Several working groups have been set up as part of the Health Policy 

Forum, including the Citizens and Health Information Working Group. This will present a set of 

recommendations to be adopted by the Health Policy Forum as a whole in November 2004. 




Increasing Cooperation between the Member States 

While responsibility for health care rests with Member States, there are a number of common 

challenges – the ageing society, increasing demands and expectations from citizens and rapid 

technological change – which call for cooperation between Member States. Therefore, the 

Commission is currently stepping up its efforts to promote this cooperation, focusing on access to 

and financial viability and quality of health care. As part of this strategy, three recent initiatives need 

to be mentioned: 

1. Patient mobility 

In response to a number of European Court of Justice rulings (stating that patients have the right 

to access health care in another Member State with the cost borne by their own health system), 

and the realisation that health services are not exempt from the free movement rules of the EU 

Single Market, the Commission invited ministers from the Member States and representatives of 

civil society to take part in the so-called ‘High-level Process of Reflection on Patient Mobility and 

health care Developments in the European Union’ (HLRP) in June 2002. 

This led to a report outlining recommendations in five key areas.[4] The Commission has adopted 

a Communication [5] setting out its response to the HLRP recommendations in April 2004. 

Recommendations include the need for: 

• Better provision of information to patients on how to obtain treatment in other Member States. 

Even if EU law gives patients the right to seek treatment in other Member States, exercising 

these rights is not always straightforward. Accessing health care in another Member State 

depends on having information about the quality, availability and appropriateness of the 

treatments available there. It also means knowing how to get your national health care system 

or health insurer to pay for the treatment. 

• A more systematic exchange of best practice. 

• The creation of a High Level Group on Health Services and Medical Care, bringing together 

Member State representatives and the Commission, to drive this process of cooperation. 

2. ‘Open Method of Coordination’ 

The Commission has published a Communication in April,[6] proposing to apply the ‘open method 

of cooperation’ in this area. This addresses practical cooperation at government level by 

proposing to develop a series of joint objectives and indicators, providing Member States with a 

concrete framework for cooperation under three main strands of action: 

• Ensuring access to high-quality care and providing a safety net against poverty or social 

exclusion associated with ill-health, accident, disability or old age 

• Promoting high-quality care in order to improve people’s state of health and quality of life by 

promoting practices and treatments providing benefits for health and quality of life 

• Ensuring the long-term financial sustainability of high-quality care accessible to all by achieving 

a sustainable rate of expenditure development 

If adopted, Member States will need to implement national action programmes on the basis of a 

set of EU indicators and guidelines and to report back on their progress (benchmarking). 




3. e-Health Action Plan 

The Commission recently adopted a Communication [7] entitled ‘e-Health – making health care 

better for European citizens: an action plan for a European e-Health area’. All health care systems 

face major challenges, such as a rising demand for health and social services. e-Health can make 

a contribution towards meeting these challenges, improve access to health care and boost the 

quality and effectiveness of health services. 

As part of the EU’s e-Europe strategy, the e-Health action plan focuses on three issues: 

• How to address common challenges and support e-Health 

• Pilot actions to jump start the delivery of e-Health 

• Working together and monitoring practice 

EU Research Framework Programmes 

The current EU Research Framework Programme (FP6, 2003–2006 )[8] addresses health under one 

of its seven Priority Thematic Areas, i.e. Life sciences, Biotechnology and Genomics for Health. 

Research actions focus on application-oriented genomic approaches to medical knowledge and 

technologies (with as main objective the development of strategies for the prevention and 

management of human disease and for living and ageing healthily) and a number of major diseases 

such as cancer. 

Preparations for the next Framework Programme (FP7) are already underway: a first outline of the 

content is expected in the next few months. 

Other EU policies worth exploring: 

• Education: exchange programmes addressing health education and health professionals 

• Structural Funds: European Social Fund: employment in health, health infrastructure, health 

information in the workplace 

European Parliament 

A new Parliament 

A new Parliament will take office in September, providing the opportunity for new allies and new 

initiatives. One of these is a campaign to create a patient intergroup (secretariat to be provided by 

the European Patients Forum), which will actively advocate on health information and health 

education issues. Other intergroups with a health focus (for example, the Disability Intergroup, the 

Intergroup on Ageing) could also address information issues as part of their work programmes. 

Monitoring the Commission’s progress 

As stated above, the current Parliament has actively demonstrated its interest in the issue during the 

review of the pharmaceutical legislation and has requested the Commission to come forward with an 

analysis and proposal within the next three years. This means that the next Parliament will be in 

charge of monitoring the Commission’s progress in this respect and respond to the report when 

published. 




Council of Ministers 

The Dutch Presidency has already finalized its work programme, and will focus on health in a variety 

of ways. One of the most visible initiatives will be a conference on health and the internal market, 

with a central focus on the patient at the centre of all health care. Another conference will address 

priority medicines. 

The Luxembourg Presidency is in the process of preparing its Presidency agenda, and will in all 

likelihood focus on mental health and rare disorders. 

The various Presidencies will also need to continue the initiatives started by the Commission (e.g. 

closer cooperation between the Member States, implementation of the new pharma legislation). 

European Medicines Evaluation Agency (EMEA) 

EMEA/CPMP Working Group with Patient Organisations 

As a result of a EMEA/CPMP patient workshop held in April 2003, four areas where actions for 

improvement could be taken were identified: 

• transparency 

• dissemination of information 

• patient information 

• pharmacovigilance 

The workshop also recommended the establishment of a EMEA/CPMP Working Group with Patient 

Organisations to work on the follow-up, and to ensure that each of the four areas would take the 

expectations of patient groups into account by identifying: 

• current tools and mechanisms 

• new initiatives 

• whether expectations were met 

• if not, what actions could be taken 

• how to monitor outcome of the actions 

A final report, containing recommendations for all four areas, was published in April 2004.[9] 

EESC/COR 

Both the European Economic and Social Committee and the Committee of the Regions will come 

forward with Opinions on all of the Commission initiatives. 

Council of Europe 

The Council of Europe has produced a draft report on health information and the internet, which will 

in all probability be adopted before the end of the year. 




Summary 

EU institution Initiative 

Commission Sanco Public Health Framework programme 

Health Information Portal 

EU Health Policy Forum Working Group 

G10 follow up (PPP) 

Patient mobility follow-up 

References 

Enterprise G10 follow up (PPP) 

Employment Open Method of Coordination 

InfSoc e-Health Action Plan 

Research Framework Programmes 6 and 7 

Structural Funds European Social Fund 

Education Exchange programmes health professionals 

Parliament Reports on Commission initiatives 

Patient Intergroup/other Intergroups 

New MEPs 

Council of Ministers Deliberations Commission initiatives 

Presidency agendas and priorities 

EMEA EMEA Working Group with Patient Organisations 

EESC/COR Deliberations and reports on Commission initiatives 

Council of Europe Report on health information and the Internet 

1. High Level Group on Innovation and Provision of Medicines – Recommendations for Action, 7 May 

2002. 

2. A Stronger European-based Pharmaceutical Industry for the Benefit of the Patient – A Call for 

Action, COM(2003)383 final. 

3. Decision No 1786/2002/EC of the European Parliament and of the Council of 23 September 2002 

adopting a programme of Community action in the field of public health (2003–2008). 

4. High Level Process of Reflection on Patient Mobility and Health Care developments in the 

European Union – Outcome of the Reflection Process. 

5. Follow-up on the High Level Process of Reflection on Patient Mobility and health care 

developments in the European Union, COM(2004)301 final. 

6. Modernising social protection for the development of high-quality, accessible and sustainable 

health care and long-term care: support for national strategies using the ‘open method of 




coordination’, COM(2004)304 final. 

7. e-Health – making health care better for European citizens: an action plan for a European e-Health 

area, COM(2004)356 final. 

8. Sixth Framework Programme of the European Communities on Research and Technological 

Development, OJ 29/08/02. 

9. EMEA/CPMP Working Group with Patient Organisations: Outcome of discussions, 

Recommendations and proposals for actions. 




The second ‘Informed Patient’ report: ‘An EU Framework for 

Action’ 

Peter Singleton 

Background 

At the EHFG 2004, we launched the second ‘Informed Patient’ report: ‘An EU Framework for Action’. 

The report was produced by Professor Don Detmer and Peter Singleton, who are both Senior 

Associates at the Judge Institute of Management at the University of Cambridge. Professor Detmer is 

also Professor Emeritus and Professor of Medical Education at the University of Virginia, and has 

recently been appointed as President and CEO of the American Medical Informatics Association 

(AMIA). Peter Singleton is also a Research Fellow at University College London and Director of 

Cambridge Health Informatics. 

The report (available at www.jims.cam.ac.uk/research/health/tip/pdf/crstudy2.pdf) is published under 

the aegis of Cambridge University Health (CUH), the health management and policy research centre 

at the Judge Institute, bringing together expertise from across the University of Cambridge and local 

health care organisations. The study has been supported by J&J under an unrestricted research 

grant and has also been supported in its dissemination by the Nuffield Trust, a UK health charitable 

foundation. 

CUH has been working on The Informed Patient (TIP) project for the last two years and produced its 

first report, ‘The Informed Patient’ in May 2003 (available at www.jims.cam.ac.uk/research/health/tip/ 

pdf/crstudy.pdf), building on a literature review and a range of consultation events including a 

conference at Cambridge in December 2002. 

This second report builds on a conference held at Trinity College Dublin in February 2004 where a 

number of stakeholder representatives were brought together to discuss what policy actions were 

needed to improve the provision of health information and education to the public across Europe. 

The need for change 

There are a number of key drivers changing the demands (demographic, economic, scientific) on 

health care, so we need to rethink how we deliver care – and key to that is information – for both 

professionals and patients. Some of these drivers for change are: 

• Aging population and more chronic care 

• Increasing complexity of medicine 

• Patients increasingly want more information and accountability 

• Changing models of professionalism 

So it is critical that we recognise that we need to change how we deliver and coordinate care, and 

that we improve coordination between health care agencies, clinicians, and patients through better 

information. 




Does better information help? 

One of the key questions in our research was ‘how would better information help?’: 

Figure 1: Information and evidence reinforcing choice and outcomes 

May be significant 

barriers to access 

Information may 

not change 

behaviour, or 

may be 

misinterpreted 

Research may not support 

information provided, so 

information is flawed; there 

may be no firm or clear 

evidence 

It is not a foregone conclusion that better information (or even better information delivery) will 

necessary improve health outcomes or the process of health care itself. Inappropriate information or 

wasteful delivery would simply suck resources from direct patient care to the detriment of all. We 

need to create a ‘virtuous spiral’ of better information, better choices, better outcomes, and better 

evidence to direct the process of care and information delivery. 

The first The Informed Patient report (TIP-1) 

The first Informed Patient report (TIP-1) brought together evidence that showed that it is worth 

improving the provision of health information to patients – indeed, it is vital to manage care effectively 

in the future. Specifically, it showed that better informed patients are generally: 

• More involved and follow advice better 

• Less anxious – though some may be more so 

• Select fewer or lower risk interventions 

• Start treatment earlier 

• More satisfied and litigate less 

Informing 

Choice 

Evidence 

Outcome 

Change in choices 

may not materially 

affect outcomes (or 

effects 

counterbalance) 

Change in outcomes 

may not be identifiable 

or measured; may be 

lost in other effects 

• Have lower health care costs through more self-management & a more efficient use of resources 




The first report also brought together evidence that current provision is often poor, though there were 

many local instances of good practice, but little effort in dissemination and adoption of such good 

exemplars. Current information provision is generally: 

• Poor, unreadable, and badly targeted 

• Fails to address patients’ real needs 

• Inconsistent between localities 

• Fails to support minority groups and cultural differences 

• Often provided as an afterthought 

• Rarely delivered as part of health care process and tailored to individual needs 

It was clear that much could be easily improved by more effective direction of current efforts – hence 

the need for high-level action – preferably across Europe rather than locally. 

Some of the key improvements suggested were that: 

• Information provided focused on the patient experience, not just the medical facts 

• Information should be tailored to the differing needs of different segments of the population, 

allowing for literacy, education, language, and culture 

• Patients should be involved in the design of the information and the delivery process 

• The information provision should be a process through a variety of channels appropriate to patient 

needs at different stages of the ‘patient journey: 

Figure 2 – The patient journey 

What does that mean? 

What are the outcomes? 

What are my choices? 

What are the risks? 

What are symptoms? 

What is the disease? 

Is it important? 

What should I do? Whom should I see? 

Where can I find out 

more? 

Awareness 

Seek help 

What are the 

alternatives? 

How will it affect me? 

How will it affect 

my family? 

Diagnosis 

Treatment 

What can I do? 

How can I help myself? 

When do I need help? 

What help can I get? 

How can I get help? 

What can I do? 

How am I 

progressing? 

How can 

I get help? What can I do? 

Recovery 

Social care 

What help can I get? 

How can I get help? 

Self care Within health system 

(stages may well overlap) 

Self management 



Chronic care


The TIP-1 Cambridge Conference – recommendations 

From the 2002 Cambridge Conference there were four broad recommendations: 

• Create EU information framework 

• Support implementation for patients/caregivers, citizens and health professionals 

• Coordinate efforts of suppliers of information 

• Offer leadership and education 

of which the first was the call for an EU policy framework around which efforts could be coordinated 

and directed. 

The TIP-2 Dublin Conference – outcomes 

The second conference in Dublin was convened to create this Framework – bringing together 

stakeholder representatives to discuss priorities and possible actions in this area. 

The main themes from the conference were: 

• Promote health information as an issue 

• Coordinated public health information campaigns 

• Professional and public education 

• Engaging media, private sector, and new EU states 

• Promote evidence-based practice 

• Enhance trust and quality of care 

These highlighted the need to: 

• Raise awareness of health information provision as an issue – it has certainly been more topical 

of late, but we need to focus attention to create action; 

• Coordinate public health messages between players, both public and private sector – to ensure 

that message reinforce rather than cancel or create confusion (for example, HRT, MMR, BSE) 

• Support professionals in communicating better as well as educating the public to have a better 

grounding in health matters to understand what doctors tell them; 

• Bring all players and experience to bear on communicating effectively 

• Support and disseminate best practice based on clear evidence 

• Ensure that we do not undermine public trust in the professions and health care generally while 

promoting a measurable improvement in quality 

From discussions at the Dublin conference, the authors sought to create a framework that reflected 

the concerns and considerations expressed by the delegates. 




The EU Framework for Action 

The authors took five main areas: 

• Involvement of European Commission, Member State governments, & Localities 

• Public communications and engagement 

• Education of public and professionals 

• Research agenda 

• Formal network development 

which were arranged pictorially as: 

Figure 3 – The EU Framework for Action 

Public and engagement 

communications 

The four main areas were underpinned by formal network development to link the other aspects – 

though some felt that the image should show the European Commission as the foundation for action. 

This was further developed as a hierarchy of 13 goals, 20 strategies to achieve these goals, and 33 

immediate actions as the starting points for those strategies: 

Goals – objectives that need to be achieved 

Strategies – ways of achieving those goals 

European Commission, 

Member State Governments and Localities 

Education of 

professionals and public 

Formal network development 

Initial Actions – the first steps to effecting and implementing the strategies 

Instigators – those actors best placed to initiate the actions, possibly bringing together those capable 

of implementing those actions 



Research agenda


We have also suggested parties that should instigate these actions and hopefully build impetus 

across the Framework. 

While the TIP-2 report develops these in detail and provides supporting material, the Framework can 

be summarised as: 

Key Goals: 

• Higher standards for patient involvement and information provision across Europe 

• Better health and health awareness among the public, supported by better media reporting 

• Appropriate communication skills for professionals 

• Gathering evidence and promoting best practice in health information provision 

It was felt that much could be achieved relatively easily, though full implementation would require 

persistent effort over time. 

Priority areas 

The 33 actions detailed in the report could be summarised as: 

Bring together stakeholders – our report details a number of parallel initiatives that need to be 

coordinated to be fully effective; 

Communication skills curricula – for new and existing clinicians – changing their perception of 

patients from passive ‘problems’ to be solved to active participants in their care; 

Involving the media – to avoid scares and improve informal health education 

Involving the public – through formal channels for education – to increase health literacy/competence 

To improve Package Insert Leaflets (PILs) it is only too clear that these are hugely ineffective – 

patients are only just being consulted about the design of such leaflets, though still within the 

constraints of ‘one size fits all’ 

To gather evidence and to promote best practice across Europe by establishing a network and centre 

for best practice in health information provision 

Conclusions 

It is critical that policy-makers in EU institutions and member states recognise: 

• The need to involve the public more fully in their health and health care; 

• The crucial function that health information plays in effecting this; 

• How to deliver such information effectively over time and through as many channels as possible; 

• A coordinated framework of actions must be undertaken rapidly to improve the effectiveness of 

care delivery and to manage total health care costs 

The two reports and further supporting information are available on the ‘Informed Patient’ web-pages 

on the Judge Institute of Management website: www.jims.cam.ac.uk/research/health/tip/tip_f.html 




Cancer treatment: 

A priority for patients in 

Europe 




��John Smyth Availability of treatment – who actually decides? 459 

(abstract) 

��Susan Knox Keeping breast cancer on the public Health agenda: 460 

the European Breast Cancer Resolution 

��Christian Ligensa Access to care for prostate cancer patients. 462 

A patients perspective 

��Catriona Moore Access to care for patients in England 463 

Page 




Availability of treatment – who actually decides? 

John Smyth 

Abstract 

The availability of new treatments for the management of cancer is dependant on two factors. Firstly 

scientific discovery and secondly, the political and financial will to translate discovery into practical 

treatment. In Europe there are exceptional opportunities to progress scientific discovery into better 

cancer management, but tensions between academia and industry, the current threat to academic 

medicine and too much bureaucracy challenge this. The Federation of European Cancer Societies 

(FECS) seeks to address some of these challenges, by facilitating the distribution of current 

knowledge through scientific meetings, and promoting more productive discussion between the wide 

variety of professionals involved in multidisciplinary care for cancer patients with politicians and with 

patients themselves. The availability of the most appropriate treatment is a concern for all and the 

public should play a greater role in determining the actual availability of treatment, but be prepared to 

pay for it. 




Keeping breast cancer on the public health agenda: the European 

Breast Cancer Resolution 

Susan Knox 

Abstract 

In June 2003 the European Parliament passed a resolution on Breast Cancer, and Europe took a 

significant step closer to the goal of ensuring that every woman has access to optimum breast 

cancer screening and treatment. It detailed targets and quality standards on everything from mortality 

rates to how mammograms are read, and it called on member states to monitor and report back by 

2006 on their progress, giving the European Commission the task of ensuring that countries do their 

utmost to comply. For Europa Donna, The European Breast Cancer Coalition, this was the 

triumphant culmination of three years of lobbying. 

Europa Donna represents the interests of European women regarding breast cancer to local and 

national authorities as well as to institutions of the European Union. In July of 2000 we started our 

advocacy initiatives at the European level. Almost exactly three years from that date the European 

Parliament adopted as policy many of our own goals in relation to breast cancer screening and 

treatment. 

Our European campaign started off with a reception in Strasbourg in July 2000 in which 90 MEPs 

and the European Health Commissioner, David Byrne, first heard our arguments for the pressing 

need to improve the cancer services available across Europe throughout Europe.The following year 

we helped launch the European Parliamentary Group on Breast Cancer, for which Europa Donna 

now serves as the secretariat. Initially the group committed itself to carrying out at least one initiative 

a year to raise awareness and ultimately improve breast services. The first such event was an 

exhibition and reception in held in June 2002, which depicted ‘Breast cancer in the EU today’. All of 

this provided a background for the development of a Breast Cancer Report, prepared by the 

Parliament's Women's Rights and Equal Opportunities Committee, and spearheaded by Karin Jöns. 

Europa Donna was involved with this report at every step of the way providing speakers for 

meetings, and gathering information in a survey on breast services carried out by its various country 

members. The Breast Cancer Resolution was finally passed by Parliamentary vote on 5 June 2003 – 

the first resolution ever to have been passed on a specific illness category. 

The Breast Cancer Resolution 

The European Breast Cancer resolution sets a target of reducing breast cancer mortality by 25% by 

the year 2008, and reducing the disparities in five-year-survival rates across Europe from 16% to 5% 

over the same time period. It also deals in some detail with issues of screening, patients rights, 

treatment and training. With regards to treatment, the Resolution adopted by the European 

Parliament calls for patients to be treated by multidisciplinary teams of experienced surgeons, 

radiologists, oncologists, pathologists, nurses and radiographers who specialise in breast disease, 

and receive regular training to keep them up to speed with the latest developments. 

The Breast Cancer Resolution represents a major step forward for Europa Donna: in effect, the 

European Parliament has adopted our demand for quality services to be uniformly available across 

Europe. And because it has specified standards in such unprecedented detail, we now have a set of 

concrete demands that member organisations can campaign around in their own countries. 




Much still needs to be accomplished before European policy is translated into national practice and 

we need to keep up the momentum. To do this we have published a Lobbying Update in November 

2003 concerning the Resolution for distribution by all our country fora and we held five workshops on 

how to implement the Resolution nationally for the 200 advocates who attended our Pan-European 

Conference held in Cyprus late last year. Activities have been launched in 14 of our member 

countries. 

Our membership has increased from 19 to 34 countries over the last five years, ensuring that breast 

cancer advocacy initiatives are moving forward in most of Europe. 

The Resolution needs to be adopted and implemented in all EU countries: Europa Donna is 

attracting more and more women to work on this cause, because all agree on the core European 

issues that must be addressed and that unite us so that we have one voice to insist on access to 

state of the art breast services for all women in Europe. 




Access to care for prostate cancer patients. A patients perspective 

Christian Ligensa 

Abstract 

When prostate cancer is detected in a man, the normal and regular doctor’s consultation is: 

• Prostatectomy (surgery) or 

• Radiation or (in only a very few cases due to old age or comorbidity) 

• Wait and see 

This is so because men use their normal tools when they are trained to use their tools. Urologists are 

organ specialists not cancer specialists. Very often the consultation has a biased touch. There is 

quite a variety of prostate cancer treatment options, much more then the three standard therapies 

with their normal limitations to quality of life: impotence and incontinence in some cases. 

After the consultation with his doctor the patient has to decide about his preferred therapy option. He 

is lucky if his doctor gave him a complete overview about therapy options and explained the possible 

side effects. Nowadays, the patient is used to address other sources to complete his picture. All of a 

sudden he find himself in the middle of an overwhelming number of information sources. The only 

way out is to become an empowered patient. 

He then is confronted with the reality of the health system related to prostate cancer. It is actually a 

European health problem and a social disgrace. There are a lot of myths out there about prostate 

cancer. 

What kind of solutions are available, what can be done to overcome these problems? 

An interdisciplinary network has to be built, centres of excellence have to be established to identify 

best treatment options which then should be made available to all prostate cancer patients 

throughout Europe. This needs research, this needs support, this needs money. Politicians play a 

vital role in helping to solve these problems. 




Access to care for patients in England 

Catriona Moore 

Keeping cancer at the top of the political agenda should be a big priority for all of us – both from a 

public health perspective, and from our own perspective as individuals. 

Cancer affects everyone. We all know someone who is living with cancer; many of us will have the 

experience of being diagnosed ourselves, or having someone close to us receive a cancer diagnosis. 

At CancerBACUP we believe that information is an integral part of cancer care. Information offers an 

antidote to the fear of cancer: that’s why our charity was founded. 

CancerBACUP was set up in the 1980s by a doctor, Vicky Clement-Jones. When she was diagnosed 

herself with ovarian cancer, she realised how little information was available for people affected by 

the disease. That’s not just cancer patients themselves, but their families and friends, too. 

The charity’s mission is to give people with cancer and their families the up-to-date information, 

practical advice and support they need to reduce the fear and uncertainty of cancer. We provide 

information on all types of cancer, in a range of different ways. Our team of specialist nurses answers 

any question on any cancer. We publish a wide range of booklets and factsheets on all types of 

cancer, treatment and aspects of living with the disease. All our information is available on our 

website at www.cancerbacup.org.uk 

Research shows that information helps people with cancer in a number of different ways. It helps 

people regain some measure of control over their lives, helps them understand their options, and 

helps people come to terms with uncertainty. And information not only helps patients as individuals, it 

has an important role to play in improving the quality of care for everyone. 

Informed patients are powerful patients: they know what to ask for and what they should expect. 

They increasingly expect to work in partnership with their doctors. Patients are increasingly aware of 

what national guidance says about how they should be treated. We are beginning to see a situation – 

in the UK at least – where access to the best treatment and care may depend not so much on how 

much money a person has but on how much information they have. 

200,000 people are diagnosed every year with cancer in England. Cancer was identified as one of 

the Government’s top three health priorities in 1999. Ministers recognised that cancer had to be a 

priority not only because of its prevalence – one in three of the population will be diagnosed with it, 

one in four will die of it – but also because of England’s poor survival and mortality rates compared 

with other European countries. The Government has set a target of reducing by 20% the number of 

deaths from cancer among people under the age of 75 by the year 2010. 

The NHS Cancer Plan was developed as a comprehensive ten-year strategy for improving cancer 

services in England. There had never been anything like it before. It was published in 2000, so there 

has been plenty of time to see how well it is working. It has four main aims: saving lives; providing 

the best support, care and treatment; tackling inequalities; and investing for the future, particularly in 

staff and research. 

One of the biggest problems that the Government recognised it had to tackle in England was the 




problem of inequitable access to the most effective types of cancer treatment. Because of the way 

that funding decisions were taken in the national health service, a situation had developed where 

patients in some parts of the country were receiving particular treatments, while patients living 

somewhere else were told these treatments were not available. CancerBACUP was one of many 

patient organisations calling on the Government to do something about the unfairness of this. 

The result was the National Institute for Clinical Excellence (NICE). It was set up to provide 

evidence-based guidance to the NHS on the clinical and cost-effectiveness of particular types of 

treatment. Once NICE has reviewed the evidence and published its guidance, the NHS is expected 

to follow it. 

We believe that national guidance has an important role to play in helping patients have confidence 

that the treatment and care they receive is the best available, and that they are not being penalised 

for living in the “wrong” part of the country. But of course the guidance has to be right in the first 

place. 

Patient organisations have a key role to play in making sure that guidance reflects the things that 

matter most to people directly affected by cancer. What we can contribute is a unique perspective on 

what it’s like to live with cancer, and what difference a particular type of treatment can make. We 

know that one of the things that matters to patients is the chance to exercise choice, if possible. And 

patients have told us that quality of life is very important – sometimes even more important than 

extra survival time. We have tried to ensure that NICE takes account of these things when it 

develops guidance on cancer treatment. 

Above all, what we want NICE to remember is that ‘guidance’ is not simply an abstract concept: it 

affects people, and can make a big difference to the length and quality of their lives. 

I want to highlight the particular experience CancerBACUP has had of trying to improve access to 

Herceptin, a treatment that effectively targets a particularly aggressive form of advanced breast 

cancer. NICE issued guidance on the use of Herceptin in early 2002. Before this, it was only 

available to some patients in some areas – there was no way for patients to be certain that they 

would be entitled to receive it on the NHS. 

CancerBACUP, along with other patient organisations, was invited to contribute evidence, to help 

NICE decide what it should recommend to the NHS. We did our best to convey what it’s like for 

women living with advanced breast cancer, and why Herceptin – with its lower toxicity and better 

side-effect profile – was an important development in treatment. 

We also emphasised the importance of HER2 testing as an option for all patients with advanced 

disease, to ensure that all patients who might benefit from the treatment had the opportunity to do 

so. It was a long process, with many ups and downs. But finally NICE recommended that HER2 

testing, and Herceptin, should be offered to all patients who could benefit from it, regardless of where 

they lived. 

This was a very good outcome, and we welcomed it. 

But 18 months on, data collected by Roche, the maker of Herceptin, showed that variations in access 

to treatment persisted. Even though NICE had said the treatment should be available, we found that 

only 33% of eligible patients were receiving it. In other words, perhaps as many as a thousand 

patients every year were being denied access to treatment that could improve both the length and 

quality of their lives. 

There was a great deal of public and media interest in this information. The health minister, John 




Reid, demanded an immediate investigation into why cancer treatments recommended by NICE were 

not being offered to patients. 

The problem is that – while cancer is a priority and improving access to treatment is a priority – there 

is no proper mechanism for making sure that national guidance is implemented locally. And we found 

out that information is not collected centrally on what is being prescribed. Well-informed patients may 

know what treatment is recommended for their condition, and they may get it if they ask for it – but 

equitable access for all patients to the best treatment remains in many cases an aspiration rather 

than a reality. 

So what have we learned? 

Since cancer was defined as a national priority, we have learned that there’s often a significant gap 

between what is announced by politicians and what is experienced by patients. Politicians do 

sometimes seem to think that promising action on a problem is the same thing as solving it. Of 

course it’s a first step, but developing the right policy is only the beginning – the challenge comes 

with implementing it. 

Our experience has shown that patient organisations can often be very effective in highlighting what I 

call ‘implementation gaps’ – the gap between the policy and the practice. And we believe our role 

isn’t just to identify problems but also to help work out solutions. 

Finally, we have learned that the Department of Health – at least in England – doesn’t know 

everything that’s happening everywhere in the health service. We expected them to know whether 

national cancer guidance was being implemented locally, but they didn’t have this information until 

we showed it to them. 

We’ve all got a really important role to play in holding governments to account for the promises they 

make. Let’s work together when we can, and keep on doing it. 




Promoting social inclusion, 

tackling discrimination, 

improving health: 

Health, social and economic benefits 




��David McDaid Promoting social inclusion, generating economic 468 

Alex Watt benefits: European action towards better 

musculoskeletal health 

��Eva Jané-Llopis Mental health promotion and mental disorder 471 

prevention: the benefits of intervening 

Page 




Promoting social inclusion, generating economic benefits: 

European action towards better musculoskeletal health 

David McDaid and Alex Watt 

Musculoskeletal conditions, including osteoarthritis, rheumatoid arthritis, back pain and traumatic 

injuries have an enormous impact upon individuals and society across Europe, affecting 1 in 4 adults, 

but at present there are no common policies for their prevention. The recently published EC cofunded 

project European Action Towards Better Musculoskeletal Health,[1] provides strategies to 

reduce their burden, based on evidence and best practice, by promoting musculoskeletal health at all 

ages for those with or without musculoskeletal problems. The aim was to develop a common policy 

based on existing knowledge to deal with risk factors for poor musculoskeletal health and also 

enable people living with these conditions to enjoy their full health potential. Importantly a strategy for 

potential implementation was also developed. 

Musculoskeletal disorders including arthritis have substantial health, economic and quality of life 

effects.[1] As many as 25% of all adults have pain related to the musculoskeletal system and they 

are the 8th leading cause of disease burden across Europe with osteoarthritis and rheumatoid 

arthritis accounting for 3.75% of all disability adjusted life years lost. The contribution of these 

disorders to overall disease burden continues to grow as the European population ages, with joint 

diseases now accounting for over half of all chronic conditions in older people. Other risk factors 

such as the growing prevalence of obesity may also contribute to future increased burden. 

Poor musculoskeletal health generates substantial health care costs, but in common with mental 

health problems these may be far exceeded by the costs of absenteeism, sickness leave and early 

retirement from the workplace. One analysis of early retirement in Sweden in 2001 estimated that 

60% of retirees were diagnosed as having a musculoskeletal problem. In the Netherlands these 

disorders accounted for approximately 6% of all health care costs in 1994. The indirect costs of lost 

employment or informal caring costs can more than outweigh the direct health care costs, for 

instance in one UK study in 1996, these indirect costs accounted for 52% of total costs.[1] A Finnish 

study estimated that there was a 77% decrease in working capacity of people with arthritis.[2] More 

recently another study in Finland estimated that 23% of those with rheumatoid arthritis had 

discontinued work within two years of diagnosis and 38% had retired due to the condition over a ten 

year follow up period.[3] In the Netherlands around 50% of all patients with rheumatoid arthritis 

(mean duration 2.8 years) in a survey reported that it had a negative impact on their ability to perform 

paid work, and had also reduced educational and promotional opportunities.[4] This impact on 

economic performance is of clear importance given the EU’s commitment to its so-called Lisbon 

agenda promoting economic growth and social inclusion. In addition to health and workforce costs 

again in common with mental health problems individuals may also suffer from discrimination and 

stigmatisation while family members may have provide substantial amounts of care and support. 

What can be done 

Evidence from randomised controlled trials, systematic reviews and evidence based guidelines were 

collated and discussed by an expert group working in different areas of musculoskeletal health. A 

number of common themes emerged, most notably that as musculoskeletal problems are so 

common and pervasive, there is a strong argument for a European health promotion campaign 

aimed at their prevention, thus minimising their impact. There is evidence that musculoskeletal health 




can be improved by a number of health promotion strategies. These include: physical activity to 

maintain physical fitness, maintaining an ideal body weight, having a balanced diet, avoiding smoking 

and using alcohol sensibly, promoting accident prevention programmes, as well as programmes in 

the workplace and in leisure pursuits. Overall it is important to raise the awareness of problems that 

relate to the musculoskeletal system to create a more positive attitude to the importance of its 

prevention and the need for early effective management and encourage individuals to take greater 

responsibility for their own health. 

As well as having a broad public health strategy for the population at large it is also clear that some 

groups of the population are at greater risk than others and it is more cost effective to target these. 

Once those at greatest risk are identified there are now effective interventions for prevention. For 

example the progressive destructive course of rheumatoid arthritis can be reduced and osteoporosis 

can be effectively prevented and treated to reduce the risk of fracture. 

Implementation challenges 

While there is evidence that these problems can be prevented or effectively treated, improving quality 

of life, implementation of the strategy remains a major challenge. Dissemination needs to be 

planned, targeted and evaluated, and it is helpful to engage with local, regional or national 

champions for change if they exist. Clear objectives should be set, and pragmatically it may be best 

to start with those elements of a strategy that are easiest to implement and likely to have positive 

results, in order to encourage acceptance of the programme. Presenting evidence on the cost 

effectiveness of strategies can also help to facilitate implementation especially where resources are 

very limited. It can also be helpful to identify opportunities for integration with existing programmes 

and public health strategies. 

Conclusions 

There are substantial health, social and economic costs associated with musculoskeletal problems. 

Poor musculoskeletal health along with mental health problems are by far the most common causes 

of sick leave, absenteeism and early retirement from the workforce. In common with mental health, 

however, the stigma and lack of knowledge about these conditions can act as a barrier to effective 

action. A multi-sector, multi faceted approach can help facilitate implementation. Economic evidence 

can be used to help strengthen the case for action. 

At the European level there is a strong case to be made for strengthening links with public health 

groups to ensure that arguments made for greater focus on public health need also to indicate not 

only benefits in terms of reduced mortality and improved cardiovascular health but also the positive 

impact for musculoskeletal health (and indeed other health problems). There is also a need for 

further research that will facilitate the implementation of the strategies as well as the collection of 

data, perhaps through health surveys. Investment is not only needed in the provision of appropriate 

prevention and care services but also in raising awareness and knowledge amongst the public, 

patients, health care providers and other sectors such as in the workplace on how musculoskeletal 

health can be improved. 

References 

1. European Bone and Joint Health Strategies Project. European Action Towards Better 

Musculoskeletal Health. A public health strategy to reduce the burden of musculoskeletal conditions. 

University Hospital Lund: Bone and Joint Decade, 2004. 

2. Makela M, Heliovaara M, Sievers K, et al. Musculoskeletal disorders as determinants of disability 




in Finns aged 30 years or more. J Clin Epidemiol 1993;46 (6):549–59. 

3. Sokka T, Kautiainen H, Mottonen T, Hannonen P. Work disability in rheumatoid arthritis 10 years 

after the diagnosis. J Rheumatol 1999;26(8):1681–85. 

4. van Jaarsveld CH, Jacobs JW, Schrijvers AJ, Van Albada-Kuipers GA, Hofman DM, Bijlsma JW. 

Effects of rheumatoid arthritis on employment and social participation during the first years of disease 

in the Netherlands. Br J Rheumatol 1998;37(8):848–53. 




Mental health promotion and mental disorder prevention: the 

benefits of intervening 

Eva Jané-Llopis 

The magnitude of the problem: health and economic burden 

Mental and behavioural disorders are found in people of all ages, regions, countries and societies, 

being present at any point in time in 10% of the adult population.[1] More than one person in four will 

develop a mental disorder during their life. In the year 1990, neuropsychiatric conditions accounted 

for more 10% of disability adjusted life years. Estimates indicate that this will rise to 15% by the year 

2020.[2] In 2002, unipolar depression alone accounted for 6.1% of all European ill-health and 

premature death.[3] 

In addition to the health burden, the social and economic costs of mental ill health for societies are 

wide ranging, long lasting and enormous. The economic costs of mental health are estimated at 

3–4% of GDP.[4] For example in a longitudinal study in the United Kingdom, Scott and colleagues [5] 

compared the cumulative costs of public services used through to adulthood by children with no 

problems, with conduct problems and with a conduct disorder. By age 28 the costs for individuals 

with conduct disorder were 10.0 times higher than for those with no problems and 3.5 times higher 

than for those with conduct problems. Mean individual total costs added up to £70,019 for the 

conduct disorder group and £24,324 for the conduct problem group, compared with £7,423 for the no 

problem group.[5] In all groups crime incurred the greatest cost, followed by extra educational 

provision, foster and residential care and state benefits.[5] The costs associated with mental health 

problems also include premature death. More people die from suicide than from violence or war. On 

average, only today 2,600 people will commit suicide in the world, one every 40 seconds.[1, 6] 

Besides the health and social service costs, lost employment and reduced productivity, the impact on 

families and caregivers, levels of crime and public safety, and the negative impact of premature 

mortality, there are also many other immeasurable costs that have not been taken into account, such 

as lost opportunity costs to individuals and families.[1] 

Determinants of mental health 

The lack of positive mental health and the presence of mental health problems or disorders are 

determined by multiple and interacting social, psychological, biological and environmental factors.[7, 

8, 9, 10, 11, 12, 13] Some of these determinants are specific factors directly related to the 

development of a specific mental health problem. For example, a genetic history for schizophrenia 

correlates highly with the risk of development of schizophrenia.[14] Other disease specific 

determinants or risk factors can be psychological or social in nature. For example, negative thinking 

has been related to depression, and major depression to suicide. Glamorization of thinness is 

suggested to predispose to anorexia nervosa. Generic factors are those that can be antecedents and 

that can increase the potential risk common to more than one disorder. For example, child abuse is a 

risk factor common to several mental problems such as depression, anxiety and substance 

abuse.[15] 

In addition, major determinants of health, such as poverty, lack of work or social exclusion have an 

impact on both physical and mental health. For example, a lack of meaningful employment is 

associated with depression and alcohol and drug use, which in turn may result in road trauma, loss 




of employment and physical disability.[16] Furthermore, mental ill-health is also common in people 

with physical illness; for example 22% of people with myocardial infarction, 27% of people with 

diabetes and 33% of people with cancer suffer from major depression.[4] Therefore mental health is 

intimately connected with physical health and with behaviour as “health is not merely the absence of 

disease or infirmity”, but rather, “a state of complete physical, mental and social well-being”.[1] 

Intervention efficacy in mental health promotion and mental disorder prevention 

To date there is sufficient evidence demonstrating that, when properly implemented, mental health 

promotion and mental disorder prevention interventions lead to a range of positive health, social and 

economic outcomes.[7, 10] Topic-specific literature overviews and meta-analyses have confirmed 

that preventive interventions can be effective for a wide range of mental health issues and age 

groups, including interventions for infants and children up to six years of age [17], interventions for 

school-age children [18, 19, 20], child abuse and neglect [21, 22, 23], conduct disorder [24], violence 

and aggression [25], substance and drug use across the lifespan [26, 27, 28, 29] and depression [30, 

31, 32] 

Three major initiatives lead by the World Health Organization (WHO) and the International Union for 

Health Promotion and Education (IUHPE) have recently reviewed the evidence of what works in 

mental health promotion and mental disorder prevention providing the state of the art at the global 

level.[6, 13, 33, 34, 35] In addition, the European network Ìmplementing Mental Health Promotion 

Action’ (IMHPA) has translated the evidence of what works into a model action plan for prevention 

and promotion in mental health to provide a framework of support for countries and regions to 

develop policy plans that are culturally sensitive.[36] 

The evidence compiled in the different overviews derives from the available evaluation studies 

undertaken globally to monitor the efficacy and cost-effectiveness of preventive and promotion 

interventions. While research evidence studying the efficacy of interventions is growing, unfortunately 

to date there is still a scarcity of studies that monitor the cost-benefits or cost-effectiveness of 

prevention and promotion in mental health. The following sections present four examples of 

efficacious interventions and their associated health, social and economic benefits in the areas of 

parenting support, pre-school education, support for the unemployed and addressing alcohol 

dependence. For a more complete overview the reader is referred to the WHO promotion and 

prevention summary reports.[6, 13] 

Parenting support 

A classic example of an efficacious intervention that has been implemented in different sites is the 

‘Prenatal Infancy Project’, a two-year home visiting programme designed to serve low-income, at-risk 

pregnant women bearing their first child. The intervention aimed to improve maternal and child 

functioning through improving mothers’ health behaviour, parental care giving, and their own life 

course, for example by helping them to find work.[37, 38, 39, 40] Short-term physical outcomes for 

mothers showed a 38% decrease in emergency-room visits and a 25% reduction in smoking. 

Outcomes for the newborns showed a 75% reduction in pre-term deliveries, higher birth weight by up 

to 400g and a 15% decrease in child abuse during the first years of life. At four years of age, children 

held higher IQ scores and made 84% fewer visits to the doctor for injuries and poisonings. Mothers 

reported a 42% decrease in subsequent pregnancies and had an 83% increase in employment rate. 

On the long term the intervention has shown important long term social impacts, for example after 15 

years, children were 56% less likely to have problems with alcohol or drugs, had 56% fewer arrests, 

81% fewer convictions and a 63% reduction in number of sexual partners.[38, 39] 




Pre-school education 

Interventions in school mental health promotion have shown effects including improved psychological 

adjustment, reductions in learning problems, behavioural problems and aggression and more general 

improvements in mental well-being. For example, the ‘High Scope/Perry Preschool Project’ [41] 

targeted at risk 3- to 4-year-olds living in poverty. It combined half a day preschool intervention using 

a developmentally appropriate curriculum with weekly home visits. On the short term it led to less 

mental retardation, better social adjustment, school success, academic achievement, and increased 

high school graduation. Long-term follow-ups up through to later life, up to age 27 years, showed 

increased social competence, a 40% reduction in lifetime arrests, a 40% increase in literacy and 

employment rates, fewer social problems and welfare dependence and improved social 

responsibility.[41] The Perry Preschool Programme cost US$1,000 per child, but the benefit produced 

was estimated at around US$7,000, due to decreased schooling costs, increased taxes paid on 

higher earnings, reduced welfare costs, decreased justice system costs, and decreased crime victim 

costs.[42] 

Providing support to the unemployed 

In the workplace, promotion and prevention programmes in mental health have for example 

increased job satisfaction, motivation, confidence in coping abilities, and have shown a decrease in 

psychological distress. Also those suffering from unemployment are under psychological strain and 

related social exclusion. An example of an intervention targeting this problem is the JOBS 

Programme, an intervention of five sessions aimed at people who suffered involuntary job loss, 

economic hardship and depressive symptomatology.[43] The programme addressed job searching 

skills, self-efficacy and social support in order to help the participants to find a new job and to fight 

against social exclusion that unemployment brings. At the individual level, the intervention resulted in 

improved self-esteem and job-seeking confidence, more job satisfaction and motivation, as well as 

reductions in depressive symptomatology.[43] The JOBS Programme, also resulted in less 

unemployment among participants, in increased possibilities of finding a new job more quickly and 

obtaining better jobs in terms of pay and stability. Importantly for employers, there is also evidence of 

decreases in the frequency of sick leave due to mental disorders (for example, depression). Cost 

effectiveness analysis of the JOBS programme showed a three-fold return on the investment after 

two years, and more than a ten-fold return after five years.[43] 

Addressing alcohol dependence 

Effective regulatory interventions, which can be implemented at international, national, regional and 

local jurisdictional levels include taxation, restrictions on availability and total bans on all forms of 

direct and indirect advertising.[26] One of the most effective interventions has proven to be the 

taxation of alcohol products as price is one of the largest determinants of alcohol use. Although the 

impact of price varies across countries and beverage categories, a 10% tax increase in price can 

reduce the long term consumption of alcohol by about 7% in high income countries, and, although 

there are very limited data, by about 10% in low income countries.[44] Direct health and social 

outcomes of taxation policies include the reduction of the incidence and prevalence of alcohol-related 

liver disease, traffic accidents, and other intentional and unintentional injuries, such as suicide, family 

violence, and the associated negative mental health impacts of the consequences attributed to 

alcohol consumption. In Europe cost-benefit analyses have estimated the average cost per DALY 

(Disability Adjusted Life Year) prevented with current tax measures is €266 which currently prevents 

1,365 DALYs annually per million population.[45] Estimates indicate that if there was a 10% increase 

in the cost of alcohol this would imply a 6% decrease in harm of alcohol-related neuropsychiatric 

disorders [46, 47]; which would in turn save €5 billion per year due to less alcohol related mental ill 

health.[45, 46] A 10% increase in the price of alcohol would also lead to a €1 billion increase in 




government revenue per year from tax.[46] 

Policy development in mental health promotion 

The described examples demonstrate that, in addition to programme efficacy, prevention and 

promotion have been shown to bring about changes in more than one mental health domain, in other 

physical health and social domains, and, ultimately, in promoting economic development. The links 

between mental health and physical health and the continuous battle to obtain increased resources, 

emphasize the necessity to find new and more efficient strategies for intervention and to strengthen 

policy development in the field of mental health. 

Increasing associated efficacy of mental health promotion interventions 

As previously stated, co-morbidity is highly prevalent both within mental health, with one half of those 

with a mental disorder having more than one diagnosis, and also between mental health and 

physical ill-health. The co-occurrence of several mental health problems has been attributed, among 

other reasons, to similar paths of development in psychopathology or to the presence of multiple risk 

factors that are common to more than one health problem. The fact that multiple risk factors can lead 

to multiple problems identifies potentially new opportunities for the systematic improvement of 

programme efficiency, such as addressing a combination of generic risk and protective factors to 

promote a simultaneous reduction in the risk of different problems. The accumulation of multiple 

outcomes across different domains of functioning, including behaviour, social skills and adjustment, 

or emotional competence and mental well-being can simultaneously bring about more efficient 

strategies than those collections of programmes with fragmented outcomes. One area for investment 

is, for example, school programmes that address social competence skills, resilience and selfefficacy 

because they can lead to a decrease in aggressive behaviour, a decrease in harmful 

substance and an increase in positive mental health. It has been argued that concerted efforts to 

provide training in social-cognitive skills, problem solving and social skills in the early years would 

pay dividends in the future [48], because of the breadth of action and the potentially large scope of 

impact. However, in most evaluations, programmes still present a lack of breadth in their measured 

outcomes, which precludes the making of confident statements about the extent of their impact and 

which argues that “broader nets should be cast” in the development and assessments of programme 

effects.[49] 

Mainstreaming mental health in health promotion 

Secondly, the relationships between mental and physical health provide another opportunity to 

increase efficiency of intervention. This approach can be two-fold, firstly measuring the mental health 

impacts of health promotion interventions and secondly encompassing or embedding mental health 

promotion components into existing and sustained health promotion initiatives. 

Existing interventions to promote physical health might in turn be promoting mental health and viceversa. 

One example is the promotion of exercise in older populations. While its primary goal is to 

deal with the physical disabilities that age can bring, some recent controlled studies suggest that 

exercise, such as aerobic classes and Tai-Chi provide psychological benefits such as reductions in 

depressive symptomatology and increased mental well-being.[50, 51, 52, 53, 54] In addition, 

research efforts within the mental health field are scarce in evaluating the mental health impacts of 

community-integrated initiatives such as the World Health Organization’s Healthy Cities Project.[55] 

As Manson noted in this example, the interventions embodied in efforts like this, employ a wide 

range of community mobilization and development strategies intended to recalibrate social attitudes 

toward various behaviours, to engineer critical changes in decision-making processes, and to extend 

responsibility. Research on mental health in such initiatives should be stimulated to make 




conclusions on the reach and impact of comprehensive strategies. 

A second approach that can lead to increased efficiency of interventions is to embed mental health 

promotion components in already existing health promotion programmes such as schools, primary 

health care or community interventions. The potential of the combination of mental and physical 

health strategies can lead to increased health, social and economic outcomes and larger savings on 

resources.[56] 

Towards achieving the benefits of investing in prevention and promotion 

Prevention and promotion have shown their potential to increase a population’s mental well-being, to 

decrease social exclusion and to increase social capital and the economies of Europe. The challenge 

remains to increase efficiency of interventions, to implement effective strategies in the real world and 

to ensure their sustainability while simultaneously monitoring their impacts. For this to happen there 

is a need, first, that prevention and promotion are developed and integrated within mental health 

policies and that, secondly, they are included, recognized and made visible in the current national 

and local public health frameworks. 

Mental health policies should include a population approach that has a broad reach, if a population 

shift that leads to increased mental health in society is to be achieved. Mental health promotion 

policies should embrace different settings through actions such as offering early school based 

interventions for healthy development, stimulating protective mental health and family friendly policies 

at the workplace, providing increased personnel, resources and training throughout the health 

services, creating accessible child care services and support systems in the community, and 

providing health opportunities that would reach high risk populations. 

In addition to specific investment and development of mental health promotion and prevention 

policies within mental health, these should be recognized and integrated within the broader public 

health framework. The relationships between physical, social and mental health denote the crucial 

need for a comprehensive public health approach that also encompasses action through different 

sectors in society, such as the environment, social welfare, labour and employment, education, 

criminal justice and urban planning. Interventions across sectors should be designed and 

implemented with a horizontal understanding of the different aspects that influence an individual’s 

positioning in today’s society. 

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Special Issue, 2004. 




International networking to 

address inequalities 




International networking to address inequalities 

John Kenneth Davies 

For at least the last 25 years our knowledge of the significant and increasing inequalities in health 

between and within countries has been well documented. The need to take action has been justified 

on the basis of human rights, social cohesion and solidarity, efficiency and effectiveness. Health 

promotion policy and action have been put forward as a major intervention approaches to tackle 

inequalities 

Health promotion is a field dedicated to combining education and policy initiatives to provide 

individuals and communities with knowledge and opportunity to enjoy maximal physical, mental and 

social functioning. Health promotion is not just about individual lifestyle change – it also incorporates 

political action to bring about structural change in society. It is the process of enabling people to 

increase control over the determinants of their health and thereby improve their health. 

Health promotion is based on a universally accepted series of values – these include social justice, 

participation, empowerment and equity – the principles of Health for All. 

The mission of the IUHPE is to promote global health and contribute to the achievement of equity in 

health between and within the countries of the world. Our purpose is to strive for equity. The IUHPE 

is the only global NGO of its kind, with a history of over 50 years working in the field of health 

promotion and health education. Yet the interest in our work is now stronger than ever - this was 

reflected earlier this year at our 18th World Conference in Melbourne which brought together over 

3,000 delegates. 

As a global professional network, the IUHPE decentralises its activity through its seven regional 

offices. I am Chair of the European Regional Committee. The IUHPE members and the quality of 

their skills and knowledge lie at the heart of the organisation, and are the cornerstone of its strength. 

With a world-wide membership of around 2,000 professionals, the work of the IUHPE Regions is vital 

to carrying out the mission, goals and objectives of the organisation. 

The work of the IUHPE can best be summarised in its four main goals: 

1. To advocate for health and health promotion 

2. To build a knowledge base for health promotion 

3. To advance the quality of policy and practice 

4. To develop capacity globally, regionally, locally 

The IUHPE embarks upon its work to achieve its goals and objectives by implementing a set of 

strategies. The IUHPE has six core strategies: 

• Advocacy 

• Knowledge development 




• Professional and technical development 

• Networking 

• Partnership building 

• Strengthening the organisation’s capacity 

I would like to highlight today three of these strategies which lie at the heart of IUHPE's work, namely 

advancing knowledge, advocacy, and networking. The field of health promotion is well established in 

Western Europe, North America and Australia, and at various stages of development in other parts of 

the world. A fundamental weakness is that the knowledge base for effective practice is produced in 

just a few countries with well-endowed research infrastructures and traditions of international 

publishing. This inequity related to culture and language is a barrier to health promotion 

development. Responding to this challenge the IUHPE has launched three initiatives: 

1. To expand the scope of its multi-lingual scientific international journal, Promotion & Education – 

more languages, innovative articles from all parts of the world, assisting authors to improve their 

paper writing capacity 

2. Establish an equity project in the health promotion publishing arena – with Editor for Developing 

Countries, and support from Editor in Chief and Managing Editor 

3. Producing a Global Reader with health promotion contributions from all regions of the world 

through a network of regional editors 

The priorities for advocacy activities are established on a global level by the IUHPE's Board of 

Trustees, and the significance that the IUHPE attaches to advocacy in health promotion is reflected 

by the fact that there is a position of Vice-President for Advocacy. 

The advocacy work in the IUHPE's European Region is three-fold: 

• Reflect the IUHPE advocacy priorities established at the global level (i.e. tobacco control, health 

and social clauses in trade agreements, etc.); 

• Raise the profile of and address IUHPE European members' concerns; 

• Strengthen the position of the IUHPE European Region in influencing and contributing to 

European policy as the principal NGO/ professional association representing health promotion 

and education expertise and interests. 

There is an opportunity to advocate for the development and implementation of health promotion 

policies to European decision-makers. 

The IUHPE strategically utilises its expansive network for dissemination and advocacy efforts carried 

out in partnership with other agencies. The IUHPE disposes of a wide range of communication tools, 

both in print and electronic, which allow the organisation to facilitate a broad-based communication of 

a message and/or call for action. 

This brings me to networking, a strategy that relies upon partnership building, communication, and 

participation in other European networks. This particular strategy demands a cross-cutting approach 

that includes targeting the various audiences and stakeholders which the IUHPE aims to reach. With 

the number of existing health promotion networks in Europe, it is fundamental that the organisation 




also relies upon its network of members to feed this information back into the network. 

A final example of networking can be found in the IUPHE's global and regional conferences in health 

promotion. As the founding and oldest region, the IUHPE/ EURO has extensive experience in 

organising European Conferences. These events are strategic opportunities for networking with 

health promotion experts in the Region or from across the globe. The European region provides a 

further added value in terms of its conference series in that it offers two triennial meetings, one 

generic health promotion conference and one research-based conference focussing on the quality 

and effectiveness of health promotion. The latest conference is the 6th European Conference to be 

held early in June 2005 in Stockholm in partnership with the Swedish National Institute for Public 

Health. 

Networking is a logical introduction for me to discuss the IUHPE's strategic priorities in professional 

development. As a professional association, the IUHPE is involved and interest in health promotion 

education and professional development. This interest is manifested in a number of ways: 

• The development of professional standards for post-graduate health promotion training in Europe, 

as a core part of the EUMAHP phase 2; 

• European Professional Exchange programme (in collaboration with the Swedish Association for 

Health Promotion and Public Health); 

• Mentoring in the area of writing for publication – I have already mentioned; 

• Leadership development in health promotion (in collaboration with the Australian Institute for 

Health Promotion); 

• An on-going series of health promotion training workshops at the trienneial IUHPE World 

Conferences 

In terms of our membership development a more equitable fee structure was recently implemented. 

This new structure arranges the world's nations according to their purchasing power parity and other 

data into ten different strata, according to which annual membership fees have been attributed to 

each category of membership. For example, in Europe annual individual membership fees range 

from €10 per year for a member in Uzbekistan to €100 per year for a member from Germany. 

The European region is saturated with a multitude of nations, cultures, languages, and history, not to 

mention various approaches to health promotion activity. This powerful concentration provides the 

field of health promotion in Europe with a rich pool of ideas, knowledge, and know-how to be shared 

and disseminated. Along with the wealth of experiences also comes the challenge of effectively 

bringing all of the European players to the table to work together in partnership to develop health 

promotion in the Region. It is for this reason that the IUHPE/EURO will invest its future development 

work in the region on strengthening its primary focus at the national level. The establishment of 

IUHPE Country Focal Point Coordinators aims to facilitate contact with potential and existing 

members in countries and to solidify the membership development activity in a given country through 

an established CFP. Often these Focal Points may also be organised according to cultural or 

linguistic synergies. 

In summary then NGOs, such as IUHPE, have a potentially powerful role in partnership with others 

at national and local level to reduce health inequalities. But the task ahead of us is vast with currently 

19 million unemployed within the EU, with a disproportionate number from underprivileged groups. 

We need far more investment in health promotion – which is often seen as a short-term cost and not 

long-term investment. Improving health must become an economic priority. 




Need for effective partnerships based on openness and civil society participation – the EC has begun 

this process through the EU Health Forum, on which the IUHPE is represented along with other 40 

or so Pan-European NGOs, and the first meeting this summer of the Open Health Forum. 

I would invite you to visit the IUHPE's website where information is available on the IUHPE's current 

projects, membership, publications, and a complete events calendar of global and regional health 

promotion meetings and conferences. 



Authors’ biographic information 

Who’s Who 



Who’s Who – authors’ biographic information 

Brian Ager; Director General, European Federation of Pharmaceutical Industries and Associations. 

Stefan Bandol (1961) Romanian; geologist; Executive President of Aripi Association; Bachelor of 

Science; Hamlet Trust Regional Associate, Mental Health Europe; monitoring and evaluating mental 

health NGOs in Slovenia and Bulgaria. 

Dr Jacques Baudouy; Doctorate in Medicine, Master’s degree in Public Health; Director of Health, 

Nutrition and Population, Human Development Network (since July 1, 2003); previously assignment 

at the World Bank, Director, Human Development Sector Middle East and North Africa Region, a 

position he held from 1996 until June 2003; joined the World Bank as Principal Public Health 

Specialist/Africa Region in 1984, responsible for several health, population and social programmes in 

various countries; prior to joining the World Bank, experience in health sector policy and 

management (consultancies for USAID and EC), community-based development (operational 

research with the Harvard Institute for International Development) and relief operations (Doctors 

without Borders). 

Ulrich Becker; Director, Max Planck Institut for International Law. 

Roel Bekker (1947) Dutch; studied Law at the University of Groningen; civil servant in the Ministry of 

Housing, Physical Planning and Environment in 1979, deputy Secretary-General; then joined a 

private consultancy firm, as senior partner; appointed Secretary-General of the Ministry of Health, 

Welfare and Sport in 1998; responsible for a number of publications on management in the public 

sector. 

Philip C Berman (1947) UK; Director of the European Health Management Association (EHMA), 

completed three major multi-national studies for the European Commission: an evaluation of the 

effects of the introduction of market forces in health systems; an assessment of the impact of EU 

directives on health services in the European Union; and a study exploring the management of 

services for older people; now leading a study on the ‘basket of services’ offered by certain Member 

States; acted both as a World Bank and WHO consultant, advising on healthcare management 

strategies in Poland, Hungary, Romania and Turkey; member of the Editorial Board of the 

International Journal of Health Planning and Management; was a member of the EU’s High Level 

Committee of Reflection on patient mobility and health care developments in the European Union; 

member of the Board of the Adelaide and Meath Hospital in Ireland, and he is also a member of the 

Irish Health Services Accreditation Advisory Council. 

Dr Luigi Bertinato (1955) Italian; graduated in medicine at the University of Padua; PhD in Internal 

Medicine at the University of Verona; for the WHO in Zimbabwe from 1988 to 1990; from 1990 to 

1997 he worked in Rome at the Italian National Institute of Health and the Italian Agency for 

Regional Health Care Services, and was a member of the Technical Cabinet of the former Italian 

Minister of Health, Professor E Guzzanti; since 1998 Director of the Office for International Affairs at 

the Department of Health and Social Services of the Veneto Region, based in Venice; Member of the 

Italian Society for Tropical Diseases, member of the IUHPE and of the ALASS; Board member of the 

WHO Regions for Health Network; he is a focal point for collaboration with the World Health 

Organization, as well as member of the scientific committee of the WHO European Office for 

Investment for health and development in Venice. 

Xavier Bonnefoy (1950) French; Regional Adviser, head of the noise and health and housing and 

health programmes, European Center for Environment and Health, Bonn office, of the WHO Regional 

Office for Europe; Civil engineer, Sanitary Engineer and post graduate degree from the faculty of 




medicine of Nancy in Public Health (CES de santé Publique); currently developing the WHO 

nighttime noise guidelines for transport noise, and coordinating a team in charge of the 

implementation of the Budapest conference declaration aspects related to housing and health in the 

European region of the WHO. 

John Bowis (1945) British; Conservative (EPP/ED) Member of the European Parliament for London 

since 1999; EPP/ED Coordinator/Spokesman on the Environment, Health and Food Safety 

Committee; Rapporteur on Food Safety, the Health Impact of Enlargement and the European Centre 

for Disease Prevention and Control; Member of the Development Committee and the EU/ACP Joint 

Parliamentary Assembly; Member of the British Parliament (1987–1997), Health Minister 

(1993–1996), Transport Minister (1996–1997); 1997–1999 worked on WHO Global Campaigns on 

Mental Health and Epilepsy. 2003 Hon Fellow Royal College of Psychiatrists. 

Zsolt Bugarszky; Soteria Foundation. 

Paul Bundgaard (1943) Danish; Proprietor pharmacist; President of the Danish Pharmaceutical 

Association; Member of the Board and Past President of the Nordic Pharmacy Association; Member 

of the Executive Committee and Past President of the Pharmaceutical Group of the European Union 

(PGEU). 

Monica Burchell (1973) British; Appraisals Project Manager for the Patient Involvement Unit at the 

National Institute for Clinical Excellence, UK. 

Sandra Canadelo; member of the Liga Portuguesa contra as Doenças Reumáticas (Portuguese 

League Against Rheumatic Diseases) and joined the league in 1999 after having been diagnosed 

with rheumatoid arthritis in 1997; in 2000 Ms Canadelo was appointed as co-representative for the 

PARE. 

Indu Capoor (1957) Indian; Leadership and Management of NGOs Fellow Programme for Asian 

Leaders Institute for Development Research, USA (1991); Health Care in Developing Countries, 

Certificate Course, Boston School of Public Health, USA (1988); MSc (Foods and Nutrition) with ‘A’ 

Grade, Faculty of Home Science, M.S.University, Vadodara, Gujarat, India (1977–79); Social and 

Development Work, Founder Director–CHETNA (Centre for Health Education, Training and Nutrition 

Awareness) India; 1999: Salzburg Fellow, The Independent Sector: Looking at the Past, Building the 

Future; 1994 onwards: Ashoka Fellow: Associate Member, Ashoka Innovators for the Public, 

Washington, USA; Co-chair of White Ribbon Alliance India (for reduction of Maternal Mortality and 

Morbidity) and Representative of National White Ribbon Alliance in the Global Decision Making 

Committee (DMC) at the International level; National Coordinator for Women and Health (WAH!), 

Program, India; Board Member of Asia Pacific Resource & Research Centre for Women (ARROW), 

Malaysia Steering Committee Member of Health Watch Trust: A National Network working for 

Advocacy for Health and Rights; Governing board member of Gender Resource Centre; Nutritionist 

and Founder Director of CHETNA, has conducted and contributed as a resource in about 1,500 

workshops, trainings and seminars for government and non-government health and development 

functionaries; Development of CHETNA as a model support organization, particularly for effective 

and widespread health education and communication, has been her significant achievement over the 

past two decades. 

Dr Naomi Chambers (1956) British; University lecturer, researcher, consultant; Senior Fellow in 

Health Services Management at the University of Manchester. Previous background as linguist and 

NHS manager. Member of the Institute of Health Service Management. Teacher and course director 

on Masters programmes in health services management; consultant to NHS organisations on change 

and development. Current interests in Board governance, middle manager development, health 




service commissioning. 

Dr Hong-jen Chang (1956) Taiwanese; Deputy Minister; Health Insurance, Public Health; MD, MPH, 

MS; Former CEO and President of Bureau of National Health Insurance (2004); Former Director- 

General of Taiwan CDC; Taiwan’s NHII programme; US-Taiwan pharmaceutical trading negotiator. 

Dr Chien-jen Chen (1951) Taiwanese; Minister; Epidemiology, Molecular Epidemiology; Minister of 

Health of Taiwan; SARS Advisory Committee; ScD of Johns Hopkins University; Professor of 

National Taiwan University; Academician of Academia Sinica; Fellow of American College of 

Epidemiology; Outstanding Anti-Cancer Research Award, Taiwan Cancer Foundation. 

Sylvie Cohu; Ministry of Health, France. 

Francesca Colombo; OECD. 

Professor Angela Coulter (1948) British; Health Services Research, Health Policy Analysis, Medical 

Sociology; Chief Executive of Picker Institute Europe in Oxford and Honorary Professor of Health 

Services Research at the University of Oxford; author of The Autonomous Patient (pub. Nuffield 

Trust) and The European Patient of the Future (pub. Open University Press, winner of the Baxter 

Award, 2004; UK-registered charity, the Picker Institute works with European health care providers to 

obtain feedback from patients and promote patient-centred care; social scientist by training, doctorate 

in health services research from the University of London and has published widely on health policy 

topics; Honorary Professor in Health Services Research at the University of Oxford, a Governor of 

Oxford Brookes University, an Honorary Fellow of the Faculty of Public Health and a lay member of 

the Postgraduate Medical Education and Training Board of the UK; her books include The European 

Patient of the Future (with Helen Magee, Open University Press 2003), The Autonomous Patient 

(Nuffield Trust 2002), The Global Challenge of Health Care Rationing (with Chris Ham, Open 

University Press 2000), Informing Patients (with Vikki Entwistle and David Gilbert, King’s Fund 1998) 

and Hospital Referrals (with Martin Roland, Oxford University Press 1992); founding editor of Health 

Expectations, an international peer-reviewed journal of public participation in health care and health 

policy; from 1993–99 Executive Director of the King’s Fund in London leading their work on health 

policy analysis, research and service development; prior to that she worked for ten years at the 

University of Oxford where she established and directed the Health Services Research Unit. 

Dr Marc Danzon (1947) France; medical doctor, specialisation in public health, psychiatry, health 

administration and economics; WHO Regional Director for Europe from 2000, 1992–1999; Director of 

the Department for Country Health Development, subsequently Director of the Department of Health 

Promotion and Disease Prevention, WHO Regional Office for Europe; 1989–1992 Director of the 

French Health Education Committee; 1985–1989 responsible for communication and public 

information at WHO Regional Office for Europe. 

John Kenneth Davies Vice-President, Euopean Region, IUHPE. 

Kees de Joncheere Master’s degrees in pharmacy and business administration from the 

Universities of Groningen and Amsterdam in the Netherlands, and from National University, San 

Diego, USA/San Jose, Cost Rica; Previously he worked for ten years with PAHO/WHO in Latin 

America (Central America, Brazil and the Mercosur countries) and before that on secondment of the 

Dutch government in the Middle East; among others, his particular interest is in public policy on 

medicines, especially in pharmaceutical pricing and reimbursement in Europe, as well approaches to 

improve the use of medicines; currently responsible for the area of Health Technology and 

Pharmaceuticals in the WHO regional office for Europe, based in Copenhagen; coordinates the WHO 

country assistance in the pharmaceutical sector for Central and Eastern Europe, as well as the 




countries of the former Soviet Union; and collaborates closely with western European countries and 

the European Commission on pharmaceutical policy issues; He is co-editor of the WHO publication 

Drugs and Money, 7th edition, 2002, and author of several articles and book chapters on 

pharmaceutical issues. 

Paul de Raeve (1963) Belgian; registered nurse working as General Secretary of the Standing 

Committee of Nurses of the EU (PCN), obtained a University degree in Nursing Science at the Free 

University of Brussels in 1989 and in Statictics at the Catholic University of Brussels in 1996; Work 

as a Nurse in the 'Bijtjes', a centre for children with muscular disease; Head nurse Neanotology in Al 

Hada Hospital in Saudi Arabia; staff manager at the Free University hospital of Brussels; part-time 

delegated to the Belgium Ministry of Health and Environment; responsible for coordinating the 

Nursing Minimum data collection in the Belgian hospitals, developing a nursing data warehouse at 

national level, increasing the visibility of nurses and nursing, introducing qualitative indicators within 

the hospital financing system and providing data for the political decision making process; 

participation in the political discussion concerning 'The value of nurses and nursing' which resulted in 

a new legislation for nursing care providers, the campaign to promote nursing as a career and the 

reorganisation of the health care sector; wrote several books and articles in the nursing area. 

Elizabeth Docteur (1968) American; health economist; Principal Administrator, Health Policy, OECD, 

Paris; principal author of the final report on the OECD Health Project, a three-year initiative geared at 

measuring health system performance, assessing factors contributing to cross-system differences, 

and developing policy recommendations; research and management positions in legislative and 

executive branches of US government; research and published work has addressed reform of health 

systems and programmes, health care quality, and access to health services; master’s degree (MS) 

in public policy analysis from the University of Rochester in Rochester, New York (US). 

Dr Martina Dören (1959) German; Gynecology/women´s health research; head of the Clinical 

Research Center of Womens Health at the Charité – Universitätsmedizin Berlin; Member of: the 

WOMAN consortium, an EU-funded project to establish a web-based information system on midlife 

health issues for women in various European countries, of an advisory group to the web-based 

information system on ‘Women´s Health and health promotion’ of the Bundeszentrale für 

gesundheitliche Aufklärung (BzgA = Federal Center for Health Information) of the Drug Commission 

of the German Medical Association; head of the writing group for recommendations ‘Menopausal 

Hormone Therapy’ in 2003, of an advisory group to the Federal Ministry of Health and Social 

Security regarding ‘Menopausal Hormone Therapy’, 2004,of the steering group of a new 

postgraduate programme „gender competence’ at the Free University, Berlin; one of the editors of 

‘Maturitas’; Founding member of the International Osteoporosis Foundation (IOF). 

Rodney Elgie (1944) Former lawyer, currently President of GAMIAN-Europe (Global Alliance of 

Mental Illness Advocacy Networks) and President of the European Patients' Forum; Vice President of 

the European Men's Health Forum, member of the Board of the European Brain Council, the 

international Society of Bipolar Disorders, EPPOSI and the UK Health Coaliton Initiative; Member of 

the EU Health Policy Forum, the High Level Reflection Group on Patient Mobility, the International 

Society of Affective Disorders, the Advisory Board of the L'Institut des Sciences de la Sante and the 

Public and Patient Reference Group of the UK General Medical Council. 

Nick Fahy; university studies in philosophy; administrator in the Health and Consumer Protection 

Directorate-General of the European Commission, working in the health strategy unit of the public 

health and risk assessment directorate and responsible in particular for work on health systems 

issues, including the High Level Group on health services and medical care; previous experience 

within the Commission includes consumer protection, social protection and social exclusion issues. 

Before joining the European Commission work for the UK Department of Health on international 




affairs and pharmaceutical policy, and as private secretary to the then Minister of State for Public 

Health, Tessa Jowell MP. 

Dr Armin H Fidler (1958) Austrian; MD MPH MSc (Health Policy and Management, Public Health, 

Health Economics); Health Sector Manager, World Bank: Head of the World Bank's Europe and 

Central Asia Health Group at the Bank's Headquarters in Washington DC. Responsible for overall 

strategy, management and the Bank's portfolio in Health, Nutrition and Population in 28 client 

countries in the Europe and Central Asia Region. Adjunct faculty, George Washington University, 

Washington DC. 

Dr Josep Figueras (1959) Spanish; MD MPH PhD Head of the Secretariat and Research Director, 

European Observatory on Health Care Systems; Head, European Centre for Health Policy WHO, 

Regional Office for Europe. 

Dr Julio Frenk (1953) Mexican; Medical Doctor, Master of Public Health, Doctor of Philosophy in 

Medical Care Organization and Sociology; Minister of Health of Mexico; Executive Director, Evidence 

and Information for Policy, WHO; Executive Vice President and Director for the Centre for Health and 

Economy, Mexican Health Foundation; Visiting Professor, Harvard Centre for Population and 

Development Studies; Founding Director General of the National Institute of Public Health of Mexico; 

International Fellow in Health, W.K. Kellog Foundation. 

Dr Michelle Funk; Coordinator of Mental Health Policy and Service Development at World Health 

Organisation, Geneva; over the last few years led the development of key resource materials related 

to mental health reform; organising international, regional and national training activities; responsible 

for technical assistance to countries in mental health policy, service development, human rights and 

legislation; her professional background is Clinical Psychology and Public Health. 

Brigitta Geissler-Gruber (1963) Austria; studied Psychology at the University of Salzburg 

(1982–1993); First occupational experiences in the participation approach during neighbourhood 

planning projects in new settlements in Salzburg and Vienna, additional living and city studies as a 

network partner of Wohnbund (1989–1996); 1997 vocational training for occupational health and 

safety consulting in Austria; since 1999 associate and managing director of ‘arbeitsleben KEG’ 

located in Gmunden and Hamburg, doing consulting projects for occupational health promotion as 

work psychologist; main topics are: health promoting leadership, age-oriented work design and 

career planning, measurement of work-related psychosocial factors, learning from near accidents. 

Dr Iain Gillespie (1959) British; International Civil Servant; Head, Biotechnology Unit, Organisation 

for Economic Cooperation and Development (OECD); BSc (Biological Sciences), MA (International 

Relations and European Politics), MBA PhD (Microbiology); responsible for OECD Working Party on 

Biotechnology (programmes on biotechnology, innovation and health; biotechnology and industrial 

sustainability; biotechnology metrics; and infrastructure) and for OECD’s work on health technology 

assessment; previously: Secretary to UK Pharmaceutical Industry Competitiveness Task Force, Head 

of Policy Support Unit for UK Chief Scientific Adviser. Member of GlobalScot Network. 

Dr Martin Gleitsmann (1957) Austria; Law; Head of social policy and health department in the 

Austrian Economic Chamber; as additional function (Vice) President of the Board of Administration in 

the Main Association of Austrian Security Institutions; Member of the Austrian Social Partners' 

Advisory Council for Economic and Social Affairs; Committees on social affairs and health, 

Parliament; Member of the consultative committee for the social security of migrant workers, EU. 

Joana Godinho (1951) Portuguese; Medical Doctor Postgraduate degrees in Public Health and 

Communication. Since 1993 Senior Health Specialist, World Bank, working on human development, 




environment and infrastructure. Assistance to Governments of the Former Soviet Union and other 

stakeholders carrying out analytical work, and preparing and implementing investment operations on 

reproductive health, water and sanitation, TB and HIV/AIDS control, and health sector reforms, 

including establishment of health promotion and primary health care. Since 1998, Management of 

HIV/AIDS studies and operations in Europe and Central Asia, including in Russia, Belarus, Moldova, 

Central Asia and Balkans. Before she joined the Bank, she was working working the Lisbon Health 

Authority; Professor at the University Nova of Lisbon; Project Leader European Commission funded 

Project ‘Tipping the Balance Towards Primary Health Care’, a R&D operation financed by the 

European Commission. 

Dr Eberhard Goepel (1947) Germany; Professor of Health Promotion at the University of Applied 

Sciences in Magdeburg, Research and projects in Community Health Promotion; Member of the 

IUHPE European Regional Committee and several scientific networks in Health Promotion and 

Urban Health; Director of the European Master in Health Promotion (EUMAHP) in Magdeburg. 

Dr László Gulácsi (1957) Hungarian, MD PhD medical specialist in public health, economist, health 

economist; Chair Professor, Unit of Health Economics and Technology Assessment in Health Care, 

Department of Public Policy and Management, Corvinus University of Budapest; Hungary and head 

of the (INAHTA member) HunHTA (Hungarian Office for Health Technology Assessment). 

Professor Louise Gunning-Schepers (1951) Dutch; Epidemiology and social medicine; Dean and 

chairman of the executive board of the Academic medical Centre at the University of Amsterdam; 

was the first president of the European Public health Association; was a member of the Scientific 

Council for Government Policy (advisory to the prime minister); is a member of the Health Council 

and recently sat on the Marimon committee of the EU. 

Ludwig Grillich (1966) Austrian; Scientific advisor and head of department ‘evaluation’ at 

diepartner.at (a company planning, consulting and evaluating projects in both social and health care 

fields); teaches at the University of Vienna; member of the ‘Quality-circle Evaluation’ which is 

organized by the Austrian Health Institute (ÖBIG); member of the German Evaluation Association 

(DeGEval e.V.). 

Anders Gustav; President, Commission ECOS, Committee of the Regions. 

Dr Françoise Hamers (1956) Belgian; medical epidemiologist (MD 1981, MPH 1991); EuroHIV 

project leader, at the Institut de Veille Sanitaire, France; coordinates the surveillance of HIV/AIDS in 

Europe, Director of a WHO collaborating Centre, and is member of numerous international expert 

groups on HIV/AIDS. 

Corinna Hawkes; Consultant, International Food Policy Research Institute. 

Dr John H Henderson (1929) British; Psychiatrist (retired); Senior Policy Adviser to Mental Health 

Europe, a Europe-wide Non Governmental Organisation; trained in clinical psychiatry and in public 

mental health; formerly Regional Officer for Mental Health in World Health Organisation, Regional 

Office for South East Asia and Regional Office for Europe. 

Dr Chris Henshall (1954) British; Group Director, Science and Engineering Base, Office of Science 

and Technology, UK Department of Trade and Industry; responsible for management of government 

science and innovation funding; previously responsible for R&D funding in Department of Health and 

NHS; President of Health Technology Assessment International; Honorary Professor, London School 

of Hygiene and Tropical Medicine. 

Dr Hristo Hinkov (1953) Bulgarian; Psychiatrist; Chief expert in National Center for Public Health; 




WHO National counterpart on mental health; Country project manager of the Stability Pact project 

‘Enhancing social cohesion through strengthening community mental health services in South East 

Europe’; member of the Executive Council of the National Mental Health programme. 

Imre Holló; Deputy State Secretary of the Ministry of Health, Social and Family Affairs. 

Michael Hübel (1962) German; MA; living and working in Luxembourg; Political Science; European 

Commission, Health and Consumer Protection Directorate General, Public Health Directorate, 

Luxembourg; joined the European Commission in 1995, and started in the DG on Employment and 

Social Affairs; now working on Public health policy development, and on its links to other Community 

policies related to health; previously, European representative of the German Red Cross and worked 

for different organisations in the social and youth field. 

Dr Manfred Huber; Head, Health Indicators, Health and Ageing, Social Policy Division, OECD. 

Clemens W Huitink (1952) Dutch; policy employee international affairs Dutch Mental Health 

Association (GGZ Nederland); advisor for consumer related issues in Eastern Europe and South 

America, member of the WHO taskforce on destigmatization; former secretary of the European 

Network of users and ex-users and survivors of Psychiatry; former advisor of psychosocial 

rehabilitation in Greece. 

Jeremy Hurst; Head of Unit, OECD. 

Hugo R Hurts (1954) Dutch; General and Monetary Economics; director of Pharmaceutical Affairs 

and Medical Technology, Ministry of Health, Welfare and Sport, The Netherlands (since June 2004). 

Involved in the health reform debate in the Netherlands during the period 1986–2004, ranging from 

staff member of the so-called Dekker Commission (1986/87) to the post of deputy-director and 

director of Health Insurances at the Ministry of Health, Welfare and Sport (1995–2004); Member of 

Advisory Commission on Health of the Dutch Liberal Party (VVD). 

John Hutton; Medtap. 

Catalina Iliuta (1979) Romanian; Psychologist; Project Coordinator of Harm Reduction activities at 

ARAS – Romanian Association Against AIDS; Bachelor degree in Psychology at Bucharest 

University; member of CEEHRN (Central and Eastern European Harm Reduction Network). 

Dr Rui Santos Ivo (1961) Portuguese; pharmacist; President of the Executive Board of INFARMED 

(National Institute of Pharmacy and Medicines) in Portugal and Chairman of the Heads of Medicines 

Agencies Management Group; Postgraduate education in Health Law and Pharmaceutical 

Legislation and in Regulation and Management of Health Units; Member of the Portuguese 

Pharmacists Association and of the Royal Pharmaceutical Society of Great Britain; Administrator at 

the EMEA (European Medicines Agency) between 2000 and 2002. 

Dr Alan Ingram (1971) British; Lecturer in the Human Geography of Europe. MA in Geography, PhD 

in Political Geography; Previously Policy Officer at the Nuffield Trust and now Academic Coordinator 

for the Nuffield Trust and Nuffield Health and Social Services Fund UK Global Health Programme. 

Professor Rachel Jenkins (1949) British; Psychiatrist; Director of WHO Collaborating Centre, 

Institute of Psychiatry, London (MB BChir FRCPsych); Distinguished Fellow of American Psychiatric 

Association, working for last two decades on mental health policy and implementation, both 

nationally and internationally; she is also an epidemiologist and has led mental health surveys in a 

number of countries. 




Robert Johnstone; lived with arthritis since the age of three; studied international relations and 

spent two years in full-time employment; since then involved in a wide variety of unpaid activities for 

voluntary organisations which include Arthritis and Rheumatism International (ARi), the Long Term 

Medical Conditions Alliance, the Disabled Living Centres Council, and the People with Arthritis and 

Rheumatism in Europe (PARE) Manifesto; on a number of advisory bodies to the national healthcare 

service (NHS) in the UK and disability equality / action trainer. 

Bengt Jönsson; PhD; is Professor in Health Economics, Stockholm School of Economics; BA in 

Economics, Statistics and Political Science, and a PhD in Economics from Lund University; lecturer 

in Economics at Lund University 1969–1982 and professor in Health Economics at University of 

Linköping 1982–1991; in addition to previous academic appointments, he was the Director of IHE 

(the Swedish Institute for Health Economics) and is currently a member of the IHE Board; member of 

the board of the Karolinska University Hospital and of the Scientific Advisory Board, National Board 

of Health and Welfare, Sweden; chairman of the Expert Group and member of the Committee on 

Funding and Organisation of Health Services and Medical Care in Sweden (HSU 2000) from 

1992–1997, member of the board of the National Social Insurance board 1992–1994, and member of 

the scientific advisory board The Swedish Council for Medical Technology Assessment (SBU), 

1988–2002; member of the Editorial Boards for several journals including the Journal of Health 

Economics, The European Journal of Health economics, Research in Health Care Financial 

Management, and of Pharmaco-Economics; Professor Jönsson has been a temporary adviser on 

many issues to WHO and a consultant to OECD and UNIDO; presently he is president of iHEA, the 

International Health Economics Association; extensive publications in the health field include over 

200 papers, reports and book chapters. 

Professor Dr Yves Jorens (1968) Belgian; Professor of Social Security Law and European Social 

Law at the Faculty of Law of the Ghent and Antwerp University, Belgium; Project Director of the 

European Observatory for the Social Security of Migrant Workers, European Commission; DG 

Employment and Social Affairs; Coordinator of a European Network SPECIAL (Social Protection in 

Europe. Convergence Integration, Accession and the Free Movement of Labour), 5th Framework; 

Partner in ‘Europe for Patients’, 6th Framework; Expert and Team Leader in different Phare and 

Consensus programmes on European social law, Consultant for the European Union and Council of 

Europe’. 

Panos Kanavos; London School of Economics and Political Science. 

Dusan Keber; Minister of Health, Slovenia. 

Dr Ilona Kickbusch; German; political sciences and public health; senior health advisor; 

distinguished career with the World Health Organization and Yale University; initiator of the Ottawa 

Charter for Health Promotion, the WHO Healthy Cities project and other world wide initiatives; 

distinguished scholar leader of the Fulbright New Century Scholars programme ‘Health in a 

Borderless World’; recipient of many prizes in the field of health promotion and public health 

Dr Angelika Kiewel (1952) German; Economics, Social Policy, Public Health; Lecturer and Author; 

Head of Pharmaceutical Care Policy Unit at the Bundesverband der Innungskrankenkassen / 

Bergisch Gladbach; responsible for negotiations with associations of physicians, pharmacists and 

pharmaceutical industrie; Member of the Federal Committee of Physicians and Health Insurance 

Funds; Member of the AIM Pharmaceutical Expert Group/Brussels. 

Professor Alison Kitson; British; Nurse; Executive Director Nursing, Royal College of Nursing – 

leads the RCN's professional nursing agenda, nationally and internationally, BSc in Nursing; PhD in 

nursing and social sciences; Fellowship of Royal College of Nursing, Fellow of Green College, 




University of Oxford, Visiting and Honorary Chairs at Ulster, Leicester and City Universities in the UK. 

Niek Klazinga (1957) Dutch; MD PhD, professor of Social Medicine at the Academic Medical Centre 

– University of Amsterdam since 1999; present research activities concentrate on public health and 

health services research, more specifically on the development and use of quality indicators and 

quality systems in health care systems; represents at present the Dutch government in the OECD 

project on quality indicators and serves as technical advisor towards WHO/EURO in a project on the 

development of a Hospital Performance Indicator Framework; between 1985 and 1999 Niek Klazinga 

worked at the Dutch Institute for Quality Improvement in Health Care (CBO) as (chief) scientific 

officer, and was associate professor at the department of Health Policy and Management of the 

Erasmus University Rotterdam between 1994–1999. 

Dr Howard Klee (1945) American; Programme manager, World Business Council for Sustainable 

Development, Geneva Switzerland; prior to joining the Business Council worked with Chevron and 

British Petroleum and served in a number of executive and business functions, including strategic 

planning, business development, environmental affairs, and manufacturing; received an 

undergraduate degree in Chemistry from Williams College, and a doctorate in Chemical Engineering 

from MIT; previously served on President Clinton’s Council on Sustainable Development, and as a 

Director for the Foundation for Research on Economics and the Environment; While working in the 

private sector, holding adjunct faculty appointments at the University of California (Davis), the 

University of Michigan, and currently at the University of Geneva. 

Judith E Klein (1967) American; Lawyer, University of Miami School of Law; Director of the Mental 

Disability Advocacy Programme (MDAP) at the Open Society Institute in Budapest; Member of the 

Florida and Michigan Bars; MDAP works in 23 countries of Central Eastern Europe and the Newly 

Independent States; MDAP aims to ensure that people with mental disabilities are able to live as 

equal citizens and actively participate in society which fully respects their human rights; A number of 

MDAP-supported projects across the region have had significant impact on the development of 

health and social welfare policies and governmental financing mechanisms. 

Els Klinkert (1958) Dutch; Rural Development Sociologist; HIV/AIDS focal point of the Social Policy 

Division of the Ministry of Foreign Affairs in the Netherlands; responsible for policy formulation, 

technical advisory services; member of Share-net, Dutch network of experts on HIV/AIDS and 

reproductive and sexual health and rights. 

Professor Martin Knapp (1952) British; economist and social policy analyst; Professor of Health 

Economics and Director of the Centre for the Economics of Mental Health at the Institute of 

Psychiatry in London; also Professor of Social Policy and Chair of LSE Health and Social Care at the 

London School of Economics. 

Susan Knox; USA; BA Smith College, MA Columbia University; breast cancer survivor, Liaison 

Officer, EUROPA DONNA – The European Breast Cancer Coalition, appointed Executive Director 

1999; responsible for organizing three Europa Donna Pan-European Conferences, exhibits and 

meetings with members of the European Parliament, and all ongoing lobbying and advocacy 

initiatives; developed the Europa Donna website and various publications concerning breast health 

for women; over the last few years designed and developed the Europa Donna European breast 

cancer advocacy training course; extensive experience in the non-profit and for-profit sectors, various 

posts including Director of Therapeutic Activities at Menorah Home and Hospital for the Aged (a nonprofit 

long-term care facility in Brooklyn, New York) and VP for Strategic Planning at Citibank in 

Milan. 

Mihály Kökény (1950) Hungarian; MD MP; Medicine (Internal Medicine and Cardiology); Health care 




management; Minister for Health, Social and Family Affairs of the Republic of Hungary; Faculty of 

General Medicine, Semmelweis University of Medicine; MP since 1994; Parliamentary Secretary of 

State at the Ministry of Welfare from 1994; Minister of Welfare (1996–1998); Chairman of the Health 

and Social Affairs’ Committee of the Hungarian Parliament (1998–2002); Parliamentary Secretary of 

State at the Ministry of Health, Social and Family Affairs (2002–2003); Minister for Health, Social and 

Family Affairs since 15 September 2003. 

Dr Finn Borlum Kristensen (1951) Danish; MD PhD; Medical specialist in general practice and in 

public health, Director of the Danish Centre for Evaluation and Health Technology Assessment at the 

National Board of Health, Adjunct professor in Health Services Research and HTA at the University 

of Southern Denmark. Chairman of International Network of Agencies for Health Technology 

Assessment (INAHTA) and Member of Board of Trustees, Guidelines International Network (G-I-N). 

Professor Prim Dr Günther Leiner (1939), Austria, MD, an internal specialist, retired in 2004 as 

medical superintendent at the Institute of Rheumatology, Rehabilitation and Psychosomatic Medicine 

at Bad Gastein, formerly Member of the Austrian Parliament and speaker of the conservative party in 

the Health Committee. President of the International Forum Gastein. 

Dr Kimmo Leppo (1943) Finnish; Director-General of Health Department at the Ministry of Social 

Affairs and Health; medicine, social sciences, social medicine; chair or member of numerous national 

committees, working parties and delegations on health policy development; technical adviser to 

WHO/HQ and WHO/EURO in a number of fields related to health policies; former member of the 

Executive Board of WHO; member of social protection committee(SPC) of EU; member of High Level 

Group on Health Services and Medical Care. 

Diane Lequet-Slama; Ministry of Health, France. 

Christian Ligensa (1937) Dipl.-Ing. Aerospace Science, Baudirector (retired) German Government 

and NATO; Vice President of the Federal Prostate Cancer Patient Organisation ‘Bundesverband 

Prostatakrebs Selbsthilfe e.V’. 

Dr-Ing. Oliver Lipps (1965) German; Mathematics (Diploma), PhD in travel behaviour research; 

SHARE Field Project Manager, Mannheim Research Institute for the Economics of Aging, Germany; 

Analysis of the SHARE fieldwork; Stochastic population projections; Travel behaviour and 

demographic change. 

Dr Graham Lister (1945) British; doctorate in management and leadership; Senior Associate of The 

Nuffield Trust and secretary of the UK Partnership for Global Health; also working with Netherlands 

School of Public and Occupational Health on health leadership and management in EU accession 

countries; formerly: partner in charge of Coopers and Lybrand health management consulting group, 

member of health board, Partners Council of the National Institute for Clinical Excellence and Chair 

of the College of Health. 

Susanne Løgstrup (1958) Danish; Director of the European Heart Network (EHN – a Brusselsbased 

alliance of heart foundations and other like-minded non-governmental organisations from 26 

European countries); responsibilities include monitoring and responding to health-related 

developments in the European Union (EU), coordinating EHN publications, liaising with members of 

the EHN and managing pan-European projects; Degrees in Law and Business Administration (MBA). 

Dr Eva Jané-Llopis (1974) Spanish; Clinical Psychology, Social Sciences; Head of Science and 

Policy for the Prevention Research Centre in the Netherlands; senior researcher for the Academic 

Centre of Social Sciences at the University of Nijmegen, the Netherlands; consultant for the WHO, 




the EC, and other governmental and non-governmental organizations; responsible for the mental 

health promotion track of the International Union for Health Promotion and Education (IUHPE) on ‘the 

evidence of mental health promotion effectiveness; leader of the EC financed Imhpa network 

(Implementing Mental Health Promotion Action) and the European Platform for Mental Health 

Promotion and Mental Disorder Prevention. 

Luiz Loures; UNAIDS. 

Jui-fen Rachel Lu, ScD (1963) Taiwan; health economics (focus on the analyses of NHI policy, 

health care market, equity, and outcome research) ; Associate Professor (Chair, 2000–2004) at 

Department of Health Care Management, Chang Gung University, and Takemi Fellow at Harvard 

School of Public Health (2004–2005); BS, 1986 (National Taiwan University), MS, 1989, ScD, 1994 

(Harvard University) ; Member of International Health Economics Association, American Economic 

Association, Taiwan Economics Association, Taiwan Public Health Association ; Principal Investigator 

of the EU funded research project (Equity in health care financing, delivery and health status in Asia 

Pacific countries, EQUITAP), Principal Investigator of the International Quality of Life Assessment 

Project (Health Assessment Lab, US), Member of Health Insurance Committee, NHI Forum (NHRI, 

Taiwan), Task Force on NHI Case Payment (BNHI, Taiwan), Task Force on NHI Assessment (NHRI, 

Taiwan), Task Force on NHI Research Database (NHRI, Taiwan); recipient of Henry J. Kaiser Family 

Fellowship (1990–1994), Research Award, National Science Council (1995), Minister Wang Jin Naw 

Memorial Award for Best Paper in Health Care Management presented by Kimma Chang Foundation 

(2002), Best Teaching Award, Chang Gung University (2002); papers have been published in Health 

Affairs, Medical Care, Osteoporosis International, Health and Quality of Life Outcomes, Taiwan 

Economic Review, Sun Yat-Sen Management Review, and Taiwan Journal of Public Health etc. 

Dr Sir Alexander Macara (1932) UK; Public Health Physician; Chairman, National Heart Forum. 

Taught Social Medicine, University of Bristol 1963–97; Secretary General, Association of Schools of 

Pubic Health in the European Region (ASPHER) 1975–89, and of World Federation for Education 

and Research in Public Health 1988–97. CPME (Doctors in Europe) since 1980; extensive service as 

visiting Professor, WHO Consultant, etc., in Africa and Asia; Chairman of British Medical Association 

1993–98. 

Peggy Maguire; a political scientist; graduate of Trinity College Dublin, and Director General of the 

European Institute of Womens’ Health; member of steering group of the EAC (The European 

Advisory Council on gender and womens Health); Member of the WHO consultative expert panel on 

Gender Mainstreaming in EU; Member of the Executive of the European Men's Health Forum; also 

been a member of the EU Commission External Advisory Group on ageing and Disability, 5th 

Framework Programme; Initiated and coordinated the research and publication of several 

publications. 

Professor Marshall Marinker (1930) British; Medicine; Independent Consultant, Health Policy and 

Professional Development; Visiting Professor, GKT, King’s College London; Chair, MSD Health 

Targets European Academic Advisory Board; Editor ‘Health Targets in Europe’ (2002). 

Dr Christine Marking; The Netherlands; Psychologist; specialization clinical and social psychology 

of ageing; currently active as independent consultant on EU health, social and ageing policy; 

previous positions: European Commission DG EMPL, Director of Eurolink Age/AGE, Head of Pharma 

& Health Team with Weber Shandwick Adamson. 

Dr John Martin (1948) Irish; Public Health Physician; Director of the WHO Office at the European 

Union; in addition to steering the collaboration between WHO and the institutions of the European 

Union, his office is also responsible for WHO collaboration with the OECD and the Council of 




Europe; Fellow of the Faculty of Public Health of the Royal College of Physicians, UK. 

Micheál Martin TD; graduated from University College Cork with an MA in Political History and was 

a secondary school teacher; first elected to Dáil Eireann through the Cork South-Central 

Constituency in 1989 and was opposition spokesperson for Education and the Gaeltacht from 1995 

to 1997; member of the Cabinet since 1997 when he became Minister for Education and Science 

and subsequently Minister for Health & Children from January 2000 to date; recently been awarded 

the gold Medal by the European Society of Cardiology for the recent introduction of the workplace 

smoking ban. 

David McDaid; Editor, Eurohealth; Research Fellow, LSE Health and Social Care & European 

Observatory on Health Systems and Policies, London School of Economics and Political Science. 

Clare McGrath; (1959) British; Scientist/Researcher; Currently Director in charge of Outcomes 

Research for Europe Canada, Africa and Middle East, Pfizer Pharmaceuticals; educated in 

Physiology, Clinical and Outcomes Research; recently completed a review of HTA systems 

throughout Europe. 

Professor Martin McKee; British; Medicine; Professor of European Public Health, London School of 

Hygiene and Tropical Medicine; Research Director, European Observatory on Health Care Systems. 

Mag Dr Dr Oskar Meggeneder (1945) Austria; Social economics, political sciences, communication 

sciences and sociology; Managing director of the Upper Austrian Sickness Fund; President of the 

Austrian Public Health Association (ÖGPH); Vice-president of the Institute of Health Planning (IGP); 

Contact partner of the European Network Workplace Health Promotion (ENWHP). 

Dr Bettina Menne (1963) German; Public Health; Medical Officer Global change and health 

Programme, World Health Organization Regional Office for Europe; Medical Doctor, specialized in 

Hygiene and Public health, additional training in health promotion and tropical diseases; convening 

Lead Author of the Inter-governmental Panel of Climate change (IPCC), on several editorial boards 

and coordinating several European research activities. 

Dr Bernard Merkel (1949) United Kingdom; currently Head of the Unit in the European Commission 

responsible for health strategy; before joining the Commission for many years civil servant in the UK, 

working on various health policy issues, including AIDS and reform of the NHS, as well as social 

policy questions; visiting Fellow at LSE Health in the London School of Economics and as Honorary 

Senior Lecturer at the London School of Hygiene; he is on the Editorial Board of Eurohealth and has 

written a number of articles on health policy; Doctorate in political theory. 

Manuela Messmer-Wullen (1950) German; Marketing and Advertising Manager; Communication 

Sciences; Head of International PR Department Philips Speech Processing, responsible for Speech 

Recognition Technology; Stroke Patient; Retirement; Chairwoman Austrian Stroke Selfhelp 

Association; Member of Board SAFE – Stroke Association for Europe; Member of Board General 

Assembly Austrian Selfhelp Association. 

Jonathan Mogford; Department of Health, UK. 

Gerard Molleman (1954) Dutch; MA, Psychologist and Health Promotion Specialist; director NIGZ 

Centre for Knowledge and Quality Management (NIGZ = Netherlands Institute for Health Promotion 

and Disease Prevention); member of EuroHealthNet, member of IUHPE, project leader of EU-project 

'Getting Evidence into practice'. 

Catriona Moore (1972) UK; Patient Advocacy; Policy and Advocacy Manager, CancerBACUP; MSc 




in Public Policy and Management; responsible for ensuring that CancerBACUP effectively represents 

the views and interests of people affected by cancer to politicians and policy-makers. 

Antony Morgan (1960) British; Epidemiologist; Head of Research and Information for the Health 

Development Agency in England; Originally an applied chemist, later trained in information science 

and epidemiology and has worked in Public Health in the English NHS for the last 17 years, at 

district, regional and national level; he is an honorary member of the Faculty of Public Health 

Medicine; currently responsible for leading a team of research and information specialists to deliver 

on one of the HDA’s key functions to develop an evidence base for public health with a key emphasis 

on getting that evidence into practice and to finding out 'What works?' to promote health and reduce 

inequalities; special areas of interest and expertise include social action for health (using the concept 

of social capital) and development of inequalities targets and indicators for programme planning, 

implementation and evaluation. 

Matthew Muijen; Regional Advisor on Mental Health, WHO 

Clive Needle; Director and EU Policy Advisor, EuroHealthNet, at its Brussels office; this EU policy 

network links national and regional agencies and institutes responsible for health promotion, disease 

prevention and public health; also an independent policy advisor, consultant and writer on EU affairs, 

and formerly a Member of the European Parliament. 

Bente Nielsen (1945) Danish; Nurse; Member of Aarhus Regional Council and member of Danish 

Regions Presidency; Head of the Socialist People’s Party group in Aarhus Regional Council; Member 

of the Budget Committee in Aarhus Regional Council; Vice-president of the Business Committee and 

the Committee for Equal Rights in Aarhus Regional Council; Vice-president of the Baltic Sea 

Commission in CPMR (Conference of Peripheral Maritime Regions); Alternate member of the 

Committee of the Regions (COR); Chairman of a cooperative housing society; Rapporteur on COR 

opinion on EU action programme in the field of Public Health and rapporteur on COR opinion on the 

communications concerning the ‘Follow-up to the high level reflection process on patient mobility and 

health care developments in the EU’ and the ‘Modernising social protection for the development of 

high quality, accessible and sustainable health care and long-term care: support for the national 

strategies using the open method of coordination’ . 

Mona Lisa Norrman (1954) Sweden; work as a social worker and therapist for disabled people 

children and adults (both mental and physical disabilities) for 20 years; masters degree in social 

work; the last six years full time politician and member of the board of the county council of Jämtland 

in Sweden; member of the Committee of Regions and recently rapporteur for a draft opinion on the 

proposal for a Council Directive on implementing the principal of equal treatment between women 

and men in the access to and supply of goods and services. 

Thomas E Novotny (1947) USA; Professor of Epidemiology, Consultant to World Bank ECA Region 

Director of International Educational Programmes, Professor in Residence, Epidemiology and 

Biostatistics, UCSF Institute for Global Health; B.S., Zoology, University of Nebraska, Lincoln, 1969; 

MD, University of Nebraska Medical Center, 1973; Postgraduate Training in Family Medicine, UCSF, 

1977; Postgraduate Training in Preventive Medicine, CDC, 1987; Masters in Public Health 

(Epidemiology), Johns Hopkins University School of Public Health, 1992; Member: American Public 

Health Association; American College of Preventive Medicine; International Health Economics 

Association. 

Anders Olauson; Agrenska Foundation. 

Eva Orosz; OECD. 




Kim Ostjacobsen; Danish Nursing Association. 

John O’Toole; Masters Degree in Economics, as well as a Masters Degree in Public Sector 

Analysis, and studied at the Ecole Nationale d’Administration in France; Health Counsellor at the 

Permanent Representation of Ireland to the European Union; prior to his appointment in Brussels, 

John O’Toole worked in the Department of Health in Ireland, where he held various responsibilities in 

that Department and previously worked in the Finance Ministry and the Office of the Revenue 

Commissioners; written several works on the operation of the machinery of Government in Ireland 

and has presented papers at many international conferences. 

Camilla Parker (1965) British; lawyer (LLB, LLM); independent legal and policy consultant 

specialising in mental health, disability and human rights; consultant to the Mental Disability 

Advocacy Program, Open Society Institute, Budapest. 

Ing. Peter Pazˇitný; MSc; Analyst; 2003 he completed his postgraduate MSc. studies at the 

Semmelweis University in Budapest with Healthcare management and Health policy; Principal 

Advisor to the Minister of Health of the Slovak Republic; graduate of the University of Economics in 

Bratislava (1999); he works as an analyst in the think tank MESA 10 (Centre for Economic and 

Social Analyses) since 1997; Along with macroeconomic development, economic transformation and 

fiscal policy analyses, he pays attention mostly to the systemic changes and reform process in the 

healthcare sector; he is the co-author of the publication ‘Healthcare Reform Strategy – Real Reform 

for the Citizen’, together with current Health minister Rudolf Zajac; from October 2002, he serves as 

the minister’s external advisor. 

Professor Jürgen Pelikan; University of Vienna 

Ignacio Pérez Caldentey (1960) Spanish; Law, International Relations, Diplomacy; Counsellor, 

Spanish Ministry of Foreign Affairs; Senior Advisor to the Commissioner for Human Rights, Council 

of Europe; responsible for the follow up of human rights in Andorra, Hungary, the Czech Republic, 

Poland, Spain, Slovakia, Bulgaria and Romania. 

Greg Perry (1961) British; Director General of the European Generic Medicines Association (EGA); 

Editor of the Journal of Generic Medicines; Member of the Management Board of the International 

Generic Pharmaceutical Alliance (IGPA); Managing Director of GPA Public Affairs and 

Conferences.M.A. in European Integration and BSc (Hons) International Studies. 

Teresa Petrangolini; Tribunale per i Diritti del Malato, secretary general of Cittadinanzattiva. 

Arrety Pinel; The Global Fund to Fight AIDS, TB and Malaria. 

Andy Porter (1954) British; Social Work; Masters degree in Social Work from Sussex University; 

Lead Commissioner for Mental health at Brighton and Hove City NHS Primary Care Trust; varied 

career in community, social and health settings – specializing in mental health – extensive 

experience of developing and providing community mental health services. 

Silvia G Priori; University of Pavia, Fondazione S. Maugeri. 

Dr Josef Probst (1954) Austrian; studied law; member of the management board of Main 

Association of Austrian Social Insurance Institutions, the main organisation of the Austria Insurance 

System, responsible for the reimbursement of pharmacy, contracting with physicians and the 

reclamations of the mandetory social insurance. 

Elizabeth Pott; Director, Bundeszentrale für Gesundheitliche Aufklärung. 




Dr Dainius Puras (1958) Lithuanian; Medicine, Mental health; Head and Associate professor of the 

Centre of Child psychiatry and social paediatrics in Vilnius University; member of EC Mental health 

Working party; past President of Lithuanian Psychiatric Association; main areas of professional 

interest – analysis of changes in health care and social welfare sectors in countries of eastern and 

central Europe, with special emphasis on public mental health issues. 

Gerard Quinn; Professor and Dean of the Law Faculty at the National University of Ireland, Galway 

Director of its Disability Law and Policy Research Unit; a graduate of Harvard Law School, 

coordinator for the EU Article 13 Network of Disability Discrimination Legal Experts; currently 

member of the Human Rights Commission of Ireland and the European Social Rights Committee 

(Council of Europe); acted as head of the Rehabilitation International (RI) delegation to the United 

Nations Working Group to draft a UN treaty on the rights of persons with disabilities; publications 

extensively on international, European and comparative disability discrimination law; his most recent 

publication in the field (with Theresia Degener) was ‘Human Rights and Disability: an Examination of 

the Current Use and Future Potential of the UN Human Rights Treaties in the Context of Disability’ 

(Office of the UN High Commissioner for Human Rights, Geneva, 2002). 

Herta-Maria Rack; Expert Federal Ministry for Health and Women. 

Scott C Ratzan (1962) MD from the University of Southern California; MPA from the John F. 

Kennedy School of Government, Harvard University; and MA from Emerson College; Vice President, 

Government Affairs, Europe, Johnson & Johnson, Brussels; Dr Ratzan has been engaged in health 

policy with activities in global health policies, effective communication of risk issues such as BSE, 

and other public health activities including HIV/AIDS; Editor-In-Chief of the Journal of Health 

Communication: International Perspectives and faculty appointments at the University of Cambridge 

and the College of Europe, as Tufts University School of Medicine and George Washington 

University. 

Maria Rauch-Kallat (1949) Austrian; Politician; graduated of Pedagogical Institute as teacher 

English, Russian, Sports, Geography and Economics; Federal Minister of Health and Women; 

Secretary General of the Austrian People’s Party (ÖVP) (1995–2003); Federal Minister (1992–1995); 

Managing director „Soziales Hilfswerk’(non-profit organisation); running projects for children, families, 

seniors, handicapped people Social networking in Vienna and international projects in Central 

America and Eastern Europa (1983–1992); other functions and memberships: President of the ÖVP 

– Austria Women’s Association, President of Alpha (a political academy specialised on women), 

President of the Austro-Hungarian Association, Board member of the Dr Maria Schaumayer 

Foundation, Board member of the ÖVP Political Academy, Board member of ‘Lobby for children’, 

Member of the Austrian Management Association , Member of the Christian Teacher’s Association of 

Austria. 

Graham Robertson; Chief Executive, NHS Health Scotland. 

Tamsin Rose (1969) English; BA Hons in International Relations; General Secretary of the European 

Public Health Alliance, a network of 100 NGOs in 23 European countries committed to promoting 

health; Previous experience of running a network of local authorities, managing an EU funded eastwest 

cooperation programme; working as a journalist and communications trainer. 

Dr Magdalene Rosenmöller (1960) German; MD MBA; Lecturer and Researcher at IESE Business 

School, Spain and free lance consultant; At IESE she teaches management in the health sector in 

the MBA and other executive education programmes; she has extensive experience in policy advice 

to health care reform and health policy in Europe and Latin America to the European Commission, 

the European Health Policy Forum and others; her executive experience includes two years as 




health economist at the World Bank; she is member of the Board of EHMA, the European Health 

Management Association. 

Alric Rüther; Director, German Agency for HTA at the German Institute for Medical Documentation 

and Information. 

Dr Andrzej Rys; graduated from Medical School in Cracow, specialized in radiology and public 

health; 1991 established and was running till 1997 the School of Public Health of the Jagiellonian 

University, first such institution in CEEC; member of the board of ASPHER (Association of School of 

Public Health in the European Region); 1997–1999 director of the city health department; this time 

he developed a master plan and implemented a reform of outpatient clinics in Cracow; 1995–1999 a 

Polish director of ‘Harvard-Jagiellonian Consortium for Health’ – a project focus on local 

government’s role in health care; 1999–2001 a deputy ministry of health; new system of emergency 

medicine, a reform health allied professionals education, a member of Polish-UE negotiation team; 

currently director the Center for Innovation, Technology and University Development at the 

Jagiellonian University; also working as a consultant for WHO, WB and EAR; Vice President of 

Institute of Emergency Medicine (NGO) and chief editor of the Journal of Health and Management. 

Dr Petko Salchev (1961) Bulgarian; PhD, 1987 graduated from the Faculty of Medicine of the 

Medical University in Sofia; 1991 postgraduate study in social medicine at the Department of Social 

Medicine and Public Health of the Medical University in Sofia; postgraduate courses in health care 

insurance and management in several Europe countries; 1987 district therapist and hospital 

therapist; assistant professor and chief assistant professor, Department of Social Medicine and 

Public Health, Medical University in Sofia; Director of the Regional Health Centre, Sofia and 

Executive Director of ‘Trud i Zdrave’ Voluntary Health Insurance Fund; since 1999 lecturer, New 

Bulgarian University, Sofia and ‘St. Cyril and St. Methodius’ University; from 2002 Chief Executive 

Officer of the ‘Queen Giovanna’ University Hospital Sofia; 2003 Deputy Minister of Health more than 

35 publications in the field of medical education, systematic analysis for health protection, medical 

ethics, etc.; member of a number of Bulgarian and international medical associations, Vice President 

of the Bulgarian Medical Law Association. 

Dr Katrin Saluvere (1959) Estonian; medical doctor; Deputy Secretary General on Health in the 

Ministry of Social Affairs of Estonia; Board member of Estonian Health Insurance Fund; Member of 

the Standing Committee of WHO EURO; experience in establishing health promotion fund under the 

health insurance fund, in primary health care reform process and in reforming hospital sector. 

Peter Scherer (1944) Australia; Counsellor to the Director of the Employment, Labour and Social 

Affairs Directorate at the OECD, Paris; after studying at the Monash University, the Australian 

National University and Cornell University in the US, lectured at Sydney University and was a 

research fellow at the Australian National University; then work in various Australian Government 

Departments, eventually becoming Acting Director of the Bureau of Labour Market Research; when 

that Bureau was abolished in 1986, he came to the OECD, initially heading the Division responsible 

for the annual OECD Employment Outlook; from 1991 to June 2002 he was Head of the Social 

Policy Division; published in the fields of labour economics, industrial relations, comparative social 

expenditures and social policy trends. 

C Schmaltz; Cancer Sector, DG Research, European Comission. 

Karl-Juergen Schmitt; Director Health Policy, Siemens Medical Solutions, Vice President EHTEL. 

Ted Schrecker (1953) Canadian; trained in political science and specializing in political economy 

and in issues at the interface of science and public policy; Research Associate, Saskatchewan 




Population Health and Evaluation Research Unit, University of Saskatchewan, Canada; a co-author 

of Fatal Indifference: The G8, Africa and Global Health (University of Cape Town Press, 2004). 

Ingrid Anna Rosian-Schikuta (1960) Austrian; Health Economist; Senior Researcher and Head of 

Health Economics at ÖBIG/Austrian Health Institute; Focus on international research in the field of 

pharmaceutical systems (pricing, reimbursement, registration, margins, generics, innovations..) and 

health care systems; economic evaluations and Health Technology Assessment; Lecturer at Donau 

University Krems and International Management Centre; Member of the ‘Unabhängige 

Heilmittelkomission’/Independent Pharmaceutical Commission). 

Shombi Sharp; MA in Economics University of Colorado; Graduate School Certificate, The 

Economics Institute, Colorado; BS in Business Administration University of Kansas; Assistant 

Resident Representative and Head of both the Governance and HIV/AIDS Units, oversees a portfolio 

of 12 technical assistance projects and supporting overall programme management and 

representation of the UNDP in Russia; broad experience in international development, the private 

sector and development economics; advised the Russian Government on performance-based 

planning on the consolidated federal plan; Several publications for UNDP; relevant Professional 

Affiliations: The Human Development and Capability Association (HDCA), Harvard University. 

Gaudenz Silberschmidt; Office of Public Health, Switzerland. 

Peter Singleton; Senior Associate, Cambridge University Health. 

Professor Peter C Smith (1952) English; Professor of Economics, Center for Health Economics, 

University of York; MA Mathematics, University of Oxford; council member, Royal Statistical Society; 

board member, Audit Commission for England and Wales; Editor-in-Chief, Health Care Management 

Science; numerous publications on health system finance and performance; policy advisor to many 

national and international health care agencies. 

John Smyth (1945) British; has been Professor of Medical Oncology at the University of Edinburgh 

since 1979 and is currently the Director of their comprehensive Cancer Centre; research focused on 

the development of new drugs for the treatment of cancer and he has served on a wide variety of 

international committees in this regard; member of the Commission on Safety of Medicines in the UK 

and of the European Medical Evaluations Agency Scientific Advisory Group; he has sought actively 

to promote the development of medical oncology in Europe and has served as President of the 

European Society of Medical Oncology, and Treasurer of the Federation of European Cancer 

Societies (FECS); currently President-Elect of FECS and Editor-in-Chief of the European Journal of 

Cancer. 

Dr Viorel Soltan (1971) Moldovan; MBA at Newport University; Country Program Director, leading 

American International Health Alliance’ (AIHA) Moldova office and assuming primary responsibility for 

managing all facets of the USAID financed TB programme; lecturer at the State Medical University in 

Moldova’s School of Public Health teaching project management and evaluation as part of the health 

management education programme; holds United Nations – Moldova 2003 Award for outstanding 

leadership and commitment in prevention of HIV/AIDS and providing support to people living with 

HIV/AIDS. 

Giovanni Sperti; Bristol-Meyers Squibb. 

Dr Hans Stein (1937) Germany; Ministerialrat a.D; FFPH; School education in Germany, India and 

Egypt. Universities Geneva, Innsbruck and Munich, degree in Law; large number of publications on 

European health policy issues. Consultant in ‘EU Health Policy’ for various European and national 




institutions such as the European Commission (GD Health and Gd Research), the European 

Observatory on Health Systems Brussels, the European Public Health Centre Düsseldorf, the 

European Health Forum Gastein; lecturer in German schools of Public Health in Düsseldorf, Munich, 

Magdeburg; till end of 2002 Department Head in German Ministry for Health Bonn, responsible for 

‘European Health Policy’; German representative in large number of Council and Commission 

committees on public health, health policy, health services and public health research. 

Simon Stevens (1966) United Kingdom; health policy and management; President – European 

group, United Health Group; previously the British Prime Minister's Health Policy Adviser, 10 

Downing Street; visiting Professor of Health Policy, London School of Economics. 

Dr Jeffrey L Sturchio (1952) US; Vice President, External Affairs, Human Health-Europe, Middle 

East & Africa at Merck & Co., Inc., in Whitehouse Station, New Jersey; responsible for the 

development, coordination, and implementation of a range of health policy and communications 

initiatives for the region; Member of the Private Sector Delegation to the Board of the Global Fund to 

Fight AIDS, TB and Malaria; Publications include ‘Successful public-private partnerships in global 

health: lessons from the MECTIZAN Donation Program,’ (with B Colatrella), in The Economics of 

Essential Medicines, edited by B Granville (London: Royal Institute of International Affairs, 2002). 

Nicoline Tamsma (1960) Dutch; International health policy, senior adviser international affairs 

Netherlands Institute for Care and Welfare NIZW; Master’s Degree in Psychology; member of EHFG 

advisory committee and EHMA EU advisory panel; international collaboration, EU policy analysis, 

training and consultancy; previous experience includes work on European health systems reforms at 

the Nuffield Institute for Health in Leeds (UK) and on integrated HIV/AIDS policies with WHO Europe; 

recently published EU policy recommendations on advancing integrated care for older people based 

on EHMA’s CARMEN project. 

Dr Joop ten Dam (1953) Dutch; previously lecturer Social and Health Sciences, Utrecht University; 

Since 2000 project coordinator of the NIGZ – Support centre for Community Health (a project of the 

Netherlands Institute for Health Promotion (NIGZ), NSCH offers services to organizations to help 

them address health inequalities in local settings, works and publishes in the fields of urban policy, 

inequalities in health, community-based health promotion and health policy. 

Dr Toma Tomov (1944) Bulgarian; Community Psychiatry, Psychoanalysis, Psychiatric 

Epidemiology; Director, Institute of Human Relations, New Bulgarian University, Sofia; member of the 

Bulgarian Psychiatric Association, honorary member of the Royal College of Psychiatrists, board 

member of the Geneva Initiative on Psychiatry. 

Ann Tucker (1949) British; Educationalist/Double Carer ; Community Coordinator Adult Education in 

Central London; Member of: Carers – advisory part of the National Service Framework for Mental 

Health (responsible for producing guides to support carers and professionals ), Women's Safety 

Committee SLAM NHS Trust (responsible for establishing a women's safe crisis house), Sainsbury's 

Centre for Mental Health – Breaking the Circle of Fear Project (producing a report on discrimination 

within mental health services ). 

Dr Georg Vana (1967) Austrian; Veterinary Medicine; Director, Corporate Affairs of Pfizer 

Corporation Austria in Vienna; responsible for Reimbursement, Media Relation, Corporate Social 

Responsibility and External Affairs, experience in Regulatory and Medical Affairs; started 1994 in 

Research and Development (Drug Discovery). 

Anna van Poucke (1960) Dutch; Psychology and Management Sciences (masters degree), 

Economic Sciences (PhD in preparation for January 2005); vice-chairman of the board of governors 




of the Dutch patients’ organization for cardiovascular diseases; became acknowledged with 

cardiovascular diseases and their influences on the lives of patients and their relatives, when her 

mother had a stroke aged only 55, due to which she became partly paralyzed; Management 

consultant and interim manager in health care; counsellor and manager in several mergers of 

hospitals and strategic innovation projects. 

Dr Sabine Vogler (1970) Vienna, Austria; Health Economist, Researcher at ÖBIG/Austrian Health 

Institute, working in Health Economics; Focus on international research in the field of health care 

systems (organisation, financing, reforms) and pharmaceutical systems (pricing, reimbursement, 

margins, generics, innovations) in the enlarged European Union. 

Susanne Volqvartz (1953) Denmark; CEO The Danish Heart Foundation; Chair European Heart 

Network. 

Dr Sarah Wamala (1967) Swedish-Ugandan; PhD in Medicine (Public health), also trained 

economist and epidemiologist; Research manager at the National Institute of Public Health, Sweden; 

Associate professor and senior lecturer at the Karolinska Institutet; Research activities include 

macrosocial and economic determinants of health including social capital, from a gender and 

lifecourse perspective and effects of globalisation on public health; has co-edited two books: Gender 

and socioeconomic equities in health (2002), and Globalisation and Health (Oxford University Press, 

forthcoming); conducts postgraduate courses at the Karolinska Institute and supervises PhD 

students; member of various international professional organisations, and has received international 

scientific awards. 

Dr Birgit Weihrauch (1943) German; MD; Social Medicine; Permanent representative of Head of 

Health Department, NRW Ministry of Health, Social Affairs, Women and Family in Düsseldorf; 

responsible for principle questions concerning health policy, health protection and innovative health 

structure development, including questions of international health policy. 

Dr Paul Weissenberg; law degree (Assessor) at the University of Freiburg (Germany), followed by 

post-graduate studies in European law in Geneva (Switzerland) and by a PhD (Docteur en droit) in 

European law at the University of Geneva; Director in the European Commission, DG Enterprise, 

since 2000, in charge of single market issues, management and legislation for consumer goods, 

covering areas such as cars, pharmaceuticals and biotechnology; joined the European Commission 

in 1990 and was nominated Director in 1994, responsible for capital goods industries like aerospace 

and maritime industries; before joining the European Commission he worked in the German Ministry 

of Economics, dealing with East-West economic relations and competition policy; also posted to 

Paris, La Paz and Toronto; was lecturer at the University of Cologne on constitutional law. 

Antoinette Wenk Lang; Swiss/ Danish; lic. rer. pol, MSc; Master Degree in Economics/Business 

Administration and Master of Science in Health Economics; held various roles in the field of health 

economics, reimbursement and pricing both in consultancy and in the health care industry 

(pharmaceuticals and devices); Director of Health economics and Reimbursement in Europe at 

Boston Scientific Corporation, responsible for health economics and market access strategies in 

Europe; independent solution focused management coach. 

Susan Williams; Royal College of Nursing. 

Professor Rudolf Winter-Ebmer (1961) Austrian; Economist, specialist in labor economics, ageing, 

education, wage formation; University of Linz and Research Professor at Institute for Advanced 

Studies (IHS) Vienna, research fellow at Centre for Economic Policy Research (London) and Institut 

zur Zukunft der Arbeit (Bonn). 




Dr Matthias Wismar (1965) Health Policy Analyst, European Observatory on Health Systems and 

Policies, WHO/EURO, Brussels; Political Sciences in Frankfurt am Main (Germany), Southampton 

(UK) and at the Nuffield College, Oxford (UK); teaching at the University of Essen, joined the 

Department of Epidemiology, Social Medicine and Health System Research, Hannover Medical 

School in 1996; Since 1999 head of the research unit on health policy; In 2003 joined the 

Observatory in Brussels. 

John Wyn Owen CB (1942) British; Health Services and Health Care Policy and Management, 

Secretary Nuffield Trust, BA Cambridge 1964, DipHSM 1967; Fellow Australian College Health 

Service Executives, Member US Institute of Medicine, Chairman European Foundation Centre 

International Comittee and Europe In The World; Chair Young@Heart, Member WHO Technical 

Committee on Globalisation, Trade and Health; Member US AcademyHealth International Board; 

Board Member International Society for Quality in Health Care. 

Georg Ziniel; Wiener Gebietskrankenkasse.

Global Health Challenges - European Health Forum Gastein

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