Congress report - European Health Forum Gastein

Organiser: International Forum Gastein 

Co-organisers: Federal Ministry for social Security and Generations 

Austrian Broadcasting Corporation (ORF) 

EU Committee of the Regions 

With the support of: European Commission, DG for Health and Consumer Protection 

European Commission, DG Information Society 

World Health Organisation, Regional Office for Europe 

Federal Ministry for Economy and Labour 

Land Salzburg 

Programme co-ordinator: Paul Lincoln, National Heart Forum, UK 

Programme organisers: Philip C. Berman and Paul Belcher, European Health Management 

Association (EHMA) 

Maggie Davies, NHS Health Development Agency (HDA), England 

Michael Hübel, European Commission, DG for Health and 

Consumer Protection 

Genon Jensen, European Public Health Alliance (EPHA) 

Monika Kaiser, Gesellschaft für Versicherungswissenschaft und 

gestaltung (GVG) Cologne, Germany 

Jerry O’Dwyer, Haughton Institute, Ireland 

Matthias Schuppe, International Forum Gastein (IFG) 

Publisher: Günther Leiner 

International Forum Gastein 

Tauernplatz 1, 

A-5630 Bad Hofgastein 

Austria 

www.ehfg.org 

Editors: Günther Leiner 

Matthias Schuppe 

Co-editor: Christoph Köstinger 

ISBN-N° 3 – 9500989 – 3 - 3 

Printed in Austria 2002

Congress report 

European Health Forum Gastein 

2001 (EHFG) 

Bad Gastein / Austria 

26 to 29 September 2001 

Integrating Health across Policies 

Creating a better Future for Health in Europe 

www.ehfg.org 

Organiser: International Forum Gastein 

Co-organisers: Federal Ministry for social Security and 

Generations 

Austrian Broadcasting Corporation (ORF) 


with support of: 

European Commission, DG Health and Consumer Protection 

European Commission, DG Information Society 

World Health Organisation, Regional Office for Europe 

Federal Ministry for Economy and Labour 

Land Salzburg

The International Forum Gastein gratefully acknowledges the vital contributions, efforts and 

achievements of our co-organisers and members of the advisory committee of experts which 

have been instrumental in planning and organising the 4th European Health Forum Gastein 

2001. 

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

expertise, generous support, sponsorship and fruitful co-operation 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: 

European Commission 

WHO – Regional Office for Europe 

Austrian Ministry for social Security and Generations 

Austrian Broadcasting Corporation 

Austrian Ministry for Economic Affairs 

Land Salzburg 


Communities Bad Hofgastein and Bad Gastein

Sponsors & Hosts: 

Austrian Airlines 

BSMG Worldwide 

Bundesverband der Pharmazeutischen Industrie, Deutschland 

Casinos Austria AG 

CEPCO Holding AG 

Department of Health (England) 

Engelhorn Foundation for Rare Diseases 

Gasteiner Bergbahnen AG 

Gasteiner Quellversand 

Gasteinertal Tourismus GmbH 

GlaxoSmithKline 

Hauptverband der Sozialversicherungsträger Österreichs 

Interpharma 

Kur- und Tourismusverband Bad Gastein 

Kur- und Tourismusverband Bad Hofgastein 

Kur- und Vitalzentrum Bad Hofgastein 

Lauda Air 

Merck, Sharp & Dohme (MSD) 

Mobilkom Austria 

Österreichische Ärztekammer 

Österreichische Lotterien 

Pharmig 

Salzburger Nachrichten 

Serono International S.A. 

Telekom Austria 

Tyrolean Airways 

Supporting & Associated Organisations: 

Boehringer Ingelheim, Österreich 

Deutsche Krankenversicherung AG 

European Federation of Medical Informatics 

Fachverband der chemischen Industrie Österreichs, Gruppe Pharmazeutika 

Hilfswerk Austria 

Oesterreichische Nationalbank 

Wirtschaftskammer Österreich 

Thank you very much for your confidence and for taking the chance of working with us 

towards the realisation of the European Health Forum Gastein

Co-organisers 

Sponsors

Table of Contents 


TABLE OF CONTENTS 7 

PREFACE 12 

David Byrne 12 

Herbert Haupt 13 

Reinhart Waneck 15 

Günther Leiner 16 

GASTEIN HEALTH DECLARATION 18 

OPENING CEREMONY 25 

Words of Welcome 

Herbert Haupt 25 

Gyula Pulay 26 

James Walsh 28 

Günther Leiner 29 

PLENARY SESSION I + II 33 

The Work of WHO in Championing Health in Development 

David B. Evans 33 

Investing in Better Health in Wales 

Jane Hutt 34 

The Potential and Limitations of Health Impact Assessment 

Roscam Abbing 39 

Progress and prospects for promoting and protecting health across EU policies and actions 

Bernard Merkel 39 

Establishing Health as a Key Component of Economic Policy 

Sarah Burns 39 

The WHO Investment for Health Project and the Verona Initiative (*) 

Erio Ziglio 48 

Introduction to Parallel Forum Sessions 

Paul Lincoln 66 

FORUM I: HEALTH IN OTHER POLICIES AND SECTORS 67 

Bridging the Gap from Policy to Practice and Awareness 

John Bowis 67 

Does the media have a role in promoting health policy and bridging the gap between 

policy and implementation? PR or “ER”? 

Shirin Wheeler 71 

International Forum Gastein, Tauernplatz 1, A-5630 Bad Hofgastein 

Tel.: +43 (6432) 7110-70, Fax: Ext. 71, e-mail: info@ehfg.org, website: www.ehfg.org 

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European Health Forum Gastein 2001 

Carlos Ribeiro 71 

The Swedish Experience 

Bosse Pettersson 71 

The Experience in Wales 

Mike Ponton 72 

Measuring Progress and Impact 

Mojca Grunter Cinc 73 

Luigi Bertinato 74 

Summary Report of Forum I 

Cecily Kelleher 75 

FORUM II: GLOBALISATION, WORLD TRADE AND HEALTH 81 

Introduction - Health and Free Trade Conflict or Synergy 

Julius Weinberg 81 

The stakeholders - Statements on organisational and professional interests 

Nina Hvid 84 

Mehtab Currey 84 

Mihaly Kökeny 84 

Ron Labonte 85 

Maurice Mittelmark 87 

The expert witnesses: European Trade policies and their impact upon health 

Paul Strickland 88 

The role of international agencies in health protection and in developing health positive 

trade policies 

Robert Beaglehole 91 

The role of health issues in multilateral trade agreements 

Rolf Adlung 93 

The role of commercial enterprises in health 

Petra Laux 96 

Summary Report of Forum II 

Julius Weinberg 97 

FORUM III: HEALTH AND THE SINGLE EUROPEAN 

MARKET 101 

Introduction: The European Union and health care 

Philip Berman 101 

The labour market for doctors and nurses 

Bie Nio Ong 101 

Annette Kennedy 112 

Public procurement of goods and services: a legal analysis of the Spanish case: 

Fernando Silio 121 

Soren Berg 141 

The free movement of patients 

Matthias Wismar 142 

Alain Coheur 143 

The SEM and health care – policy conclusions from the EHMA project 

Reinhard Busse 158 

Summary Report of Forum III 

Philip Berman 161 


Tel.: +43 (6432) 7110-70, Fax: Ext. 71, e-mail: info@ehfg.org, website: www.ehfg.org


FORUM IV: BUILDING A HEALTHY COMMON 

AGRICULTURAL POLICY (CAP) 166 

Shifting CAP's objectives to the provision of healthy, sustainable food production and 

safeguarding the health and vitality of rural communities and landscapes 

Aileen Robertson 166 

Local level: Using urban agriculture and local sustainable food production to safeguard 

food security, reduce health inequalities and preserve cohesion in rural communities 

Jeannette Longfield 172 

National level: Austrian farmers call for a radical change in CAP to provide healthy food 

Elisabeth Baumhoefer 173 

EU level: Interpreting the multifunctional role of agriculture and rural development 

across Europe 

Elisabeth Guttenstein 174 

The EU farmers’ views on the development of the CAP 

Anton Reinl 177 

European level: European supermarkets set standards for their suppliers in response to 

growing consumer demand for environmentally sustainable and pesticide free products 

Nigel Garbutt 180 

Summary Report of Forum IV 

Mike Rayner 181 

FORUM V: THE INFORMED PATIENT / CITIZEN: A NEW 

PARTNER IN THE POLITICAL HEALTH ARENA 184 

What are the information needs of citizens? Results from research & academia 

Angela Coulter 184 

The Right to Health and Patients’Rights: Population-based assessment 

Anne Brunner & Manfred Wildner 184 

Information needs: Results from a Spanish study 

Albert Jovell 193 

The advocacy work of the Italian Tribunal 

Theresa Petrangolini 194 

The European Experience with examples from the UK 

Rodney Elgie 201 

The US-Experience 

David Lansky 204 

How to involve citizens in health policy development and implementation? Current 

activities of the European Community 

Walter Baer 206 

Summary Report of Forum V 

Stipe Oreskovic 214 

FORUM VI: HEALTH IN THE INFORMATION AGE – 

HEALTH TECHNOLOGY AND POLICY DEVELOPMENT 225 

Visions of eHealth – revisited 

Ricky Richardson 225 

Providing eHealth Services in Europe : A case study 

Carl Brandt 226 



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Online information system for rare diseases in Europe 

Michael Schubert 237 

NHS Direct 

Bob Gann 239 

Legal aspects of eHealth 

Petra Wilson 239 

Quality of health information on the Internet - Moderated Panel Discussion: 

Statements of professional interest 

Albert van der Zeijden 243 

Charlotte de Roo 243 

Michèle Thonnet 243 

Petra Wilson 244 

The French experience 

Michèle Thonnet 244 

The German experience 

Otmar Kloiber 244 

Summary Report of Forum VI 

Rolf Engelbrecht 245 

PLENARY SESSION III 251 

Marc Danzon 251 


Reinhart Waneck 251 

Health across other policies 

David BYRNE 257 

SPECIAL INTEREST SESSIONS 263 

Public Health Research and the Proposal for a new Framework Programme on Research 

Kevin McCarthy 263 

Summary Report of Workshop II: EUEnlargement: Implications for Health Systems 

Laura MacLehose 265 

FINAL PROGRAMME 2001 276 

LIST OF AUTHORS, WHO IS WHO 287 

LIST OF PARTICIPANTS 297 




The views presented in this publication are those of the authors and not necessarily those of 

the organizations for which they work! 



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Preface 

David Byrne 


In 2001, the European Health Forum Gastein drew our attention to 

one of the crucial challenges of health policy making in Europe: the 

need to integrate health issues across different areas of policy. This 

volume brings together the different presentations and contributions into a useful 

background document on this important topic. 

It is important to recognise that the health of our citizens is not only – and perhaps not even 

primarily – influenced by decisions taken in the health policy sphere. This is why we have to 

understand how decisions in other policy areas – such as economic and social policy or 

environmental and agricultural policy – impact on public health and how conversely, these 

policies can contribute towards achieving a high level of health protection in Europe. 

The 2001 Gastein Forum focussed on a number of key areas of policy which are particularly 

important in this respect: trade and health, the Single European Market, the Common 

Agricultural Policy and health and information technology. The message is encouraging and 

deserves to be spread: there is considerable scope for health gain if health considerations 

are systematically taken into account when taking decisions on policy orientations. 

Implementing this conclusion must be a clear priority for policy makers at all level of 

government. 

Within the European Community, we have made considerable progress in this respect. Health 

plays a central role in most of the Commission’s cross-cutting policy initiatives. Let me give 

three examples. First, the Community’s sustainable development project, where health is 

mentioned as one of four major challenges our societies are facing. Second, e-Europe, which 

promotes the use of IT in different areas of European societies, includes a large health 

chapter; and third, in the Community’s enlargement process, health issues are being actively 

taken into consideration. 

But much more needs to be done, and the proceedings of the 2001 EHFGH published in this 

volume provide ample illustration of some of the problems we have to address. There is still 

a lack of awareness about the relevance of other policies to health, and much too little cooperation 

across government services to address shortcoming. Often, health enters the 

political agenda too late, and with a limited focus on specific health threats. Protecting and 

improving health is a vast challenge which requires intensive political commitment. The EHFG 

provides ammunition needed to secure the necessary support. 

The Gastein conference has again proven its worth in providing a platform for discussions, 

reflections and encounters between different partners interested in health across Europe. Its 

real value lies in providing opportunities for an all-European dialogue across the boundaries 

of day to day work. This book captures some of this unique Gastein spirit, and should be 

required reading for policy makers across Europe 

David Byrne 

European Commisioner for Health and Consumer Protection 



Preface 

Herbert Haupt 

The “European Health Forum Gastein” is a conference that goes beyond the confines of the 

European Union and the barriers of societal sectors and sets health political accents for the 

21st century. Since 1998 international health experts from politics, science, industry and 

patients’ organisation have found an interdisciplinary platform for a responsible dialogue on 

an integrated health policy in Europe in Bad Gastein. 

The question of responsibility for health has, in the course of political history, found many 

different responses. Nevertheless we see that today in all European states, health is 

understood as a task for the whole of society. 

The debate has taken on renewed topicality, regarding personal and social responsibility for 

health, through the intensification of attempts for reforming the health system over the last 

ten years. Aims such as securing quality, increasing efficiency and keeping costs down in the 

health system are seen in the context of the participation of the individual for their own 

health. Through a discussion on sustainable strategies which consider health and social 

aspects, the aim of health policy on an European level begins to take shape and reach a 

wider audience. 

The question of the importance of market mechanisms or state driven initiatives in health 

policy does not only have an economic component. It reflects also the different positions in 

responsibility for health. On the road to the future therefore we need a social policy which 

promotes health so that different parts in society can become conscious of their 

responsibility for health and accept this challenge. 

In Austria even in the 19 th century, medics did not only work on cures for the day but also 

sought long-term improvements in living conditions and hygiene. The “Public Health” 

movement of the last decade is new, however, since it sees health as an increasingly 

complex system that is understood as requiring its own interdisciplinary multiprofessionalism. 

The interrelationship between the origins of illness and of environmentlinked 

and chronic sickness are more complex than the field of illnesses concerned with 

infections. This means that the public responsibility for health in some areas must be newly 

defined. 

Our aim is to give people through the promotion of health optimal forms of therapy and to 

provide the maximum orientation in the health system for patients. We also want to 

strengthen an awareness of issues related to health in areas such as work, economy, the 

environment, transport, education and environmental protection. 



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Only if we work together we will succeed in securing a healthy quality of life for ourselves 

and in the future for our children. In this way we can make the promotion of health a 

political issue for the whole of society. This year the “European Health Forum Gastein” is 

once again concerned with finding trans-national solutions for the important questions in 

European health policies. In the European Union much has been done in recent years to 

strengthen awareness in the interest of the needs of health requirements. I am optimistic 

that through joint efforts we will succeed in overcoming regional obstacles to make health 

policy truly healthy politics. 

Herbert Haupt 

Federal Minister for social Security and Generations 



Preface 

Reinhart Waneck 

For some years now, Health Ministers from EU-states have shown the 

political determination to gain more influence concerning healthrelated 

decisions which are being made in other political areas. It is a 

positive development that the topic “Integrating Health across 

Policies“ was debated in such an open, professional and futureoriented 

way during the European Health Forum, Gastein 2001. 

But the question has to be raised, if Health Ministers have been successful in their efforts in 

the past years? To a certain degree the answer is “yes“. As is well known, the legal basis has 

been extended in the Amsterdam Treaty and topics have become much broader with regard 

to the content, but an the other hand it has not been possible on an EU-level to gain 

decisive influence an decisions being made by other departmental cabinet councils; not to 

mention the securing of a right of say. 

Now as ever, Health Policy is primarily a national competence, and on a European level more 

intensive co-operation, as well as the handing over of competences only takes place on 

certain conditions. Quite symptomatic of the hard struggle to reach a joint basis for a 

European Health Policy is the long-drawn-out history (of origin) of joint European Health 

Policy Strategies with the addendum Public Health. 

Substantiated by the fact that health is an important economic and employment factor, too - 

the trend has emerged that health-questions especially the ones concerning financing and 

Health Insurance are being discussed also under the visual angle of the European (domestic) 

market. Regarding the dissolution of national structures and the “growing-together“ of 

member states, these discussions are certainly not insubstantial, but they should not remain 

the sole “pan-European“ aspect of Health Policy. 

“Integrating Health across Policies“ is a topic that deserves to be continued at the next 

European Health Fora in Gastein, especial in regard to the fact that at the EHFG 2001 only 

parts of the relevant policies were being discussed. 


State Secretary for Health 

Ministry for social Security and Generations 



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Günther Leiner 


Environmental factors, lifestyle, nutrition or the workplace are 

fundamental determinants of the health status of an individual. For this 

reason health policy can not be seen in isolation, but has to be 

recognised in its social and economic environment. If we believe that 

health protection and promotion ought to be the aim of health policy 

then “healthy” policies also have to be implemented across other 

policy areas. 

By choosing the general theme of "Integrating Health across Policies", this year we have 

addressed one of the key issues of European health policy. This concept of health as a 

multisectoral issue is proof of a new awareness that successful health policy requires 

approaches reaching across disciplines and sectors. Therefore, just as in other areas, 

networked thinking and acting is becoming increasingly important. 

Only an interdisciplinary and intersectoral approach can lead to successful solutions. This 

does not only apply to the delimitation of policy areas but also to the fact that many 

problems can no longer be regarded from a strictly national perspective. A crisis like, for 

instance, BSE, requires actions reaching beyond individual policy areas and national borders. 

The principles of the four freedoms as implemented in the Single European Market are 

becoming more and more relevant in the health field. As a result, the borders between EU 

level and national policies are becoming increasingly permeable. 

At the 4th European Health Forum Gastein many speakers, amongst them Commissioner 

David Byrne have critically assessed the role the European Court of Justice plays in defining 

the application of single market legislation to health issues. The Court has moved to fill the 

vacuum Member States have left by neglecting the possible effects of single market 

interventions on health systems. By doing so the Court has de facto assumed the position of 

a policy maker in the health field. 

As a politician I am clearly not very comfortable with a situation in which the judiciary 

defines policy goals on a regular basis. Therefore I warmly welcome the increased attention 

given to health policy matters by the Council and the European Commission through the 

practical implementation of the new EU health strategy and the consideration of future 

developments in health care and care for the elderly. Hopefully this will result in the reestablishment 

of a leading and pro-active role for politics rather than the current muddling 

through approach 

As a physician I hope that these new initiatives will quickly translate into concrete benefits 

for patients. It has been confirmed again in this years Forum that health services in Europe 

need to become more patient oriented. Experts indicated that health systems can only be 

further developed if the communication chain between politicians, providers, and patients or 

all citizens is improved. Therefore, in terms of practical benefits I also welcome the 

introduction of a European health card which Commission President Romano Prodi 

announced recently. However having been involved with the legislative process of 

introducing a health card in Austria I believe that the European card needs to become more 

than just a replacement for the E111 and other forms. Should the European card become of 

real value to citizens and patients it will need to integrate the various national health card 

initiatives. Only by integrating medical data and in particular emergency information the card 



Preface 

will be of real (life saving) use for patients. This Forum and previous events have assessed 

eHealth issues in detail. The technical solutions are there. What currently lacks is political 

will. For the benefit of patients we should have the courage to implement these solutions. 


Presiden 

International Forum Gastein 



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Gastein Health Declaration 

European Health Forum 

Gastein 2001 


Creating a better Future 

for Health in Europe 

Bad Hofgastein, 29 September 2001 



Gastein Health Declaration 2001 

A MESSAGE FROM THE PRESIDENT ON INTEGRATING HEALTH ACROSS POLICIES AND 

SECTORS. 

The European Health Forum Gastein. 

The European Health Forum at Gastein 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 NGO’s, academics and the private sector. A significant 

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

emanating from the discussion from 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 “Integrating Health across Policies”. Six parallel Fora 

were organised around the theme. Practical experiences at the national and regional levels, 

the Common Agricultural Policy, international trade and globalisation, and the Single 

European Market and information developments were all included. The Fora provided the 

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 main observations of the six parallel Forum for this year are grouped below. Our hope is 

that you find them timely and useful in application to your responsibilities for health 

development. 

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

individual level as well as at the local, regional, national and supranational levels. The 

EHFG includes the 51 countries within the WHO European area i.e. the EU and accession 

countries, Central and Eastern Europe and the EEA countries. Every effort is made to ensure 

that all of the different interests and perspectives are covered. 

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 



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1.) General EHFG observations and recommendations 

Integrating health across policies is an issue that has now moved centre stage. Citizens and 

the public at large will judge politicians and organisations by their ability to place health at 

the Centre of other policies. 

a.) Principles for promoting health across policies and sectors 

The EHFG elaborated the following principles for promoting health across other policies and 

sectors: 

• Health should be the driving force shaping economic and social development and be 

considered as a public good and societal investment. 

• Health is an ideal vehicle for building good governance, effective organisations and 

social cohesion. 

• Health policy should be transformed from a reactive into a proactive force for shaping 

society. 

• The promotion and protection of health should be routinely considered in all policy 

areas and sectors. 

• Health policy should always consider the wider determinants of health and public health 

should routinely be considered when reforming and developing health systems and 

services. Health policy should consider the right mix of “upstream” and “downstream” 

solutions 

• Health should be regarded as a core component at the heart of sustainable development 

and economic policy. 

• “Joined up working” across sectors, settings, disciplines policies and programmes for 

health should become standard practice. 

• Actions to promote the public health should be genuinely consultative and transparent. 

• Governance and accountability for health and its determinants should be clearly and 

publicly defined. 

• Health policies should consider the global dimension and be characterised by a sense of 

social responsibility. 

• Organisations should ensure that policies and programmes narrow and do not widen 

health inequalities. 

b.) Other general EHFG observations and recommendations 

• A special international expert committee (similar to the WHO Commission on 

Macroeconomics and Health) should be established to comprehensively review the links 

between health, economics and sustainable development policy for Europe, European 

countries and citizens. 

• Academic (Health) economists should be encouraged to undertake more studies on 

macroeconomic issues. 

• The precautionary principle for protecting and promoting health should be applied 

across all policy areas and sectors. 




• Health impact assessments should become standard practice for all relevant policy 

developments and programmes. 

• The EU and national governments should ensure that sustainable development 

incorporates health as a fundamental component in all such considerations. 

• Policies in the public and private sectors should be independently audited for their 

impact on health and development. 

• New forms of promoting health literacy for the public should be piloted and developed 

that include the determinants of health as well as the beneficial use of health services. 

2.) Specific Forum observations and recommendations 

Forum I: Health in other Policies and Sectors 

• Health policy should be developed according to the principles and mechanisms set out 

in the WHO’s Ottawa charter for health promotion (1986), (i.e. it should include the 5 

key dimensions of building healthy public policy, strengthening communities, 

• 

reorientating health services, promoting healthy lifestyles and creating supportive 

environments.) 

The WHO Ottawa health charter (1986) should be updated in relation to a. the health 

impact of globalisation and b) the reduction of poverty and other determinants of health 

inequalities. 

Forum II: Globalisation, World Trade and Health 

• There is a need for greater plurality and balance between nation states, corporations 

and civil society in the development process for international trade agreements. 

• Health and human development goals should be central to the development of 

international trade agreements. 

• The principles of transparency and accountability are essential components of 

international trade. 

• Urgent funding is required for research into the interaction between trade and health 

and on the health impact of international trade agreements. 

• Urgent measures are required to develop a critical mass of researchers on international 

trade and health and globalisation at national and international levels. 

• There is an urgent need to develop and accelerate training for policy experts and 

influencers, both within and outside health and across sectors in trade/health 

interactions. 

Forum III: Health and the Single European Market 

• There is a need for the EU to monitor the impact of the SEM in respect of: 

o The labour market and movement of doctors and nurses. 

o Patient movement across national borders. 



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o The impact of the SEM on candidate countries, especially in relation to financial 

differences, loss of trained professionals and patient influx as a consequence of 

areas of expertise and lower costs. 

• Making “Citizens Europe” a reality for health the major pillar of the new EU health 

strategy. 

• Article 152 of the Amsterdam Treaty should be revised to allow SEM issues to be 

considered in a health context. 

• The Directorate General for Health and Consumer Protection needs to take leadership of 

SEM discussions and other crosscutting health issues such as trade and competition 

policy and advising on universal minimum standards for health services. 

• There should be more SEM policy – relevant research within the 6th research framework 

programme. 

Forum IV: Building a healthy Common Agricultural Policy 

• It should be universally affirmed that a “multifunctional” agriculture should incorporate 

health objectives. 

• The European Commission should publish its Action plan on Nutrition Policy by the 

spring of 2002. 

• An inter-service working group should be established on the Common Agricultural (and 

food) Policies which should consider farming and food policy and health. 

• The Common Agricultural Policy should promote the consumption of fruit and 

vegetables. 

Forum V: The Informed Patient/Citizen: a new partner in the political health arena 

The development of new technologies and information systems in the past two decades has 

led to an increase in patient power and participation in decision making and increased 

informed choice and consent. 

• Health care systems should be reoriented away from the needs of institutions, 

procedures and technology towards being centred around the relationship with the 

patient and citizens they are there to serve. 

• The crisis in healthcare could be remedied to some extent by patient participation in 

evidence based decision- making. 

• Regional, national and international institutions, governments, NGO’s and private 

corporations working in healthcare should consider their involvement in: 

o Supporting research to increase the body of knowledge about civic 

participation in health and healthcare. 

o Developing supportive mechanisms to increase the availability of balanced, 

accurate and comprehensive health information to patients and citizens. 

o Introducing mechanisms to support a change in the traditional frame of 

reference of perception about the roles of professionals and patients in the 

healthcare system. 




o Analysing the consistency of the practice of institutions as compared to their 

declared missions. 

o Making available information and case studies about good practice in 

healthcare services and involve citizens in prioritisation and clinical decisionmaking. 

o Analysing, reporting and acting in case of overuse, misuse and under-use of 

healthcare services and involving citizens in prioritisation and clinical decisionmaking. 

o Providing citizens with supportive information to help them choose the most 

appropriate doctors, services and insurers. 

• There is a need to increase citizens/patients literacy about evidence-based decisionmaking 

and develop mechanisms and incentives to increase the public disclosure of 

information. 

• The mechanisms of the EU – European Health Forum should be designed so that they 

ensure the development of citizens/patients centred health policy. 

Forum VI: Health in the Information Age: Health Technology and Policy 

Development. 

• eHealth should be defined as the usage of new information and communication 

technologies and innovative ideas on the organisation of health services to benefit all 

actors. 

• eHealth should develop a pan European strategy that includes a content quality 

management process and an architecture/platform to integrate existing or new systems. 

• The use of eHealth in the healthcare system can improve efficiency; quality and patient 

orientated services. But a number of side effects have to be considered. 

• Information and communication technologies do not change the healthcare system, but 

can be used to facilitate changes in the system. 

• Successful eHealth needs regulatory, organisational and technological improvement. 

• eHealth applications enable (international) co-operation between actors. For reasons of 

interoperability - standardisation is a very important task. Standardisation has to be 

undertaken for terminology, data definitions, content, data format and structure. 

International standards should be followed, and European and national diversity 

recognised. 

o The process of standardisation should be given more attention and speeded up. 

Furthermore rules and agreements on a legal or contractual basis are needed when 

looking at cross-border solutions or looking at usage of healthcare services in 

foreign countries. [as information and communication technologies (with the 

Internet as a backbone) enable such solutions]. 

• The EC should speed up eHealth standardisation and harmonisation work on an 

international level in co-operation of the European nations and promote the results. 

• The EC should co-ordinate national eHealth initiatives to ensure interoperability 

within Europe. 



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Inserat A1

Opening Ceremony 


Words of Welcome 

Herbert Haupt 

Dear Mr. Leiner, 

Dear Minister, 

Ladies and Gentlemen, 

It is a great pleasure for me to welcome you to the 4th European Health Forum for which the 

Federal Ministry for Social Security and Generations has been a co-organiser for the second 

consecutive year. 

I am very pleased to see that so many prominent guests are attending this year's event. 

I believe the fact that, this time, we are looking at the beautiful Gastein Valley from a 

somehow different perspective will not have any adverse effects on the high quality of the 

Forum we have been accustomed to. I would even go so far as to assume that this year's 

venue will be of benefit to the further development of the European Health Forum. 

A glance at the conference programme will convince you that, once again, the organisers 

have done an excellent job. 

The European Commission, the WHO Regional Office for Europe, the Government of the Land 

of Salzburg, Austria's business community, leading international and national health 

institutions, non-governmental organisations, and last but not least my Ministry have 

contributed to the solid preparation of this year's themes, laying the foundation for 

interesting debates. 

It is very rewarding for me, and I reckon for you as well, to see how the European Health 

Forum has developed in recent years. The theme chosen for this year's conference is 

"Integrating Health across Policies". 

This topic indeed deserves a more in-depth discussion. It is not surprising that the issue of 

integrating health in all areas of policy is a major concern of all European health politicians. 

We are well aware of the unpleasant fact that health policy decisions are often not taken by 

health politicians but by those from the economic, agricultural, social, traffic, environmental, 

and other sectors. 

At this point I intentionally include the EU institutions, and in particular the European 

Commission's Directorates-General and the Council. We are still lacking an institutional 

participation and co-decision right for health politicians for issues relating to health policy 

that are, however, discussed and decided by other ministerial councils. 

A positive development of these institutions has been the integration of the areas of food 

health and consumer protection under Commissioner Byrne, who, by the way, will participate 

at this year's European Health Forum Gastein. 



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Another issue that is very important to me and I wish to share with you is the health 

compatibility check. This term is probably familiar to you, but why has the health 

compatibility check not been put into practice yet? 

The health sector does not have a lobby similar to that of the environment, and "health" is 

obviously still regarded by politicians in other sectors as being an "appendage" of their 

special fields and is not perceived as an independent, equal subject. 

It is true and noteworthy, that, especially in the European Union, a lot has been done in 

recent years to enhance awareness for the needs of health protection in other policy areas. 

Nevertheless, I personally believe there is still a lot left to be done! 

I very much welcome the expansion of the topics at this year's Forum to include the area of 

commerce, also touching issues in connection with globalisation. 

I believe this topic is extremely relevant to health policy and I hope that a sector-specific 

debate on the issue of globalisation can help bring the emotionally laden climate of the 

current political debate back on a rational level. 

Another important item I assume will be on the agenda of all forums – and, looking at the 

list of participants, I am sure the discussions will be of high-quality, authentic, and 

competent - is the EU enlargement. 

This year's Health Forum has once again succeeded in bringing together a series of 

representatives from the membership candidates in Gastein. 

Although health is not a central topic of the accession negotiations due to the lack of a 

comprehensive Community acquis, I believe that issues relating to health care and health 

services are of major importance on a personal, emotional level. This is true not only in the 

EU member states, but also in particular in the membership candidates. 

I think that in this area, too, we must take the existing concerns and hopes of the people 

very seriously. 

Therefore, we should take advantage of events such as the Health Forum to discuss these 

issues. At this point, allow me to draw your attention to the workshop on the EU 

enlargement that will take place on Friday afternoon and which was largely prepared by 

members of my Ministry. I cordially invite you to participate at this workshop. 

Finally, I wish to all participants, the speakers, and the organisers of this year's European 

Health Forum in Gastein all success and an interesting event. 

Thank you very much for your attention. 

Gyula Pulay 

Distinguished participants, Ladies and Gentlemen, 

It is a great honour for me to have the opportunity to address the Opening Ceremony of the 

Fourth European Health Forum in Gastein. 




Looking at the list of the invited speakers to this Session, I thought I would touch upon the 

topics of the Forum not only from the point of view of the Republic of Hungary, but also 

from that of other Central and Eastern European countries being in the process of accession 

to the European Union. 

It might be needless to emphasise that health is one of the most important values for 

citizens of candidate countries as well. We all expect that as a result of our accession to the 

European Union, inter alia, the quality of living conditions, consequently the health status of 

the population will improve. The more we learn of common values of the European Union, 

the more we understand the evidence that improving the health status of the population 

cannot be regarded simply as a gain of accession, but at the same time, it is a precondition 

to becoming a successful member of the European Union. The Internal Market of the 

European Union is an economy, where competitive advantages may primarily be gained by 

the development of human resources. Consequently, a high level of competitiveness cannot 

be reached or maintained without making efforts to improve the health status of the 

population and of the workforce. States, companies, entrepreneurs failing to invest in health 

can only be losers of economic competition. 

This recognition has essentially contributed to the recent decision by the Hungarian 

Government to pass a 10-year public health action programme, identifying the major health 

threats and health determinants in Hungary, and launching 17 well-defined projects. The aim 

of the programme is to attain major improvements in the health status of the Hungarian 

population, and to promote the convergence of the Hungarian health indicators to the EU 

average. 

Objectives of the 10-year public health action programme can closely be linked to the main 

theme of the Forum, namely how to consider the health aspects, as well as health impacts, 

when forming other sectoral policies. The leading strategy behind the Programme is a 

multisectoral approach, collaboration and co-operation among various ministries, inter alia 

the ministries of agriculture, transport, environment, education and health, governmental and 

non-governmental organisations. 

May I draw your attention to the fact that, after accession, development policies in candidate 

countries will significantly be determined by the characteristics of the development support 

to be provided by the European Structural Funds. It can realistically be expected that the 

grants to be received from the Structural Funds may, as a whole, reach 30% of the state 

budget of certain new member states. One of the eligibility conditions for these grants is the 

provision of co-financing by member states. Presuming the average rate of co-financing will 

be some 50%, we might come to the conclusion, that it will be reasonable to allocate some 

30% of the central state budget of new member states to support such programmes which, 

at the same time, fulfil EU eligibility criteria. Consequently, development priorities of the 

European Union and the new member states will essentially converge. In case, health is to 

be regarded as a priority area, when allocating European Structural Funds, and presuming 

that health requirements in horizontal policies become more explicitly expressed at the level 

of Community legislation, it is then very likely that the same situation will take shape in new 

member states as well. Hence, it is our joint responsibility to act accordingly. 

When examining the process of accession so far, we are faced with a dual picture. On the 

one hand, in programmes supported by the European Union (Phare, pre-accession funds, 

ISPA, SAPARD), the development of the health care system has not been paid too much 

attention. The only exception to that is the development of the public health institutions 

which has received major financial resources from the European Union. It is our concern, that 

we might face a similar situation when benefiting from the support to be provided by the 

Structural Funds. On the other hand, the process of learning more and more about 



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Community legislation and norms, has essentially contributed to widening the horizon of 

Hungarian health policies. 

In the European Union, a comprehensive and extensive body of Community legislation aims 

at protecting life and health of humans. These Community norms can be found in areas like 

health at work, environmental health, product safety, food safety, etc. Adapting to this 

comprehensive and deeply rooted interpretation of health protection requires a multisectoral 

approach. Our attention is called to the fact that the health status of the population is, to a 

great extent, influenced by factors like the quality of drinking water or food, of the 

conditions in the natural settlement, or of the working environment, of our ability to reduce, 

or if possible to eliminate, health hazards. 

During recent years, priorities in health legislation have significantly been influenced and 

determined by this approach in Hungary. In the last 2-3 years, approximately half of the acts, 

government or ministerial decrees, prepared by the Ministry of Health, served the 

transposition of the relevant Community acquis, and have been accompanied by major 

institutional capacity building and investment programmes, supporting the implementation of 

Community health protection requirements. This process brings about a major shift in 

priorities not only within the health sector, but also in other sectors of economy, through a 

more conscious acknowledgement of public health aspects. 

Within health policies of candidate countries another topic, also touched upon by this 

Conference, is gaining more and more importance, namely the issue of the Internal Market. 

It is evident for all of us that health should also be viewed as an integral part of the internal 

market. Community legislation concerning, for example, consumer protection, competition, 

transparency of state aid, or a number of other areas of Community competence within the 

internal market, should be respected and implemented in the health sector, as well. Several 

health-related measures taken in Hungary during the last few years are aiming at contributing 

to the smooth and safe operation of the internal market. 

Let me mention just a few of them: providing the legislative basis for the right of 

establishment in the health professions; transposing and implementing Community 

legislation concerning medical devices, together with the establishment of the necessary 

institutions; transposing legislation on the registration, marketing and social insurance 

reimbursement of pharmaceutical products; introducing an up-to-date national legislation for 

chemicals etc. 

I do hope, the examples mentioned above reflect accordingly the fact that health policy 

challenges for Hungary and other candidate countries mainly coincide with those in member 

states of the European Union. This Fourth European Health Forum in Gastein is aiming at 

discussing the most important ones from among these challenges. Consequently, lectures, 

debates on this occasion might teach candidate countries a number of important lessons. 

James Walsh 

Speech not available 





Ladies and Gentlemen, 

I am very happy to welcome you once again this year to the opening ceremony of the 

European Health Forum Gastein. 

Following the breathtaking growth of recent years, it is a particular pleasure for me to see 

that, in the meantime, our event has established itself as a fixed item on Europe's health 

policy agenda. This, however, would never have been possible without the strong support 

of our partners and sponsors who contributed contents, funding, and staff. 

It is a particular pleasure to see so many high-ranking participants from the Federal Ministry 

for Social Security and Generations this year, and to be able to welcome both Minister 

Helmut Haupt and State Secretary Reinhart Waneck. 

I wish to extend to you the greetings of the Governor of the Land of Salzburg Franz 

Schausberger, and I must unfortunately excuse Vice-Governor Mrs. Gabi Burgstaller who 

planned to attend the event as the representative of the Land of Salzburg. The President of 

the Provincial Parliament of Salzburg died unexpectedly this morning, and therefore all 

members of the Government had to stay in Salzburg. 

I am personally very delighted about the participation of Mr. Padraig, Flynn the co-founder of 

EHFG and former Commissioner for Health and Consumer Protection, and of Commissioner 

David Byrne, who will join this year's EHFG once again tomorrow. 

Allow me to extend a cordial welcome to James Walsh, the representative of our coorganiser, 

the EU Committee of Regions, and to all the other members of the CoR delegation. 

As I shall further elaborate upon later, the creation of a citizen-friendly Europe constitutes 

one of the major challenges for European Institutions. The European Parliament, represented 

today by Cathrine Stihler and John Bowis, will play a significant role in this process. 

Last year, already a large number of high-ranking representatives from EU member states, 

the regions, and especially from the applicant countries for EU membership participated in 

our event. I am very pleased to see that this circle has become even larger. 

Allow me to welcome Simon Vrhunec, Jozica Maucec Zakotnik, Mojka Grunter Cinc, Gyula 

Pulay, Pál Geher, and Maija Porsnova, the State Secretaries for Health from Slovenia, 

Hungary, and Lithuania. 

I also wish to extend a warm welcome to three high-ranking representatives of Europe's 

regions, Minister Jane Hutt from Wales, Minister Eduard Rius i Pey from Catalonia, and Mr. 

Rüdiger von Plüskow, State Secretary of Schleswig Holstein. 

This year, the World Health Organisation once again provided its strong support by sending 

several speakers, including regional director Marc Danzon, who will be joining us on Friday, 

and Director David Evans. 

Please excuse me for not personally addressing all high-ranking delegates of the various 

European, national, and international interest groups, although, representatively, I wish to 

welcome Professor Rolf Krebs, President of the International Federation of Pharmaceutical 



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Associations, Mr. Andrew Hayes, President of the European Public Health Alliance, and Mr. 

Otto Pjeta, the President of the Austrian Chamber of Physicians. 

Dear Ladies and Gentlemen, I wish to extend a very cordial welcome to all of you, the 

speakers and participants from 33 nations. 

You represent important stakeholders of the health sector: 

• Politicians and administrators on a European, national, regional, and communal 

level, 

• The financers 

• The consumers and patients 

• The health care facilities and hospitals 

• The business world 

• The scientists, and 

• All health-related professions. 

What is the use of all this new knowledge if it remains reserved to us here: the media play a 

decisive role for communication. At this point allow me to welcome all representatives from 

the world of media. 

As you must have already established beyond doubt, this year's Health Forum takes place in 

Bad Gastein. Some of you are already aware of the fact that the communities of the Gastein 

valley, Bad Hofgastein and Bad Gastein, are important driving forces and supporters of our 

forum. 

After having organised the Health Forum in Bad Hofgastein for three consecutive years, we 

hope that this change of venue will bring fresh impulses to the event. 

Allow me to welcome Mr. Manfred Gruber, the Mayor of Bad Gastein, and sincerely thank him 

for his support and cooperation. 

� “In Romania, infant mortality is three times higher than the EU average.” 

� “AIDS is the most common cause of death in South Africa.” 

� “1 million people die of malaria each year.” 

These headlines have more to do with economic policy, world trade, or the Single European 

Market than with international, European, or national health policy. 

By choosing the general theme of "Integrating Health across Policies", this year we are 

addressing one of the key issues of European health policy. 

This concept of health and health policy as a multisectoral issue is proof of a new awareness 

that successful health policy solutions require approaches reaching across disciplines and 

sectors. 

This was not least impressively demonstrated by the recent BSE crisis. The environment, 

nutrition, and social surroundings, just to name a few, are important health topics which are 

not, however, directly affected by traditional health policy. 

Therefore, just as in other areas, networked thinking and acting is becoming increasingly 

important. This does not apply only to the delimitation of policy areas but also to the fact 

that many problems can no longer be regarded from a strictly national perspective. 




As a result, the vertical borders between Member States and the European Community are 

becoming more and more permeable. 

Two indicators clearly reveal the social, political, and economic character of health in the 

population. First, there is a series of diseases and causes of death that are more common at 

the bottom than at the top end of the social ladder. The health disadvantage of the lower 

social stratum cannot be easily explained on the basis of one or two diseases attributable to 

one or two risk factors. If one examines the some 80 most important causes of death (78 

among men and 82 among women), in approximately 80% of all cases (83% among men and 

76% among women) the death rates are higher among blue-collar workers than among 

white-collar workers. The same pattern can be observed with the most important disease 

groups: infections, cancer, coronary heart diseases, nutrition-related and metabolic diseases, 

respiratory diseases, accidents, neurological diseases and mental illnesses. 

Skin cancer (the result of excessive exposure to the sun) and breast cancer are almost the 

only important diseases for which the social divide is reversed. 

The extremely wide range of diseases linked to social and economic status proves that we 

are dealing with a basically social, economic phenomenon and with society's attitude toward 

the environment and nutrition. 

This is not just a random coincidence of a few health factors that causes population groups 

to fall under the one or the other category in terms of disease incidence. 

Another very different but equally surprising indicator of the importance of social and 

economical processes are health trends in Eastern Europe. When we compare the causes of 

death in the countries of Eastern and Western Europe in 1970, by and large they match. (East 

Germany would do better as compared to the old Federal Republic of Germany. The situation 

in, say, Bulgaria and Romania was better than in many Western European countries.) 

If we compare the death rates in 1990, however, all countries in Eastern Europe did worse 

than the countries of Western Europe. 

Ever since the early 70s, the rise in life expectancy throughout Eastern Europe had become 

stagnant. 

After having reached Western European life expectancy rates in the 50s and 60s, there was 

no further improvement in the subsequent years. The health gap between Eastern and 

Western Europe became increasingly large, despite continuous economic growth in most 

Eastern European countries. 

The socio-political nature of this problem is reflected in the fact that this stagnation cannot 

be attributed to clear causes such as sinking standards in medical care, different economic 

growth, or increasing air pollution. 

In the early 70s, something went wrong in all these societies practically at the same time. 

When one looks at these trends, one cannot help wondering whether we should have 

noticed the social and economic causes and effects of the revolution of 1989; perhaps we 

would have then realized what prevented further progress in health. 

"Since health and society are so closely interlinked, we learn more about health if 

we study society, and more about society if we study health 

(Richard G. Wilkinson: Kranke Gesellschaft p.18)." 

Let me express a few more thoughts on the acceptance of the European idea by the people 

of Europe. I personally consider it very important to add these words at the end of my 

contribution. 



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Lately, there is a lot of talk about citizens in Europe, and I want to raise the question 

whether this really means that Europe's institutions are paying more attention to the citizens 

– or whether it is just a panic reaction to the citizens' increasing scepticism toward this very 

Europe, its officials, and its institutions. 

What does such a European citizen look like? 

Does he or she exist at all? 

The European citizen is, indeed mentioned in the various EU treaties – themselves being too 

complex to be citizen-friendly. 

The European citizen enjoys a series of rights, e.g. non-discrimination toward other citizens 

in other member states; free movement of labour, the right to vote and be elected to the 

European Parliament – etc. 

That's all very nice so far 

– Question – who would call himself/herself (primarily oneself) a Euro-citizen? 

The European citizen will only emerge when he or she spontaneously feel at home in all – 

today still 15, soon more to come – member states and can build upon this a European 

identity. 

Only when Pan-European events take place in different European countries, when citizens 

from all over Europe participate at the corresponding conventions in the various countries, 

then citizens will feel closer and closer to Europe and will accept it as their own. Another 

important requirement is that the authority to take decisions remains with the member states 

and the regions. These can guarantee closeness to the citizens through their political 

representatives! 

In a similar manner, the European Health Forum Gastein must belong to each citizen in 

Europe. We are here for them. 

Seize Gastein and the Health Forum as if it were something you were entitled to as a 

European. Something that belongs to you – and prove that you feel, think, and act as a 

European. 

Here in Gastein, we are a rather small, yet large European family. 



Plenary Session I + II 


The Work of WHO in Championing Health in Development 

David B. Evans 

Abstract 

WHO’s constitution has one very simple objective - the attainment by all peoples of the 

highest possible level of health. Health was defined as a state of complete physical, mental 

and social well-being and not merely the absence of disease or infirmity. Of the 21 functions 

designated for WHO, one was to assist in developing an informed public opinion among all 

peoples on matters of health. In response to this mandate, the Organization has always 

sought to provide information and evidence on how health is more than the absence of 

disease, how it is an essential component of development, and how best to improve health 

systems to attain the highest levels of health. 

In the last few years the Organization has been particularly active in championing the role of 

health in development. This has included creating a Department on Health and 

Development, with a focus on health and poverty and health and globalisation. It has 

worked with the WTO, for example, to examine the impact of trade liberalisation policies on 

health. It includes the activities of the Commission on Macroeconomics and Health, where 

one of its primary roles was to provide the best available evidence on the links between 

health and economic growth. Partly on the basis of these activities, the Organization has 

strongly advocated increasing the resources devoted to health and has been an active 

partner in the establishment of the Global Fund on Aids and Health. 

Understanding the role of health in development, and advocacy for health action is only one 

part of the process. The next step is to develop evidence on the best available ways of 

using health resources, both in terms of the organisation and activities of the health system 

and the types of interventions that it supports. WHO also has extensive activities designed 

to provide evidence of what types of health system structures and activities work, and which 

ones do not. It provides evidence on what type of interventions, or groups of interventions, 

most improve population health for the resources available, and works closely with countries 

that request it, to find ways of improving the levels of health for the available resources. 

Speech not available 

Presentation slides are available for download at the EHFG web-site 

http://www.ehfg.org/website01/abstracts.htm 



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Jane Hutt 


Introduction 

Integrating health across policies is a major challenge for us all. It is a challenge for 

governments and organisations in all sectors and a challenge that exists at all levels – from 

local through to national through to international. But, given what we know of the part 

played by the social, economic and environmental factors in determining people’s health, it 

also provides us with opportunities to achieve a far greater impact on improving people’s 

health and well being. 

For far too long, improving health has been seen as the responsibility of the health sector 

alone. That view is changing fast and the proposed health programme for the European 

Community reflects it. Effective and efficient health services to treat ill health and disease 

remains a priority but the need for more action to prevent ill health and to improve health 

has been recognised. The challenge is in making it happen and success will depend on a coordinated 

and sustained effort that harnesses contributions from all sectors. 

Integrating health across policy areas is one of my specific goals as Minister for Health. For 

this reason I am particularly glad to be here, not only to inform you of what we are doing in 

Wales, but also to learn of others’ approaches. 

The National Assembly for Wales was established as the Government of Wales in 1999, as 

part of constitutional change within the UK. From the start, I and my Cabinet colleagues 

realised that an overarching strategy was required to set the scene for connecting policies 

across the Assembly’s responsibilities. Our strategy is grounded in recognition of the range 

of social, economic and environmental factors that affect health and a desire to achieve a 

more integrated approach where policies and programmes add value to each other. 

All we do is framed by our strategic plan entitled Better Wales. Improving health and well 

being is one of its priorities, along with a better, stronger, economy; better opportunities 

for learning; better quality of life; and better, simpler, government. These, and the 

Assembly’s crosscutting themes of sustainable development, equal opportunities and tackling 

social disadvantage are all relevant to the theme of improving people’s health and well 

being. 

However, having such a strategy is only one part of the equation. We need to develop new 

ways of working, new intersectoral approaches and new tools to assist the development of a 

more integrated approach. Health impact assessment is one such tool with considerable 

potential. 

We will hear more about health impact assessment this afternoon so I won’t go into detail 

on this. However, I will say that health impact assessment is a key to our approach. Ours is 

a pragmatic approach designed to develop its usefulness from within the policy development 

process and, importantly, to learn from experience. It is helping us to understand better the 

interactions between health and other policy areas, and to identify new opportunities to 

protect and to improve people’s health. 

Making the connections is important. Health is relevant across policy areas but there is still 

some way to go to raise others’ awareness of this and, more specifically, to secure their 

commitment to improving health as something to which they could contribute through the 




policies and programmes in their sectors. Most important is recognition that it is usually a 

two-way affair. Guidance is vital in winning the argument. 

Take economic development for example. Broadly speaking, more employment is good for 

people’s health but the converse is also true. Investing in improving people’s health can help 

achieve economic development by helping them to break down health-related problems that 

act as barriers to employment and training, and which deprive labour markets of skills and 

families of incomes. We await the findings of the WHO Commission on "macro economics 

and health" with interest. 

To implement our vision we recognise that Wales must be served by modern, effective, and 

accessible public services that compare with the best. We must also work actively in our 

local communities where the voice of our local people can be heard and we want Wales to 

be a fairer place where everyone is valued and given an opportunity to play a full part. 

It is important that the National Assembly for Wales leads by example and with this in mind 

our we are changing the way we organise and deliver our work. We are working to put 

health and well-being on everyone’s agenda within the National Assembly, whether in 

education, economic development, transport or agriculture, local government or social policy, 

health impact and opportunities to improve health so that it is seen as everyone’s 

responsibility. 

To show how we are connecting policies and integrating action to improve health and wellbeing 

I will describe our plan to renew the National Health Service in Wales. The Plan has 

been designed to be a sort of ‘Trojan Horse’ to get inside organisations. We are not only 

looking to improve the balance between the protection and promotion of health and the 

treatment of illness and disease, but we also intend to reinvigorate and strengthen the 

partnership between statutory, social and business partners to engage the ‘whole system’. It 

seeks to strengthen health advocacy and protection and establish a new focus on community 

health development in which all policy makers, organisations and citizens can combine their 

efforts for a better, healthier tomorrow. We intend to use the renewal of the NHS in Wales 

as a catalyst for change across the policy sections at local and national levels. 

These are challenging aims but Wales has often led the field in innovative and effective 

public policy, particularly in the field of health and health services and we intend to lead the 

field again. 

The challenge for us is to improve the health of our population. 

Our public health strategy `Better Health Better Wales’ published in 1998 was a land mark for 

us. It recognised that the factors affecting people’s health are not always within the direct 

control of individuals. It was built on evidence of the importance of joined up working and 

joined up policies between the NHS, Local Government, NGO's and other bodies with an 

interest in the well-being of communities. 

Additionally, the implementation of the Objective One programme in Wales has given us the 

opportunity to address strategically the broad range of social, economic and environmental 

issues that impact on health and well-being. 

In February of this year we published The Plan for the NHS Wales with its partners and it has 

set the scene for the NHS over the next ten years. The Plan is underpinned by the 

recognition that the NHS was always intended to be a service for all, provided free at the 

point of use and must meet the collective aspirations of the Welsh people for better health 

for all. The implementation of the Plan will involve a decade of change and development in 

which we intend : 



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• To improve our performance in the maintenance, protection and promotion of 

health; 

• To ensure that all we do contributes significantly to population health improvement 

and the quality of life of our citizens; 

• To tackle inequalities in health and inequalities in access to health care and 

support. 

Life-long investment for health is one of the vehicles that will carry us along the road to 

health improvement and will help diminish health inequalities. This demands that we adopt 

strategies for investment which cover the life course and are targeted at those transitions 

where health risk to individuals is the greatest. Such strategies will provide a new balance 

between the protection and promotion of health and well-being and the treatment of disease 

and ill health. 

We base this approach on our valuable learning from the groundbreaking Verona Initiative 

and the clear need to have cohesive and holistic public policy in our communities. As you 

will see this approach is straight out of the World Health Organisation’s text books. We 

have seen that across Europe, the need for this action is not new and has been well 

documented in the literature relating to Investment for Health . As it says: “We instinctively 

recognise the need. But for this to be taken seriously and lead to action existing structures, 

habits and thinking must change. New skills will be needed. Change is difficult and the 

forces of inertia are strong. But the potential benefits are enormous.” 

We have decided that the National Assembly for Wales and our NHS must be champions of 

this cause and must work with our partners to engender a new determination to improve the 

health and well being of the people of Wales. We have learned a great deal from our 

involvement in the Verona Initiative and our approaches have been much influenced by the 

multi national discourse that Verona made possible. Wales is keen to continue to be 

involved in this and similar initiatives and we are sure that our experience in the massive 

programme of change I have described will add to the shared pool of knowledge, so 

valuable in helping us to learn and develop. We also see our membership of the WHO 

Regions for Health Network as very important. 

To enhance health and well-being, the NHS in Wales must be seen to be owned by the 

people of Wales and the voice of patients, their families and the public at large. This will 

involve greater attention to building user-centred services and citizen-centred policies. We 

seek to engage the public as partners, finding new and more effective ways of doing this. 

We are determined that Communities become key players in the definition of health needs 

and the identification of solutions. 

The health and well-being agenda is not just the business of the NHS. To make inroads into 

the legacy of ill health and to promote health, requires that the NHS - in concert with local 

government and the voluntary sector – establishes joint planning mechanisms, joint scrutiny 

of the health agenda and joint working. We have many examples of good practice in joint 

working in Wales which will act as exemplars. 

We have 22 City and County Councils in Wales and over the last two years each has formed 

a Health Alliance of a wide range of statutory, non-governmental, independent and business 

organisations to identify health issues in their communities and to find ways, in partnership 

to deal with them. These have developed well but we now intend to introduce a new 

statutory responsibility that requires Local Government and the NHS to formally enter a 

Strategic Partnership to produce and implement Health and well-being Plans for their local 

populations. They will be required to engage with the whole community and will use Health 




Alliances as a core resource for gathering grass roots health intelligence and assessment of 

need. It is at this level that local cross cutting policy will be initiated. 

The successful transformation of the NHS rests, in part, on our vision of what changes are 

necessary to deliver a service focused on health inequalities and health improvement. 

Developments will occur in the organisation and practice of primary, secondary, intermediate 

and tertiary care. These improvements will repair the fragmentation of the service over the 

last twenty years turning the NHS into a unified and whole system more capable of engaging 

with its partners and influencing their policies. Continuous improvement will be a central 

theme in all that we do. Public health professionals will have an important role and public 

health teams will be developed in the primary and community settings as a resource to all 

the community. Primary care will be strengthened and will take a more active role in 

population health, but also their surgeries will increasingly become Community Centres 

where advice on welfare, housing and other basic social needs can be provided under one 

roof and opportunities for patient involvement encouraged. 

The development of the health workforce is also necessary to deliver renewed health services 

not only to meet the rapidly changing clinical demands but also to better equip them to deal 

with the new partnerships with patients and the wider community. 

Alongside all of this, we are refining and improving how we measure the performance of the 

system and the outcome of our action. We are developing a set of measurement tools, 

health gain targets and mechanisms that will ensure the continued improvement of the NHS 

in Wales and its partners. 

The structure of the service will be made simpler, it will become more accountable for its 

action and services, and it will have a more democratic voice in the way it is governed. To 

achieve this the local and national organisations will be strengthened, our existing five 

Health Authorities will be abolished and at a local level we will set up 22 Local Health 

Boards that will include representatives of local health professionals, elected members of 

local government, NGO's and members of the public. This will provide a truly inclusive 

platform to ensure that all interests are represented. 

At the national level I am forming a Health and Well-Being Council to advise me on health 

policy. This will be an inclusive arena in which representatives of all the stakeholders in the 

community will bring their experience to bear on the development of policies and plans. 

They will look at the development of public policy and help in considering the health impact 

of policies at both a national and local level. The supporting infrastructure of the Assembly 

is being reorganised so that its policy divisions related to health and well-being will be 

better placed to provide strategic leadership and direction. 

To achieve our aims four main interconnected areas for action have been chosen to ensure 

that scientific, economic, social and political sustainability drive the implementation of health 

improvement in Wales : 

• multi-sectoral strategies to tackle the determinants of health, taking into account 

physical, economic, social, cultural and gender perspectives, and ensuring the use 

of health impact assessment; 

• health-outcome-driven programmes and investments for health development and 

clinical care; 

• integrated family and community-oriented primary health care, supported by a 

flexible and responsive hospital system; 



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• a participatory health development process that involves relevant partners for 

health at home, school and work and at local community and national levels, and 

that promotes joint decision-making, implementation and accountability. 

Of course, while the Plan for the NHS provides us with a framework for concerted action it 

builds on work already underway. The Assembly has developed – and is implementing – a 

number of cross cutting strategies to counteract social exclusion and to create a socially 

inclusive Wales. It recognises the importance of building and supporting strong communities 

where the values of citizenship and collective action can grow. A new way of making and 

implementing policy has taken root and is being nurtured. Instead of the old practice of 

restricting the development of important policies to a relatively small group of experts in 

government, the new Wales is characterised by an opening up of the policy making process. 

This Plan builds on wide consultation over the elements that make it up and is part of the 

process of replacing elite policy making by participative policy development. Our policy here 

is to build on this commitment and to continue to enhance the citizen’s voice at the heart of 

policy. 

The Assembly has begun to put right years of under-funding in the NHS in Wales and over a 

four year period ending in 2004 there will have been an increase in 37.5% in funding to a 

total of £3.6 billion. The Assembly has already initiated a number of significant 

developments aimed at improvement and the reduction of inequalities in health. For 

example, we have set up a health inequalities fund to help support action and service 

development in our most disadvantaged communities. In the first year we have a target 

action to prevent coronary heart disease. 

We are not happy that the existing health funding formula in Wales does not truly reflect the 

needs of our communities and we have set up a review, the result of which we intend to 

implement next year. This is aimed at addressing not only means to provide more equitable 

access to high quality health services, but also the particular health needs associated with 

areas of socio-economic disadvantage including rural and remote areas. 

As I have said, we are clear that the NHS must not be an island or a service that is focused 

on ill health. The renewed NHS will move centre stage into our new citizen and community 

development focus. It will be an important player but not the only one. It will become part 

of a whole system that looks at all aspects of the quality of life in the community and will 

ask itself constantly: “what can we offer to make this a better place? What can we do to 

influence the determinants of health not only as members of the community but also as a 

large organisation with social responsibilities like any other? What unique contribution can 

we make to the health and well-being of our citizens? How can we influence other policies 

that impact on health ? What could we do better if we worked closer with others and could 

they work better with help from us? Do we know enough about the health and well-being 

needs of our people and are we responding well enough? Do we listen to our people and 

communities and do we really know and understand their needs and expectations? Do we 

know how well we are doing and are we flexible enough and geared to learn and change?” 

Basic questions yes, but ones if answered well, and actioned, will transform the way the NHS 

in Wales operates. Neither are they new or original questions but we are determined that 

they will be answered. 

In conclusion I believe that we must keep on asking ourselves not only what other policy 

areas can do for health but what investment in improving people’s health can also do for 

other policy areas. We have to get this message over to others as well. It calls for a coordinated 

and sustained effort across policy areas and I was pleased to see that joint action 

is reflected in the Commission’s proposals for the Community’s new Public Health 

Programme. With this discussion of how we are renewing the NHS in Wales I hope that you 




can see that it will move from primarily being a sickness service to become a major advocate 

in health and well-being and influential in changing the face of public and business policy at 

both the national and local levels. We have a challenging agenda but we are determined to 

see it through. 

The Potential and Limitations of Health Impact Assessment 

Roscam Abbing 

Abstract and speech not available 

Progress and prospects for promoting and protecting health across 

EU policies and actions 

Bernard Merkel 

Abstract and speech not available 

Establishing Health as a Key Component of Economic Policy 

Sarah Burns 

The Speech was largely based on below copied NEF briefing 

Keeping the GP away 

A NEF briefing about community time banks and health 

”This alternative method of treatment has led to a lot of patients being taken off antidepressants. 

Too often in the past, doctors would give people drugs or nothing at all. Now 

we have this new method, and the results I have seen have been remarkable. I’ve seen 

smiling faces on people who were very depressed before they started the scheme and I can’t 

wait to start the in depth evaluation which will give us more information about how people 

use the community time bank and what they get from it.” 

Dr Richard Byng, pioneering GP at Rushey Green Group Practice 

“The regeneration of communities and individual people’s lives can also come in other 

ways [than government programmes] and particularly from within. The idea of using and 



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trading in community time has been one particularly effective and now widespread 

phenomena.” 

Tessa Jowell MP, as Minister for Education and Employment, March 2001 

This briefing provides an introduction to how community time banks – the social 

infrastructure known as ‘time dollars’ in the USA – can be adapted successfully in the health 

sector, to keep people healthy, to speed up recovery and to save scarce NHS resources. It is 

intended to do two things: 

• Introduce the concept of community time banks as a health regeneration tool. 

• Provide a brief summary of the first evaluation of a time bank used in a GP’s 

surgery at Rushey Green in Lewisham. 

The evaluation is part of a much more comprehensive three-year project involving Guy’s, 

King’s and St Thomas’ hospitals – carried out by the Socio-Medical Research Centre at St 

Thomas’ Hospital – which will not report for some time. It was carried out by one of the 

doctors at the practice, Dr Isobel Garcia, and will be published in full shortly. 

Background 

‘Time dollars’ or community time banks are the brainchild of Washington law professor Edgar 

Cahn, who developed them as a way of providing non-medical services for older people – 

helping them to stay in the own homes, keep hospital appointments and stay healthy. 

Supported from 1986 by the Robert Wood Johnson Foundation, the first wave of time dollar 

schemes in the USA a new kind of money, known in the UK as ‘time credits.’ These are now 

used in over 200 cities in the USA to fuel volunteer schemes, health maintenance 

programmes, support old people and a range of other local social projects. There are around 

700 similar schemes in Japan, backed by the government, and more in China – both places 

with high proportions of older people in the population. 

Community time bank schemes work by measuring and rewarding the time people spend 

helping each other in their local communities. Everyone’s time is worth the same and the 

time credits earned can have their value underpinned by local authorities or concerned 

businesses making goods available in return for them – reinforcing reciprocity and trust. But 

even without that, time banks are one way of putting neighbours in touch with each other, 

using people’s skills and imagination – particularly older people’s time, which is ignored by 

the market economy – and building a network of neighbourhood support. 

Evaluation conducted by the University of Maryland’s Centre on Ageing throughout the 1990s 

established that time banks were able to attract people who don’t normally volunteer, keep 

old people healthier and cut drop-out of volunteers. 1 Most dramatically, the hospital group 

Sentara, in Richmond, Virginia, found that using a time bank to provide peer support for 

people with asthma, cut emergency admissions to hospital by 74 per cent and saved 

$217,000 over two years. 2 

One of the most successful projects in the USA, is Elderplan, a social Health Maintenance 

Organisation in New York City. In their first 12 years, mutual volunteers from their Member to 

Member project have put in over 100,000 hours helping each other, teaching each other and 

supporting each other to be independent. Member to Member enables volunteers to earn 

1 

Robert Wood Johnson Foundation (1990): Service Credit Banking Project Site Summaries, University of 

Maryland Centre on Aging, Baltimore. 

2 

Time Dollar Institute (1999): Angels and Health: Time dollars and healthcare, Time Dollar Institute, 

Washington DC. 




and pay time credits for giving and receiving non-medical services like, shopping, friendly 

visiting, bill-paying, hospital visiting, home repairs, walking clubs, support groups, self-help 

courses and others – all funded by time credits earned through the scheme. 3 

"Often you can't buy what you really need," says Mashi Blech, Elderplan's director of 

community services. "You can't hire a new best friend. You can't buy somebody you can 

talk to over the phone when you're worried about surgery. But by getting people helping 

through the time bank we want to involve people as co-producers of their own health care.” 4 

The New Economics Foundation (NEF), supported by a grant from the King’s Fund, organised 

a series of UK seminars by Edgar Cahn in 1997. The visit generated a great deal of interest, 

particular from the health sector and the King’s Fund agreed to support NEF to pilot a UK 

approach to time banking over a two-year period – and in particular to set up an 

experimental community time bank in London around a hospital or health centre, primarily 

with and for older people. Since then, a range of other partners have become involved in 

the development of time banks – including the South London & Maudsley NHS Trust – and 

there are two major networks of time banks up and running, the London Time Bank (www 

.londontimebank.org.uk) and Time Banks UK (www .timebanks.co.uk). 

Rushey Green 

The pilot community time bank was developed in partnership with the Rushey Green Group 

Practice, based at two locations in Catford, in south east London. It has a team of 14 

clinicians: six GPs, two nurses, together with a nurse practitioner, a psychologist, a 

counsellor, a child mental health specialist and a health visitor. 

Interest in developing a time bank at the practice was sparked by GP Richard Byng, who was 

keen to explore and develop alternatives for tackling isolation and depression. Initial 

research found that both staff and patients supported the idea and felt that the scheme had 

the capacity to generate much-needed social support for the most isolated older people – as 

well as families and provide low level practical help to enable older people to stay in their 

own homes. 

Cllr Mee Ling Ng, the deputy mayor of Lewisham officially launched the time bank in March 

2000. Now, 18 months later, the Rushey Green Time Bank has 68 members: 59 individual 

members and nine organisations, including the health centre itself, the local garden centre, a 

local nursing home, Voluntary Action Lewisham, Lewisham Community Health Council and St 

Laurence Church. The time bank is co-ordinated by Liz Hoare, who recruits new members and 

links up their offers and requests for help. 

The time bank has generated over 2,950 hours of service. The range and type of services 

include: befriending, running errands, giving lifts, arranging social events, woodwork, poetry 

writing, teaching sewing, babysitting, gardening, lifting that requires muscle, swimming, 

fishing, teaching the piano, catering, form-filling, design work, drawing and giving local 

knowledge. 

New members join the time bank, on average at the rate of one to two per week and 

turnover is low, with most of the members who joined at the beginning still involved. By far 

the most common reason for leaving the time bank is returning to, or finding paid 

employment. Other members have moved and three older members have died. There are 

3 

See for example: Boyle, David (2001): The Sum of Our Discontent, Texere, New York. 

4 





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also 23 people who initially contacted the time bank and decided subsequently not to get 

involved. 

The time bank is made up of 29 per cent men, 71 per cent women. Of these, 44 per cent are 

from minority ethnic groups and 52 per cent have some kind of disability. Exactly a third of 

members are over 65 and 18 per cent are over 80 years old. The oldest member is 91 years 

old; the youngest 16. 

What difference has the time bank made? 

A two-year evaluation, supported by the King’s Fund has now been launched by the Socio- 

Medical Research Centre at St Thomas’ Hospital, led by Dr Tirril Harris. Combining both 

qualitative and quantitative approaches, the research will document how the time bank 

works and measure how it impacts on participants and their: 

• Confidence and self-esteem 

• Social networks 

• Access to preventative as opposed to merely reactive care 

• Self-perception of health as well as clinical health 

• Possible cost savings to the NHS. 

Initial research was conducted by Dr Isobel Garcia, a GP at the practice. She interviewed 24 

time bank participants, and surveyed practice staff about their experiences of the scheme. 

Her main finding has been that – as well as the volunteer support to local people who need 

it generated by the time bank – it has also helped to build people’s confidence and selfesteem 

by shifting the emphasis from areas where they are challenged or failing, to activities 

and skills that they enjoy and can share with others. 

In this way, the scheme has given a sense of self-worth to people who had previously been 

passive recipients of care. Many of the members are elderly or disabled and cared for, at 

least to some extent. The time bank has also given them the opportunity to give and 

become ‘carers’ themselves in different ways in the community. 

By blurring the distinction between givers and receivers and encouraging more vulnerable 

people, such as the elderly and those with mental heath needs, to get involved and share 

their time, the time bank is helping to build more community based self-help and mutual 

support: 

• “I was asked to go and sit with an elderly lady. She was blind and very isolated 

but she lived just across the road from me and by getting to know her and starting 

to look after her, I came out of my depression.” 

• “ I am supporting them, but if there’s a time I need to be supported, I am sure 

they will be there for me.” 

Other impacts include the following: 

Support for traditional carers 

Because participants are very much involved in the management and development of the 

scheme, they have come to take more responsibility for each other. This has helped to 

reduce the burden on traditional carers in the form of both family and social services to 

some extent by providing support from other local people: 

• “We discuss who can help and who’s had a stroke or who’s just returned from 

hospital and may need someone just to come in and sit for a while.” 

Respondent to the research questionnaire 




Peer support 

Participants have also drawn support from sharing health challenges with peers: 

• “Talking to other people who have had the same problem that I have calmed me 

down.” 


Widening support networks 

The time bank has also been successful in increasing the number of people, participants felt 

they could trust and call on for help when they needed it. Some participants even felt that 

the time bank offered an alternative to visiting the GP: 

• “It makes me feel good that I can actually trust people again... It’s just nice to 

know you have someone you can call on.” 

• “Rather than just keep going to your GP, you can always go to the Community 

time bank people.” 

Respondents to the research questionnaire 

Getting people active and engaged 

Being involved in the time bank has enabled people to play a more active part in their local 

community: 

• “And at the same time, because I felt better, I was able to get involved in other 

things…and I think it’s all because I went out doing my Community time bank that 

gave me the push.” 

• “It has made me feel brighter about Catford.” 

Respondents to the research questionnaire 

Broadening the professional view of health 

The time bank was also found to have had an impact on GPs and nurses at the practice, who 

are now able to offer a friendly chat or a helping hand when it is needed – rather than 

prescribing medicine or a lengthy referral to another agency. 

• “The time bank has broadened the view of how we as clinicians see patients; so 

patients get some benefit even if we don’t refer them to the time bank. We 

consider patients in more societal terms. The time bank has helped form an 

identity for the practice, and a focus for patients. Patients’ groups often fail 

because they focus too much on illness. But [through the time bank] we’ve formed 

a community.” 


• “Community time bank members have made a great difference to people arriving at 

the Central Lewisham surgery. The flowerbeds at the front of the building were 

dismal – full of weeds and rubbish – and they had been like that for years. Then 

the members started taking care of it. Mothers coming to our clinics often comment 

on the change – especially the wonderful display of daffodils in the spring. It 

cheered them up and made them feel better even before they got to see a health 

visitor or GP!” 

Local health visitor Mercynth Johnson 

Challenges 

With any social innovation like community time banks, there is bound to be a considerable 

amount of on-the-job learning. For example, while many members have a great deal to offer, 



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they need time and encouragement before they feel ready to give. At least half the 

membership requires ongoing support to keep them involved and contributing. This is one of 

the main tasks of the time bank co-ordinator, requiring special listening and people-skills. 

Other challenges include: 

• Safety of participants: To make sure community time bank members feel safe, 

references are taken up for all new members. This can pose a problem for some 

people, like refugees and people who are very isolated and have nobody who can 

give information about them. By offering group activities, such as gardening or 

shared meals, the time bank has been able to provide a safe space for people who 

are without references to participate and gives the co-ordinator, as well as other 

participants time to get to know them better. 

• Diversity of participants: Referrals to the time bank from people with mental health 

needs have been very high. But the success of the scheme has rested on its ability 

to mix people up and engage them on the basis of what they can do, rather than 

segregate them and confine them to activities organised around their particular 

health condition. The health centre is part of a rich network of help and support in 

local people’s lives and the research implies that the time bank is most effective as 

part of this and therefore an integral part of the local scene. Links have been made 

with voluntary groups, churches and local businesses and the bank will continue to 

foster these ties. 

• Getting people to ask for help: Whilst most time bank participants enjoyed giving 

and receiving help, one third found it more difficult to ask for help. Bad weather, 

illness and depression were the main barriers which periodically deterred some 

members from being actively involved. Links were most successful when 

participants had already met – normally through the time bank – and when there 

were additional social opportunities, like parties. 

Conclusions 

It is becoming clear that participation – and especially participation through time banks – can 

make an important difference to people’s experience of the NHS, to their health and to the 

cost of curing people and keeping them healthy, although what those cost savings might be 

remain to be seen. 

Community time banks do seem to provide a way to make it clear to professionals and 

patients alike that they need each other if either are going to succeed. Doctors need 

patients, as much as patients need doctors, in other words. And although this is a truism, it 

has been hard to make that mean something in a health context. The key findings of the 

initial research at Rushey Green are as follows: 

1. The community time bank approach does help to engage patients as partners in the 

business of delivering health. 

It does this by helping to shift the focus from people’s problems to their abilities. 

Professionals traditionally concentrate on what patients can’t do: often this becomes the 

accepted way of triggering help. And traditional volunteering makes a distinction between 

those who can give and those who need help. Community time banks focus instead on 

people’s assets, what they can do and how these activities can complement and support 

existing services. In this way, time banks can provide a valuable force for social exclusion. 




2. Time banks can lever hidden resources in the community. 

The Rushey Green model seems to be able to access people’s time and goodwill in such a 

way that they can provide a useful arm to the surgery. Seen like that, the local community 

can relieve some of the support burden from health professionals. 

3. Time banks allow health centres to supply a broader view of health. 

Time banks are not a stand-alone model, but a flexible approach that can be grafted onto 

existing activities. By linking up and using these hidden resources in the community – 

including organisational resources (like other community groups), health centres are able to 

provide access to a much wider range of services than traditional surgeries – anything from 

basic DIY to self-help bereavement counselling. 

4. Mutual support can make a difference to the way people experience the NHS. 

Mutual volunteering among patients through a time bank can benefit both the giver and the 

receiver, can have an effect on people’s health, and can be far cheaper than conventional 

drug therapies by themselves. 

Recommendations 

We propose that the time banks model should be developed further in a health context. 

This will require: 

1. Other layers of NHS provision need to experiment with time banks: Sandwell Health 

Authority and South London & Maudsley NHS Trust have both launched their own 

programmes, but there need to be experiments building time banks and mutual 

volunteering into other forms of care-management and hospital discharge planning. 

2. Boundaries between the different providers of health service need to break down 

further: Local authorities and education authorities using time banks need to be 

able to link up with other providers – from surgeries to social services – to make 

the health component more effective. 

3. Community participation and involvement should be recognised and rewarded as 

work: This can’t be done with money, but it can be done with time credits. 

4. The remaining bureaucratic hurdles for people on benefits taking part in time banks 

need to be removed: Given the high proportion of members who are disabled, or 

have mental health problems, it is essential that time bank participation is seen as 

a therapeutic self-help activity, without implications for receipt of incapacity benefit. 

5. The ambiguity about the charitable status of time banks needs to be cleared up: As 

mutual institutions, the Charity Commission doesn’t necessarily recognise time 

banks as charities – though they are clearly a regeneration tool for the benefit of 

disadvantaged people. 

6. We need to develop more sophisticated accounting methods, so that the savings on 

future NHS spending from time banks can be clearly recognised. 

7. There needs to be a legal obligation on any public institution to involve clients as 

equal participants in the business of health: Time banks are a useful mechanism to 

help them do this. 

Appendix A 



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Further information 

There are a number of websites that can provide more information about the time banks 

idea, notably the Time Banks UK website (www .timebanks.co.uk), the London Time Bank 

website (www .londontimebank.org.uk) and the Fair Shares website in Gloucestershire 

(www.fairshares.org.uk). The American Time Dollar Institute also has a useful website 

(www.timedollar.org). 

If you would like more information about how to develop time banks in a health setting, you 

can contact: 

Sarah Burns (New Economics Foundation): 

tel: 020 7089 2859, email: sarah.burns @neweconomics.org 

Liz Hoare (Rushey Green Time Bank): 

tel: 07946 411177, email: liz.hoare @neweconomics.org 

Tirril Harris (Socio-Medical Research Centre at St Thomas’ Hospital): 

email: tirril.harris @kcl.ac.uk 

Gill Seyfang (University of East Anglia); 

email: g.seyfang @uea.ac.uk 

Jason Evans (Sandwell Health Authority): 

email: jason.evans @sandwell-he.wmeds.nhs.uk 

Karina Krogh (South London and Maudsley NHS Trust): 

email: karina.krogh@slam-tr.nhs.uk 

Appendix B 

Other UK research 

The national evaluation of community time banks in the UK, currently being conducted by Dr 

Gill Seyfang at the University of East Anglia, shows that they are a successful tool for 

engaging socially excluded groups in building their local community. 5 Whilst most schemes 

surveyed were still relatively young, participant involvement increased over time rather than 

burning out and moving on after a short period of activity. Significantly, most participants 

were active both as givers and receivers of time. 

The social groups which constitute time banks are precisely those who participate least in 

traditional volunteering – the poor, unemployed, those with disabilities, the elderly. 6 

Compared to the demographic profile of traditional volunteers, time banks are attracting a 

different constituency of participants - notably a higher proportion of women, retired, 

disabled or sick people, jobless and low-income participants. 

For example, while only 16 per cent of traditional volunteers have an annual household 

income of under £10,000, the proportion of time banks participants in this category is 58 per 

cent - nearly four times as many. Also, while 40 per cent of traditional volunteers are not in 

5 

Seyfang, Gill (2001): Spending time building communities, Time Banks UK, London/Gloucester. 

6 

Davis-Smith, Justin (1998): The 1997 National Survey of Volunteering, National Centre for Volunteering, 

London. 




formal employment, the figure for community time banks members is 72 per cent, or nearly 

double. 7 

This reveals that community time banks are successful in their objective of attracting 

members who are socially excluded, and would not normally get involved in volunteering. 

Indeed, the majority of survey respondents (82%) were confident that they were attracting 

people who had not volunteered before, and overall co-ordinators estimated that 51 per cent 

of their members would not otherwise have got involved in volunteering. 

Other findings included: 

Over half time dollar participants (51%) are people who would not otherwise have been 

interested in volunteering. 

Time dollars are succeeding in their aim of being reciprocal – participants in the 15 time 

banks studied had earned 15,776 hours in time credits and spent 13,838 (the total figure in 

September 2001 was over 32,500 hours earned). 

Over 90 per cent of respondents said time dollars were meeting some of the needs of 

participants – as well as building new friendships and trust among them. 

Dr Seyfang discovered a range of innovative arrangements – retired people teaching 

conversational English to Iranian women, others teaching the piano to teenagers in return for 

help in the garden. In Newcastle time credits can be spent getting into local sports centres; 

in Cheltenham getting into home matches played by Cheltenham Town. 

Appendix C 

Other US research 

A report by the Time Dollar Institute in Washington outlined some of the other ways that 

time banks were being used in a health context in the USA, some of which could be applied 

in the UK too. 8 The development of time banks in the USA is happening partly as a result of 

a general push to keep down the burgeoning costs of providing medical services, and partly 

in the face of a wider long term-care crisis in healthcare as the population ages. People over 

65 are expected to make up over 21 per cent of the US population by the year 2030. By 

2020, the number of Americans who will need some kind of help because of a chronic 

condition is expected to be around 23 million. Specific innovations include: 

Member Organised Resource Exchange in St Louis, which pays time credits to participants 

across the city for visiting older people, training in health promotion (asthma and childcare) 

and passing on the training to others. They can spend the credits on help for themselves or 

in a network of time bank ‘stores’ around the city. 

Volunteer Caregiving in Richmond, Virginia, where asthmatics are enrolled in a telephone 

time bank and befriend other asthmatics: the experiment cut the cost of treating those 

involved by 73 per cent - a total of $80,000 saved in the first year of the asthma program, 

rising to $137,500 in the second year. 

Time Bank in Denver, which pays time credits to participants for visiting older patients to 

make sure they are taking important medication. 

7 

Davis-Smith, Justin (1998): The 1997 National Survey of Volunteering, National Centre 

for Volunteering, London. 

8 





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Care Xchange, part of the Blue Shield health provider in California, which runs a time bank 

devoted to mutual support and telephone reassurance – with a special concentration on 

support for diabetics to catch glaucoma early. 

Abriendo Puertas in Miami, which runs a time bank as part of its mental health programme – 

encouraging patients to find they have skills and are useful members of the community. 

PALS in Pittsburgh, where the time bank concentrates on providing support for and by 

housebound elderly and disabled people. Credits earned can be exchanged for grocery 

vouchers. 

The WHO Investment for Health Project and the Verona Initiative (*) 

Erio Ziglio 

(*) An amended version of this paper was presented at the 5 th International Conference on 

Health Promotion, Mexico City, 5-9 June 2000. 

(**) The views represented in this report are those of the author and not necessarily those 

of the organization for which he works) 

Abstract 

Can we produce health in today’s societies? Can we promote the health of the population in 

a sustainable and equitable manner? Can we identify an approach effective in integrating 

health across development policies that in addition to bringing about population health 

gains, provides added value to economic and social results in an equitable and sustainable 

manner? 

These are questions that national, regional and local governments will increasingly be 

confronted with in European countries. The author maintains that a thorough understanding 

of the social and economic determinants of health will increasingly play a major role in 

addressing the questions above. Likewise, those working in policy-making, and in healthrelated 

research, ought to refocus their efforts and methods of work. For example, still too 

much of contemporary epidemiological work focuses merely on the description of ill-health 

patterns. Far too little work is carried out with a clear focus on how to invest for the 

promotion of population health. The Investment for Health (IFH) approach, developed by the 

European Office of the World Health Organization – or even the concept and principles of 

health promotion as embodied in the 1986 Ottawa Charter – are not at the centre of current 

health work in many European countries. 

Dr Ziglio will start by outlining the background of IFH as an approach to promoting 

population health. It will be pointed out that the implementation of an IFH approach 

requires a thorough understanding of the social and economic determinants of health. 

Secondly, the issue of evidence related to the social and economic determinants of health 

will be discussed. Thirdly, the main principles characterizing the IFH approach will be 

outlined. Finally, examples on how a better understanding of the social and economic 

determinants of health will be crucial for future development in policy-making will be 

outlined. 




In order for participants to have further information and scientific documents on the issues 

related to the above, special material has been developed, mainly through the Verona 

Initiative: Investing for health: the economic, social and human environment. 

http://www.who.dk/Verona/main.htm . The Verona Initiative is a yearly forum, meeting over 

a three-year period, designed to create opportunities to learn how to invest for health by 

creating synergy among three types of development: economic, social and health. It brings 

together leading exponents of intergovernmental organizations (IGOs), nongovernmental 

organizations (NGOs), business, local and national politicians, academics and the media 

across Europe, East and West. 

1. Introduction to the Investment for Health (IFH) approach 

Population health is, by and large, determined by social, demographic, and economic factors 

and public policies well beyond the traditional remit of medicine or even public health 

(3,4,6,8,9,13,15,34,37,39,41,48). Throughout history, the greatest improvements in people’s 

health have mainly arisen from social and economic improvements which also promote 

health (18). Conversely, a healthier population can make a more productive contribution to 

overall development, requires less social support in the form of health care and welfare 

benefits. Therefore, investment aimed at securing positive health and wellbeing also brings 

social and economic benefits for the whole community. 

IFH is a practical approach based on these interlocking facts. It is based on the rationale that 

resources are best applied in a way which both attacks the main causes of ill-health in a 

credible, effective and ethical manner, and which also furthers the achievement of goals for 

social and economic development. 

Priority social and economic policy areas - such as education, income maintenance, 

workplace regulation, housing, transport, agriculture and communications – as well as private 

initiatives, have a profound influence on health. Governments, and supra national institutions 

such as the EU, have great potential to improve or worsen people’s health through their 

policy decisions in these areas. This increasingly applies to the private sector too. Great harm 

can be done to health by misguided public policies or private initiatives alike. The IFH 

approach offers practical measures to prevent this – by building social and economic 

strength together with health improvement for the population in an equitable, empowering 

and sustainable way. 

The IFH approach therefore calls for a new form of partnership. In today’s complex world, 

action for the promotion of health cannot come from the health care sector alone. It needs to 

be built on strong cross-sector alliances between health and health care, social development 

and equitable and sustainable economic development. 

Kickbusch (20) argues that at least three key questions need to be addressed in developing 

a strong and credible health promotion strategy: 

• Where is health promoted and maintained in a given population? 

• Which investment and strategies produce the largest population health gains? 

• Which investment and strategies help reduce health inequities and are in line with 

human rights? 

These questions are at the heart of IFH (77). This approach also poses and seeks to answer 

a fourth question: Which investments contribute to economic and social development in an 

equitable and sustainable manner and result in high health returns for the overall population 

(76)? 



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Hardly any of the ‘health sector’ reforms underway in many European countries address 

these four questions in a systematic manner. (77,45). IFH is a practical attempt to answer the 

above-mentioned questions by: identifying relevant policy attributes; considering factors that 

may enhance or inhibit policy change; assessing options that benefit both health and the 

specific policy sector; and planning the political process of achieving the necessary 

legislative, regulatory, financial, organizational or educational changes (76). In some 

circumstances IFH will require substantial policy change, which may involve major financial, 

institutional, human, regulatory, or educational efforts. Ensuring and managing these changes 

is a key part of IFH practice. 

In summary, IFH is a deliberate attempt to address the main “causes” of health in a credible, 

effective and ethical manner that engages other sectors of society as well as the health care 

sector (40,76). The approach develops policies and programmes that are based on, and 

address, key determinants of health. Such determinants are mainly linked to economic and 

social factors (61,66,68,73). Stimulating and securing the self-interest of other relevant 

sectors of society is critical. Positive changes for health should be facilitated at both 

individual and community level. Therefore, unhealthy life conditions (e.g. poverty, 

inequalities and social exclusion) should be modified not only bio-medical risk factors! 

Finally, it should be emphasized that IFH does not take a narrow view of solely utilitarian 

aspects of investment and economic trade-offs. It places the protection and promotion of 

the health of the population firmly within a human right perspective, as well as an indictor of 

human and social development. Thus, IFH is not confined to mere issues of costs-benefits 

analysis of selected prevention and health promotion programmes. Indeed, Investment for 

Health focuses on maximization of assets for health. This issue will be explored in more 

detail below. Likewise, IFH is sensitive to the removal of social, economic and 

environmental barriers to the promotion of health. These adverse conditions can be 

associated with a wide range of factors, including lack of democracy and infringement of 

human rights, the burden of the external debt of many developing countries, or the unequal 

distribution of resources and opportunities for social and personal development. 

2. Social and economic determinants of health: The evidence for IFH 

Until quite recently, public health practice, including the range and selection of interventions, 

has been guided almost exclusively by evidence drawn from medical epidemiology (60; 68). 

Far less attention has been given to the effect of economic and social development on a 

population’s health. The notion that public health decisions must be profoundly linked to 

wider social and economic goals to ensure sustainable benefits is still not widely 

appreciated. Nevertheless, an expanding literature has been making a powerful case for the 

relationship between health and economic development (11,12,21,30,31,33,34,41,43,44,56). 

2.1 Evidence from the Past 

In the last 150 years, in the European Region, there has been a dramatic change in the 

epidemiological patterns of ill-health. Much has been published already on the fact that in 

the more advanced industrialized nations of Europe (as well as world-wide) there has been a 

reduction in the massive toll of infectious diseases such as cholera, poliomyelitis, 

tuberculosis, etc. These were the epidemics which typically affected populations in earlier 

stages of urbanization (33). Using data from England and Wales (similar results have been 

obtained in studies carried out in several other European countries), McKeown (34) confirms 

that the halving of mortality rates (from 23/1000 in 1851 to 11/1000 in 1980) and the doubling 

of life expectancy (females: from 40 years in 1840 to 76 years in 1980; males: from 43 years 

to 70 years) are explained by the reduction of infectious causes of death associated with 




improvements in the environment (e.g. the introduction of sanitation measures), living 

conditions (e.g. better housing and nutrition), and other factors related to social and 

economic development (e.g. increased family income). Medical breakthroughs, such as the 

availability of vaccination and immunization, came after the Second World War, by which 

time the major drop in mortality rates had already occurred (35). 

In developed countries, the receding pandemics of infection during the 18th and 19th centuries 

were attributable more as a response to social, economic and environmental changes than to 

medical breakthroughs (34). The latter were few and came too gradually and too late to be 

responsible for the changes in health and disease patterns. The policy implications of all this 

are still largely overlooked. There is no doubt that the explanation for this reduction in 

mortality is strongly linked to improvements in living and working conditions brought about 

by social and economic development (14,33,34,35,41,43,79). 

To argue that falls in death rates and the decline of pandemics in the last two centuries have 

been primarily related to changes in the environment, in the nutritional status of the 

population, in the supply of clean water, in the effective disposal of excreta, rather than to a 

specific medical intervention is not to downplay the role of the medical profession in 

achieving these successes. In many cases it was physicians who saw the relationships 

between nutrition, water supply, sanitation, poverty and illness and forced the authorities to 

take action (46,47). Health professions have played, and continue to have, an important role 

to play in changing disease patterns. What is important to recognize is that the actions to 

control or eradicate diseases are often social, economic or environmental interventions. 

2.2 Evidence from the Present 

Turning to the present, a number of recent studies focus specifically on the issue of social 

and economic development as key categories of health determinants 

(8,9,13,31,35,48,53,54,56). Several studies point out that the early signs of deterioration in 

the health status of populations are, in general, determined by changes in their social, 

economic and environmental conditions (see for example: 23,48,50,56,57,58). 

At national level, there is a demonstrable relationship between economic performance, 

income distribution, and health status, which has significant implications for social and 

economic policy-making. The higher a country’s average income per capita and the more 

equal its income distribution, the greater the likelihood of longer and healthier lives for its 

population (61,64). Maternal and child health patterns often reflect general economic trends. 

For example, child and infant mortality rates have been found to be sensitive to economic 

hardship. Studies in developing countries have shown that a 10% increase in income per 

capita corresponds to a 3.5% fall in child mortality rates (57). According to the World Bank, 

this estimate reflects the total impact of income on health. It includes efforts working directly 

through income (e.g. food consumption), as well as indirectly through factors that are 

themselves mainly determined by income (e.g. access to safe water and sanitation, 

availability of health care, etc.). 

There is now overwhelming evidence that much of contemporary illnesses and death (and 

thus the potential for the promotion of the health of the population) are rooted in the 

prevailing type of economic development and linked to social factors (8,9,11,12,13,30,48,53). 

In general, if economic development goes hand in hand with decreasing social inequalities, is 

environmentally friendly and strengthens social capital, it will have positive impact on a wide 

range of social and health indicators. In both developed and developing countries the 

number of people in poverty is an especially important reason for differences (inequalities) in 

health. In every society the income and status of women exact a powerful influence on 

population health. Especially in the poorest countries, policies that accelerate family income 



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growth, reduce poverty and expand opportunities, particularly for girls, help people achieve 

better health (57). 

In his book “Unhealthy Societies”, Wilkinson confirms the necessity to bring social and 

economic issues up front in order to better understand their effects on health (56). This very 

interesting study analyses data from several European countries as well as the United States 

and Japan. From Wilkinson’s work the main lessons can be summarized as follows: 

1. above a certain level of wealth, it is not necessarily the richer societies which have 

better health, but those that have the smallest income difference between rich and 

poor; 

2. increased inequality imposes economic, social and psychological burdens which 

reduce the wellbeing of the whole society; 

3. there is no basis for choosing between greater equity and economic growth; on the 

contrary, by lubricating the economy and society, investment in “social capital” 

increases economic efficiency. 

Income distribution is important not only for health but also for social cohesion. Societies in 

which there are high levels of income inequality also tend to have higher levels of violent 

crime. Deprivation leads to stress and economic hardship, reduces people’s ability to fulfil 

roles, and contributes to psychological ill health. Income inequality must, however, also be 

looked at in the wider perspective of the extent to which social goods (e.g. free education) 

are available to lower income groups. 

Socially cohesive societies are those with well functioning institutions and well developed 

civic communities. With reduced income inequality and improved standard of living for the 

whole population, people can form and participate in social networks across society and 

through a variety of social organizations, purposes and activities. A sense of moral 

collectivity and social purpose remains important. When inequalities increase, social divisions 

become deeper. Societies which pursue more egalitarian polices often have faster rates of 

economic growth and higher standards of health. The cost of inequality is a cost incurred for 

no economic benefit, but one that imposes a substantial economic burden and reduces the 

competitiveness of the whole society (70). 

In many parts of today’s world, a rising proportion of people is living in poverty, and Europe 

is not untouched by this phenomenon. High economic growth in conjunction with rising 

unemployment, job insecurity and low-paid jobs lead to widening income gaps and to rising 

social inequality (54,56). Changes in living conditions and a widening range of family 

structures (single parent families, divorce, commuter families, etc.) are an increasing reality in 

most European countries. A narrowing labour market and fragile social and family supportnetworks 

result in a higher proportion of children at risk of living in poverty (9). We know 

that this will have serious short and long term ill-health consequences. Unless decisive, 

coordinated, intersectoral policies are explicitly designed to address these phenomena, and 

effectively implemented, the maintenance of health, let alone its improvement, will be much 

more difficult to achieve (77). There is much at stake if such strategies are not applied. 

A study by Cornia (8;9) explores the reasons behind the mortality crisis during the transition 

period (1989–1995) in the countries of central and eastern Europe (CCEE). During the first 

reform years, life expectancy at birth fell in 12 out of 16 of the CCEE for men and 10 out of 16 

for women. In all these countries, life expectancy in 1995 was still lower than in 1989. In the 

1990s, most CCEE have been affected by an unprecedented fall in output and incomes, a 

rapid impoverishment of large sections of society, an increasing level of uncertainty and a 

mortality crisis (50). According to Cornea between 1989 and 1994 “the number of the poor in 

the region rose by 75 million, the crime rate tripled and the number of additional deaths 

reached 2 million. Changes in the labour market were no less dramatic … . The mortality 




impact of these and other changes has been very large.” (8, p.1). Neither popular 

explanations nor theoretical models are able to fully explain the mortality crisis that occurred 

in this part of Europe. There is growing evidence that it was largely due to the psycho-social 

stress generated by an unguided, unassisted and unmanaged process of restructuring, the 

pace and pattern of which was (and in many cases still is) left to highly imperfect markets 

and still weak institutions (8,9,70) 

It is because of this powerful evidence that economic and social determinants play such a 

central role in the IFH approach. 

3. Principles for Strategy Development 

Through WHO’s practical work to date with governments (national, regional and local), the 

private sector, business, researchers and other interest groups, a number of common 

features of successful IFH approach have emerged. The core principles on which IFH is 

founded are: 

1. a focus on health 

2. full public engagement 

3. genuine intersectoral work 

4. equity 

5. sustainability 

6. a broad knowledge base 

The objective is effective action to tackle the root causes of ill health and create 

opportunities for better health and development. Health improvement will not always be the 

primary policy goal. But it is important to assess the population health impact (both positive 

and negative) of public policy decisions, development strategies and investment decisions, 

particularly those with social and economic implications. Economic development can be used 

as a means of improving both the social infrastructure and people’s health. But the way in 

which investments are made ought to contribute to health improvement. 

Genuinely involving the public, whose health is affected by such policy decisions, requires 

going beyond traditional electoral and consultative approaches. There must be new, formal 

opportunities for full democratic involvement at all political levels. Such opportunities must 

respect gender, age and racial differences consistent with the principles of social justice. 

In view of the importance for health of decisions and actions by sectors such as agriculture, 

education, finance, housing, social services and employment, a sensible, effective strategy to 

improve health requires the active inclusion of all sectors to achieve the synergy required to 

improve population health. 

The WHO global strategy of achieving health for all is fundamentally directed toward 

achieving greater equity in health between and within populations and between countries. 

Equity implies that all people will have equal opportunities to develop and maintain their 

health through a fair distribution of the resources that support health. 

Sustainability, as used here, has a dual significance: signalling firstly the aim to create an IFH 

process that is durable and resilient; and secondly, that investments are made and resources 

are managed in ways which do not compromise the health and wellbeing of future 

generations. 

The development and implementation of policies and plans which will contribute to the 

achievement of IFH goals cannot rely solely on technical information, but must be sensitive 

to community aspirations and goals, so that ‘knowledge’ here will include community 



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judgment and insight as well as research data and other ‘scientific’ sources and practical, 

hands-on experience. 

The ideas behind these principles are not new. We intuitively know them to be right. But 

very few (if any) countries or regions in Europe systematically apply these principles to 

decisions about improving the health of their people. 

In order to implement these principles, a strategy is required involving the concerted efforts 

of a variety of players at all levels of government and society. As mentioned earlier, the 

successful strategy must influence sectors such as health care, social services, education, 

environment, and economic and social development. Public and private initiatives, the 

media, non-governmental organizations, and all other institutional arrangements crucial to 

social cohesion, social justice, and human rights must be involved. (59; 60; 64, 66; 69). With 

so many interests visibly involved, the strategy for promoting health has to be intersectoral, 

it must involve multiple levels of policy-making in economic and social development (local, 

regional, national, and in several instances supranational), and it needs to use a wide range 

of levers for change (educational, legislative, fiscal, etc.). To achieve such broad and 

encompassing influence over so many sectors of society, those with an interest in the 

promotion of health must offer something in return to other interest groups or policy sectors. 

The IFH approach attempts to do precisely this. An analysis (IFH appraisal) conducted in 

several European countries at the request of their Parliament (including Romania, Slovenia, 

Hungary and Malta) indicates clearly that economic regeneration will not be sustainable 

unless there are parallel improvements in the health of the population. The initial findings of 

the WHO Commission on Health and Macro-Economics (chaired by professor Jeremy Sachs) 

substantiate the need to position the promotion of population health at the heart of the 

development agenda of countries. 

4. Methodologies and practical experiences 

We noted earlier that one of the key challenges in applying the concept of IFH in practice 

was moving from theory and belief to making decisions and implementing them. This section 

summarizes a selection of the tools that have been developed, applied and refined in various 

IFH demonstration projects and national IFH appraisals carried out by the WHO Regional 

Office for Europe. 9 Through these on the ground experiences it has become clear that to 

make IFH a reality requires methodologies, tools and policy-making processes capable of: 

• assessing the structures, systems and processes with a country/region or local 

area’s current and future opportunities, within and outside the health sector, that 

promote or hinder the health of its population and identifying ways in which this 

infrastructure can be improved; 

• identifying the key elements for a strategy that enhances the population’s health 

through selective investment (both within and outside the health sector) while 

supporting key economic and social priorities; 

• negotiating for investment for better health with policy makers and key decision 

takers in other leading social and economic sectors. 

It is clear that there is much to be learned regarding the efficacy of health investment 

processes. Evaluation of these is made harder by the fact that economic and social 

circumstances vary, making transfer and replication difficult (24,25). It is only by testing 

things in practice that we can begin to identify and order those variables that contribute to 

9 In this process WHO was assisted by a wide range of cooperation with countries and institutions. 

Among these it is important to acknowledge the support of the Office for Public Management. 




effective health investment processes and outcomes. We need ‘living laboratories’ where 

decision making investment processes can be observed and appropriate adjustments in 

policy targets, administrative and logistical supports, and action strategies can be made. In 

these practical experiences the focus should be on maximizing community health assets, not 

only on minimizing or alleviating the negative impact of social and economic changes. 

4.1 Maximizing health assets 

Since 1995, the WHO Regional Office for Europe has undertaken a series of advisory studies 

at the request of Member States in a spirit of mutual learning about how health investments 

can be decided, implemented and evaluated (63,67,71). These experiences have shown that 

it is important to take account of the whole spectrum of health promoting assets to pinpoint 

where new developments are needed. These assets include policy investments, regulatory 

changes, nurturing of non-governmental resources and programme initiatives, strengthening 

of health promoting infrastructures and decision-making, refocusing education, investing in 

research, training in requisite health promotion skills, and environmental improvement. 

The identification and strengthening of assets is of key importance in the IFH approach. What 

happens next – the areas that need changing – is to a large extent dependent on local 

circumstances and assets: the willingness of a community to change and improve its living 

conditions; the quality of the physical environment, the level of social capital, or any other 

collective resource that could be used to promote health and gain more control over the 

determinants of population health. 

Thinking in terms of assets for health does not come naturally. Most interventions to 

promote the health of the population ought to focus on the needs or problems of a 

population. Although appraisals take into account health needs, need reduction is not the 

primary objective of implementing IFH. The status and potential of health assets (resources) 

is, of course, the main focus of IFH (Fig. 1). 

Let us assume that a community’s level of need is A on the need axis. At this level, the type 

and degree of IFH depends on the community’s level of assets. This could be low (B) or high 

C. 

If the chosen strategy has no effect on need (e.g. from B to B1), traditional epidemiological 

or other need-based indicators would suggest that health promotion has no effect at all, 

whereas, as a matter of fact, the strategy increases the community’s assets for health. 

Similarly, if the initial condition of a community is C and, as a result of a given strategy that 

community moves to C1, according to conventional need-based evaluation there is no effect, 

but in practice C-1 is worse than the initial C overall. Furthermore, if a community moves 

from C to D, D is not necessarily in a better condition, because the reduction in need comes 

with a drop in assets for health. 

IFH involves accounting and searching for asset maximization, not just need reduction. 

Furthermore, IFH helps identify different health promotion strategies when a country, region, 

or local community belongs to different quadrants in the need/assets diagram (see Fig. 1). 



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4.2 The health gain map: the Trentino Alto Adige demonstration project 

This tool was developed as a result of an IFH demonstration project in the Northern Italian 

autonomous region of Trentino Alto Adige. In this region the major issues affecting people’s 

health and sense of wellbeing, were identified as employment, education, security, and 

housing, with transportation, urban cleanliness, and access to health care following closely. 

However, moving from general agreement on issues to operational strategies is, in most 

cases, not a simple endeavour. But this practical step is of key importance in the IFH 

approach. 

In this demonstration project various methods to assess the impact of public policy on 

health both qualitatively and quantitatively were utilized. A “health gain map” (Fig. 2) and 

other inventory of the impact of public policies, private initiatives, regulations, and 

programmes were used to form a baseline as well as an ongoing accounting system (62,75). 

Fig. 2. 

Population 

Group 1 

Population 

Group 2 

Health 

Service 

Health Gain Map 

Education Transport Social care Environment etc. 

XXX X XXX X XX O 

XX XXXXX O X XXX O 

Criteria for Action• Health Gain? 

• Implementation costs? 

• Investment trade-offs? 

• Values? 

Population Health Gain Plan 

Various methodologies can be used to create a health gain map of a particular community or 

geographical area. These include typical health impact assessment methods (1,28,40;), policy 

analysis (5,29,42,49,51,52,56), and simulations (32). Important information can be gathered 

by involving the community in the appraisal. Nominal group techniques, focus groups and 

other methods have proven valuable in this respect (2,10,26,27,74). 

These techniques are particularly useful in identifying the potential contribution to health of 

various policy sectors in a “health gain matrix”. Very often, when different IFH options have 

to be weighed according to a number of criteria. Fig. 3 shows a health gain matrix with four 



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criteria (C1–C4) that have been agreed upon for appraising the options. In the demonstration 

project these criteria included: 

• equity; 

• sustainability; 

• empowerment; 

• overall resources needed. 

The above-mentioned techniques were used in weighing the relative importance attributed to 

these criteria by various segments of the community, policy-makers and other stakeholders. 

Fig. 3. 

Population 

group 1 

Population 

group 2 

Promoting 

Healthy 

Youth 

Healthy 

Ageing 

Mapping Investment Opportunities 

C 1 

C 2 


services 

Social 

services Education Transport Housing Physical 

environment 

+ + + + 

+ 

+ + 

+ + + 

Tools such as the health gain map are very practical in the early stage of mapping 

investment opportunities to promote health across public policy . 



C 3


4.3 The bargaining framework: the Valencia demonstration project 

Policy sectors are not sitting around waiting to be reformed or even advised by health 

experts (21). Motivation for strengthening the health impact of a policy area must exist, be 

fostered, be sufficient to encourage sharing of data and exploration of options that fit a 

sector’s “culture”, and carry no negative consequence (such as additional costs, loss of jobs, 

jurisdictional conflicts). 

These lessons were reinforced in a demonstration project carried out by the WHO Regional 

Office for Europe in southern Spain in cooperation with the Valencian Institute for Public 

Health and the Valencian Regional Government (65). The main goal of the demonstration was 

to explore the possibility of developing IFH alliances with sectors crucial to the economic, 

social and health development of the Valencian region. The identified sectors were health, 

tourism (which represents a major proportion of the region’s GDP) and agriculture 

(historically a very important sector for both culture and productivity and still one of the 

largest economic domains). 

Fig. 4. 



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The demonstration identified shared goals and policy decisions (“D”) among the three 

sectors that would result in gains for all three (Figure 4). The common agenda for IFH could 

be achieved not only through search for “win-win-win” solutions (i.e. “D” decisions), but also 

through other important decisions taken with the IFH approach and placed within a 

“bargaining” policy environment. Thus, the health sector would be prepared to support “B” 

decisions for example financial incentives for developing “agri-tourism”, (win-win for 

agriculture and tourism, no effect on health) as long as the agriculture sector was prepared 

to support “A” decisions, for example, the reduction of urban congestion and pollution 

during the high tourist season (“win-win” for health and tourism) and the tourism sector was 

willing to support “C” decisions, for example, reduction of accidents and mortality in rural 

and agricultural countries (“win-win” for agriculture and health). 

Many tools and techniques can be used by policy sectors as they revisit their development 

priorities and establish new and shared ones, thereby setting a common agenda for 

Investment for Health. These tools include opportunity appraisals, conflict assessment 

analysis, multi-attribute modelling, stake-holders analysis, and behavioural and 

organizational simulations (16,17,19). 

5 Conclusions: what direction for the future? 

The arrival of a new millennium provides a unique opportunity to enhance the health and 

wellbeing of European people. New technologies, better communication and the desire for 

social and economic reform provide the scope for improving health in a radical and 

imaginative way. Decisive efforts should be made by the international community, 

development agencies and government to ensure that these opportunities are available to 

the disadvantaged nations and population groups throughout the world. Inequities, be they 

of health, social or economic nature, should be drastically reduced within and among 

countries. This is a key condition for sustainable investment for health and development. 

For IFH principles to be effectively applied, traditional policy making approaches must 

change. New commitment and skills to work both within and, most importantly outside the 

health sector, and new skills of policy analysis and assessment will all be needed. Each of 

the demonstration projects, as well as the national IFH appraisals outlined in this paper, has 

shown that the challenges of moving from an understanding of IFH to implementing it should 

not be underestimated. It is a huge step from believing that the connections between health, 

economic and social development are real to getting others, including ourselves, to change 

the way we work. Change is difficult, and the forces of inertia are strong, but the potential 

benefits of IFH are enormous. So how can the ground be prepared for cultivating IFH in 

practice? There are some essential developments that need to be fostered: 

1. There needs to be political priority given to health. Health can no longer be seen 

just as a matter for doctors, nurses, their patients and the Ministry of Health. This 

needs to be more than a commitment in principle and words. - politicians need to 

develop a better understanding of the factors that determine health and illness and 

what can be done to address them. For Ministries of Health this presents an 

unrivalled opportunity to take a leadership and advocacy role within government, 

encouraging colleagues with other portfolios to see the relevance of the health 

agenda to their own sphere of activity and interest and supporting them to develop 

the right and political skills to make decisions that improve health. 

2. Beyond political priority there also needs to be clear accountability for health 

improvement across policy sectors and departments. “Health for all is the business 

of all” has become a cliché. As in business, so in politics: there must be 




accountability for results. If ministers, policy makers and managers are to be held 

to account for their successes and failures in health improvement, there will need to 

be more effective ways of measuring health. Unless we can measure improvements 

there can be no accountability. Most countries collect data on mortality and 

morbidity, few focus on positive health indicators. So with accountability comes the 

development of systems, processes and analytical tools to assess health and health 

impacts of policy options. 

3. There needs to be a public understanding of health and how the health of the 

population can be promoted and sustained. Public opinion is too easily captured by 

hospitals and illness. Public understanding and commitment to investments that 

promote health will be essential if politicians are to be able to make the difficult 

decisions that they will need to make. 

4. There are always competing options when decisions are made on an investment. 

This is equally true for IFH. Some options may be obvious; others less so. The more 

IFH is explored, the greater the range of options that will be uncovered. There 

needs to be recognition of the trade-offs between health, economic and social 

development outcomes. Not all stakeholders who have an influence on health have 

health improvement as their main priority. Associated with this is an urgent need 

for decision-making processes that allow those in different sectors to understand 

and make those trade-offs in their decisions. 

5. At all levels of society skills need to be developed in working across sectors. Each 

sector of society has its own interests, goals, resources and ways of working. 

Common action to improve health requires common ground - shared ideas, 

resources, a place to meet. These do not just happen - there must be stimulation 

and processes to bring people, and other resources, together. 

6. New incentives need to be developed. Sectors will not cooperate because someone 

says that it is a good idea. They must see benefits for their own remit and see 

incentives sufficient to justify policy adjustments that may promote health. Political 

drive, tax breaks or special reward schemes might be needed - imagination and 

negotiation certainly will. 

7. A clear picture of what an IFH strategy can deliver needs to address not only what 

is possible at state or civil level but also what individuals and communities can do. 

Bottom up approaches that mobilize community resources can be sustainable but 

they need to have a context within which to work. 

8. New infrastructures may be required to support Investment for Health. But these 

cannot run in parallel to outmoded systems. Far more important is the adaptation 

of the current infrastructure to sustain IFH. (see also the Technical Report on 

Infrastructure for Health Promotion). 

9. A new data set of Investment for Health indicators should be developed. There is 

still a paucity of health/salutogenic indicators (as distinct from disease/pathogenic 

indicators) used at the global, national and local level. Such indicators ought to 

include measures relating to the determinants of, and assets for, health. National, 

regional and local governments should publish regular reviews of progress on 

health improvement and social and economic development against clear indicators 

of success. 

10. Crucial to all the above is a willingness to learn about how to make IFH work. 

WHO’s Verona Initiative and this Forum in Gastein have unique and fascinating 



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roles in facilitating cross-fertilization of ideas, practical experiences and research 

findings across countries and governments. 

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Introduction to Parallel Forum Sessions 

Paul Lincoln 

Speech not available. 




Forum I: Health in other Policies and 

Sectors 


John Bowis 

My theme is partnership and how to work together to take account of the impact of other 

policies on health – not just the damage that such policies can do to health but the positive 

contribution they can make. And by policy I mean the plans and actions of governments, 

councils, employers, communities and, indeed, individuals. 

When I was a national MP we had a disastrous rail crash in my constituency. What was 

impressive that morning was the cooperation of all the agencies to deal with the crisis. 

Medical teams alongside fire, police and local council personnel and all the back up from 

canteens to blood transfusion services. They were all working for health – after considerable 

forward planning – yet the headlines were all about transport. I doubt if many transport 

officials that day realised they were involved in health activity. 

In Paris at the IUHPE conference this summer I recalled visiting in my London Constituency 

an elderly lady sitting watching television with the sound off. 

I asked her why and she said she was rather deaf and could not hear the sound. Could I ask 

someone to see if she could get a better hearing aid, I asked her. 

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 disability problems. 

Neither resolved because the two agencies concerned had not had the nous to talk to each 

other. 

Another day another constituent. 

He was suffering from depression, living in a modern sheltered flat. He had previously lived 

in very poor housing on a run-down estate but, he said, he had been happy there. 

He knew people; he knew the neighbourhood and every Saturday night he played the piano 

in his local pub. 

Now he had been moved by well-meaning housing officers to a lovely flat but where the 

rules did not allow him to practice his piano. 

So he sat there, his fingers growing stiff and his life made miserable. 

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 or disability 

problems needs. 

Nor is it just services that need to work better together. 



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Government Departments rarely talk to each other and are fiercely possessive of their 

individual budgets. 

Trying to persuade Health, Education and Social Services to come together to share 

responsibility for children and adolescents with mental health needs, was a nightmare I 

fought every day, yet the child concerned needed an input from all three services. 

Now I am in the European Parliament and the same failures to form partnerships are 

apparent. 

As I said at Gastein last year – and will go on saying until we achieve results - 

if the European Union decided next week to spend billions of Euros processing heroin or 

marketing lead toys, I think I can guarantee an army of men in white coats would descend 

on Brussels and take us all away for treatment in a secure institution. 

Yet the biggest obstacle to progress on health in Europe and the success of the European 

Union’s new proposed Health Action Programme is lack of money to spend on implementing 

it effectively. 

And the biggest reason for this is that, while we propose to spend a tiny, tiny sum on health 

of Euro 50million a year for six years, we are content to increase our spending on growing 

tobacco to over Euro 1,000 million a year. 

Euro 6,000million to sponsor a known killer, a waster of lives, the biggest single cause of 

cancer and heart disease and just Euro 300million to cover all the ills of our European world 

that flew out of Pandora’s Box. 

It is immoral and ludicrous economics. 

And why does it happen and why is it so difficult to correct? 

It is because tobacco subsidies come under the Common Agricultural Policy and Ministers, 

MEPs and Commissioners from the countries that grow the stuff are more interested in the 

votes of farmers than they are of the health of their citizens. 

But now we have a 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. 

I believe that Europe needs a Health Wake Up Call. I wrote the Report for the Parliament on 

the Health Impact of Enlargement and set out the problems that most of the countries of 

eastern and central Europe had in maintaining health standards at a time of economic 

difficulties. 

The health systems are not just breaking down there, they are crumbling within our current 

EU, under the pressures of demographic change (with people living longer); and of the pace 

of scientific advances in medicine (with a new drug or treatment, often very expensive, 

immediately causing a new queue to form); and of an increasingly well informed public, who 

demand instant access to what is available and look for compensation if drugs or treatment 

fail them. 

To meet that challenge we need imaginative and cooperative partnerships 

• health professionals; and social workers; and housing officers; and benefit 

managers; and trainers; and employers; and advocates; and service users; and 

families; and NGOs; and planners; and architects; and teachers; and all 




• a one stop shop of care and support. 

I am a politician – one of those who are often portrayed as ‘Them That Will Not Hear’ 

• the Politicians, Governments, Commissioners, National and International authorities 

and agencies, 

• that have the power to do something and the purse to make things happen 

• But if we do not listen, we cannot hear and understand. 

• And we were only blessed with two ears each. 

Those ears are dominated by media and constituents’ concerns on floods, wars, rail crashes, 

traffic gridlocks, crime, drugs, food safety, animal welfare and all the “big” stories of health – 

shortage of cancer specialists, AIDS, intensive care beds, CJD and we don’t see the 

connection.. 

And as to Health promotion, there is little understanding by governments, politicians or even 

health service planners. 

The main reason is they have no idea what it is about or why they should be interested. 

So, when trying to convince my colleagues, I start from the other end. 

Start from the end, which hurts in government. 

Start from the cost of not doing anything. 

Start from the fact that 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. Start from the 

fact that, although the number of carers is steady, it is a fact that, whereas they used to be 

next generation, now they are same generation - spouses, partners and friends - who will 

have problems of their own, and may be unable to cope without support. 

And if they can’t cope, the taxpayer will have to. 

And then go on to promote the reasons for investment in health: 

• If fewer people smoke, you cut the cost of cancer services. 

• If more people eat and drink and exercise sensibly, you cut cardiovascular service 

costs. 

• If motorists drive at an appropriate speed to their environment, A & E costs less. 

• If housing policy cuts overcrowding, it also cuts the cost of TB. 

• If families in difficulty are supported earlier, you cut the cost of child and 

adolescent mental health services, by reducing the number of children with 

behavioural or, perhaps, eating disorder problems. 

• If employers have in place effective mental health-at-work policies, with, for 

example, non-threatening and confidential counselling services and flexible work 

schedules for carers, they will have employees who, individually are more able to 

cope with their own or their family’s mental health problems and who are therefore 

more able to contribute to a collectively more productive workforce. 

And perhaps light begins to dawn in the hardest of Finance hearts. 

Investment in health promotion can save us money later and enable us to pay for those 

illness costs, which we began to fear might never be affordable. 

Then we may all understand a little better that the problems of the day are a seamless 

health message. 



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• crime, drunkenness, accidents, absenteeism, street hooliganism, disruptive pupils, 

rough sleepers, beggars, neighbourhood noise. 

• Get that message across and practitioners and policymakers are astounded to find 

themselves on the same wavelength. 

• All health in origin or in effect. 

In my home city of London, a recent survey showed nearly a third of rough sleepers to have 

been discharged from the armed forces and found themselves unable to cope with civilian 

life. 

Whether the figures are wholly accurate or not, it shows even Defence Ministries have a role 

in Promotion and Prevention. 

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, is that you have someone leaving the 

army and being helped to cope with his new life. 

Any employer knows a fit and happy and informed workforce repays the investment through 

productivity, 

just as any sporting team manager knows his investment in the mental as well as physical 

fitness of his team will be returned in goals. 

My argument is that we have to look beyond the health and social care professionals; 

beyond the drugs and therapies; 

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. 

Policies for ageing work – not just policies for pensions and care but looking for ways in 

which retired people can find a role and be useful, in social and educational contexts, for 

example – and preparing people for the moment they leave the place of work they may have 

been going to for 40 years 

Collaboration between agencies can work, not just in support of an individual, but to screen 

out health risks, to identify cross-discipline problems and to ensure appropriate dual 

diagnosis and treatment. 

The Treaty of Amsterdam of course gave us a new tool – the Health Impact Assessment. If it 

works, it will make other policy areas stop and think how their sparkling new policy might 

impact on health. 

If it works, they will start by being more conscious of the negative impacts it might have. 

If it really works they will go on to understand the positive contribution their policy could 

make to the health of the nation and of Europe. They will realise that as decision makers in 

governments or commission ‘we are all health ministers or health commissioners now ‘. 

But we are at the drawing board stage – that critical point when we have to get the design 

and measurements right for the system to be effective. 




Does the media have a role in promoting health policy and bridging 

the gap between policy and implementation? PR or “ER”? 

Shirin Wheeler 

Abstract 

My position - as a member of the news media and in particular television- stems from the 

premise that it is not up to the media to bridge policy / implementation gaps. It cannot be a 

propaganda tool for government, politicians or the medical profession. 

You cannot rely on the media to disseminate information on health policy. The message the 

media seizes upon may not be the one you believe is most important as a policy maker. 

But as a policy maker bridging these gaps successfully will somewhere along the way involve 

the media. When the issue and its relevance to policy is translated into pictures, radio and 

popular press its impact can be enormous . Television for example has the potential to 

articulate visually and verbally making links between health issues and other policy sectors 

for example respiratory illness and transport policy in ways 


Carlos Ribeiro 

Abstract and speech not available. 


Bosse Pettersson 

Abstract 

In Sweden a green paper – “Health on equal terms” – for a national public health policy was 

published by a Parliamentary Committee in December 2000. It presents 18 broad national 

objectives, further broken down into 50 sub-objectives to which proposals for indicators are 

linked. 14 of the broad objectives are expressed in terms of health determinants and the 

remaining 4 deals with basic infrastructures for public health. The Governments white paper 

is planned to be presented to the Parliament in December 2001. 



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Tackling the determinants of health implies a multi-sectoral approach. This has already been 

settled in the field of environment, where national state authorities are given the 

responsibility to accomplish the environmental requirements that falls within their remit 

respectively. The National Public Health Committee is using this approach as a model. 

Simplified the rationale is built on a 3-step sequence: 

1. Identifying scientifically based determinants of health and in particular their impact 

for increased equity in health, 

2. Undertake appropriate actions in different sectors on different societal levels, 

3. Follow up health outcomes by monitoring indicators and using comprehensive 

measures for (ill)health. 

Important tools and mechanisms for placing health in other polices are considered to be: 

� Establishing a structure in the Government’s Office in which public health 

issues are managed horizontally, 

� Directing and guiding national state authorities according to the national 

public health strategy by putting the responsibility for relevant health 

determinants as part of their remit, 

� Developing a solid and politically strong monitoring mechanism. In 

addition to a public health report a report on the development of healthy 

public policy is proposed, as a resource for the Government to report on 

Public Health to the Parliament once every 4th year, 

� Implementing health impact assessments (HIA) in major issues as part of 

the decision making process, and local welfare management systems for 

integrating health in municipal comprehensive planning schemes, 

� Establishing structures for facilitation, collaboration and co-ordination 

between different authorities, agencies and other actors on different 

societal levels. A living and open debate and dialogue is fundamental to 

build credibility around a concept where health should be part of many 

considerations. 



Mike Ponton 






Mojca Grunter Cinc 

Abstract 

Although Slovenia is a small country it is extremely diverse in terms of geography, culture, 

health, economic and social development. Today, the country is in the process of 

consolidating and completing its transformation to a competitive market economy, with the 

ultimate aim of improving the living standards and quality of life of its citizens and joining 

the European Union. 

After independence, Slovenia’s political, economic and social systems have undergone 

profound changes. These changes have also effected the health care sector. These 

developments offer the opportunity to consider the potential contribution of health as a 

resource for social and economic development of a young country like Slovenia; to move 

health policy beyond health care. If the health of a population will be regarded as an 

economic asset then health promotion will be seen as economic investment. 

Health is determined by the interplay of wide-ranging factors. To achieve population health 

gains broadly based strategy must be employed which requires concerted action by many 

different players, including government, many sectors of society, the media, nongovernmental 

organisations and other public and private bodies which contribute to 

economic activity, social cohesion and human rights. 

In 1995, the Parliament of the Republic of Slovenia invited the Intersectional Health 

Development Unit (Health Promotion and Investment Unit) of the WHO Regional Office for 

Europe to assess Slovenia’s health promoting resources, supporting infrastructures, the 

efficacy of existing collaborations, and the options for decision making. The main conclusion 

of this group was that Slovenia has great potential for implementing a robust investment for 

health approach which is in synergy with its economic and social priorities. 

Slovenia joined the Verona Initiative with an aim to further develop and disseminate basic 

health promotion concepts and investment in health approach at the local level which was in 

line with proposed WHO recommendations. Furthermore, the process of development and 

testing the practical tools like benchmarking system to support politicians, policy-makers and 

practitioners in implementing the investment in health approach was appealing. 

The main lessons learned from the exercise of testing the benchmark model at the local level 

in Slovenia will be presented. Also the broader impact of the process at the national level 

will be highlighted. 




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Luigi Bertinato 


Abstract 

All too often, discussions on health policy and healthcare focus on cutting costs and not on 

improving health. The Verona Initiative: Investment for Health, in contrast, took a lesson 

from the economic and financial sectors and proposed a new approach to health policy, one 

based on the principle that the right investments can benefit all sectors and all citizens. 

With solid evidence from the past years that most of the determinants of health lie outside 

the health sector, it follows that to change health status, governments must invest (time, 

effort and money) wisely and carefully to have the desired impact on health status. This was 

the case of the Regional Government of the Veneto, one of the twenty Italian regions 

situated in the north-east of Italy, with a population of 4.5 million inhabitants. 

The First Milestone: Appraisal and Benchmarking 

The Verona Initiative revolved around three Arena meetings that served as a forum for 

debate and consensus. Meetings were held in Verona, one of the seven major cities of the 

Veneto Region, in 1998, 1999 and in July 2000, bringing together an unusually broad 

spectrum of participants in person and via satellite TV and the Internet for a non-traditional 

conference. 

The first meeting established the Verona Benchmark, which identified characteristics of 

systems that support Investments for Health. 

A document called the “Verona Benchmark” was developed for health and health system 

appraisal in a number of pilot projects. The objective was to determine what systems would 

need to exist at national, regional or local level for a government to implement the IFH 

approach. 

The appraisal examined the overall situation in the country or region, undertaking a sectorby- 

sector analysis of policy options for intersectoral considerations, and explores structural, 

organizational and institutional issues. 

Policy-Making and the Verona Challenge 

The second Arena meeting established the characteristics of the decision and policy-making 

process needed to promote IFH. Essentially, the process can be viewed as an investment 

triangle where social and economic development anchor two points of the triangle and 

health promotion holds the third spot, illustrating the main principle of IFH: that investments 

intended to improve health must also add economic and/or social value. 

The third and final meeting focused on how to persuade policy makers to take action. It 

issued a series of “challenges” that define the next steps and in effect suggest priorities for 

health: 

Highlights of the challenges include: 

• For national governments: establish a clear mechanism for coordinating policy 

development across government departments; establish a communication strategy; 

publish regular reviews of health improvement progress against indicators. 

• For local and regional authorities: establish targets for health improvement linked 

to sustainable economic and social development; engage the population in 

decisions about health; ensure integrated local and regional investment plans. 

• For industry and commerce: work with government to support initiatives 




• For international agencies: develop mechanisms for transferring learning between 

countries; provide advice on developing indicators for success, including tracking 

health impact assessment. 

• For nongovernmental organizations: mobilize community organizations and 

advocate for including health in all public policy 

• For the media: create a climate for action; hold decision-makers to account 

• For the healthcare system: reorient health services to place greater emphasis on 

sustainable economic development, health promotion and community health action; 

recognize that health is determined by policies and actions outside the healthcare 

sector 

The experience of the Veneto Region to impact some of the principles of the Verona Initiative 

into its health care system will be presented during the session. 


Summary Report of Forum I 

Cecily Kelleher 

Summary 

The objectives of this forum were threefold; to reflect on conditions necessary to move a 

given policy from objective to implementation, to provide practical exemplars or accounts of 

the development of multi-sectoral policy development in Sweden and Wales and to describe 

in Italy and Slovenia (a member and applicant European country respectively) the application 

of a benchmarking system for the implementation of a multi-sectoral policy. Each example 

highlighted the particularity of the context in moving policy forward, the need for pragmatic 

inter-sectoral alliances and the surprising progress that had been made, at International, 

National and Regional level, because of the commitment of players across sectors to the 

promotion of the public health. The fine balance between epidemiological evidence and 

effective implementation strategies was emphasised. 

The lesson for others in studying these examples is not so much why the various 

stakeholders have ignored the healthy public policy agenda, but rather, why so much 

progress has been made. The often silent partners, that is, the civil servants, have been 

much involved in operationalising this inter-relationship between elected representatives, lay 

groups, experts, statutory and non governmental organisations, often entailing a change in 

their own role to a more facilitatory one. The question of ethical practice was raised in a 

number of contributions, particularly the balance between the rights of the individual and the 

need to act at community level for the good of society as a whole. A re-examination of public 

health ethics is both appropriate and necessary. Finally the whole question of the meaning of 

health promotion was highlighted. Rather than compartmentalising it as a lifestyle education 

function, in this forum and in the meeting more generally, it means what the Ottawa Charter 

(1986) conception envisaged, a process contributed to by many players within the health 

sector and beyond, with re-oriented public policy a key component. 



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Background 

The determinants of population health are outside the control of any form of individual-level 

health care system, although self evidently it has an important contributory role (1). Crosssectoral 

collaboration is therefore not simply rhetoric but a pre-condition to the desired 

outcome, that of good health. We live in a paradoxical age, which we need to recognise and 

live with, rather than necessarily change. Particularly over the last 50 years the world has 

become a smaller place in social terms. We are more closely inter-linked and interdependent 

than ever and we have never had such unprecedented access to knowledge. 

However, we have become all the time more compartmentalised in how we deliver on any 

goal, in a climate of expertism and defined roles (2). Especially in the working world we 

define our identity as individuals through those roles. The process of policy implementation 

becomes one of complex negotiation between vested and responsible interests, often at a 

remove from the strategic objectives. Cross-sectoral strategies accordingly must strike a fine 

balance between the overall strategic objective and the practicalities of the situation at 

operational level. Each contribution at this meeting reflected this fact. 

Session 1: Bridging the gap from policy to practice and awareness 

This comprised contributions from three professionals in different roles, the politician, the 

media representative and the expert policy committee member. 

John Bowis, a current member of the European parliament and a former health minister in 

the United Kingdom, opened with practical, anecdotal examples in his constituency 

experience of how a failure by different service providers to the same individual to interrelate 

can have an all too human cost. He highlighted the paradoxes at public policy level 

that can occur through this same failure to communicate. For instance the 1800 million Euro 

budget for health research is both relatively modest and considerably less than the subsidy 

in the equivalent period of 6000m euros to the tobacco farmers in the EU region. This 

paradoxical situation is explained by the reality that the politician delivers to his 

constituents, in this case the farmers. The challenge therefore is to ensure an informed public 

who will require from their politicians what they actually need. Health Impact assessment is a 

useful potential tool because it can be used to make an understandable case for a given 

policy to the general public. A useful practical way to persuade the finance minister, who is 

not concerned primarily with the health agenda, to free up resources is to point out the cost 

of not doing anything, in a wider social rather than purely monetary, sense. Shared 

knowledge is a form of empowerment in expanded networks like the European Union, so 

that people now compare service provision across countries rather than within their own. 

Shirin Wheeler, an experienced journalist, indicated that the media have a role in equipping 

the public to deal with health issues, by informing them of what is current. Media personnel 

have no obligation to promote health in itself, nor are they propagandists. However there is 

potential for mutual collaboration between the health sector and the media, with the shared 

goal of empowering the public. The television medium necessarily distils complex messages 

into succinct short presentations, averaging reports of two to 3 and half minutes. She used 

a short report from North Karelia as an example, which combined eye-catching scenery, with 

human-interest stories and credible expert comment. The media can add impetus to an 

existing public health campaign. This works best where there is a climate of trust and 

mutual understanding of each other’s roles. The media have an obligation to entertain and 

inform in a novel way, and without strong top line facts, such as in this case apparent 

evidence of a major effect (3), such a story is not news and couldn’t be made. 




Carlos Ribeiro presented the position of the EU Economic and Social Committee in relation to 

health policy, particularly with the signing most recently of the Amsterdam treaty. He 

highlighted article 3, which stresses that health protection is guaranteed across policies and 

activities. He noted the community action programme for health for the years 2001-6. This 

includes the need to ensure increased information and knowledge of citizens across the EU 

region, to increase capacity both for a rapid action response to threats to health and to 

eliminate potential risks to human health, (whether spontaneously generated or, in part, as a 

consequence of the open market and borders across the region). The committee regretted 

the fact that while health impact assessment will go ahead as a measurement tool, the 

fourth provision of the Health Action plan, the need to take account of the health impact of 

policies generated in other sectors, had not been implemented. Integration of health 

considerations in the way envisaged by the health plan must necessarily take account of 

ethical considerations, such as the right to privacy of the individual. This in turn opens up 

the wider question of an appropriate ethical framework at every level to address these 

increasingly complex public health considerations. There is a need for partnership with 

existing organisations and quangos with a public health function, not least to avoid 

duplication of effort. 

Session 2: Experiences from Sweden and Wales 

Session 2 contrasted the experiences of public health policy development in both Sweden 

and Wales, both countries with a strong record of attempts to implement healthy public 

policy. Bosse Petterson works at the National Institute of Public Health in Sweden and is 

advisor to the secretariat of the parliamentary committee in Sweden whose work is now at 

the final stage of an almost 4 year process. The proposals will be presented to Parliament in 

December and will be launched formally next March. He opened his presentation with some 

useful general remarks. First, he likened policy to an obstinate stationary elephant. This 

means that we in the health sector may wish for policy to take a certain direction, but it is a 

matter of negotiation with a different type of animal to ourselves, rather than an imposition 

of will. There may also be good examples from different sectors. In Sweden the road traffic 

strategy is an effective example from a different sector of a move away from individual level 

behavioural education to more supportive environmental changes, with the ultimate zero 

goal that no-one should be killed or injured on the roads. He also described the 

terminological evolution of the last 25 years. Inter sectoral as understood in Health For All 

(World Health Organisation 1984) meant that the health sector took the lead and explained 

the need for actions to other sectors. In Health 21, the term multi-sectoral meant now 

showing the self interest for other sectors in taking account of the health impact of policy, as 

in the case of the response of the food industry to consumer demand. Finally, integration, 

as used in this meeting, means that the health sector aspiration must be matched to what is 

the existing strategy goal in the partner sector. He used the Swedish political and public 

health organisational structure to demonstrate both the vertical and horizontal aspects of 

policy. Vertical approaches for instance must take account of the autonomy of other bodies. 

Mainstreaming had already successfully occurred in Sweden with other issues such as gender 

equality, sustainable development and the rights of children 

The committee was based on a parliamentary process, had a selected chair and included 

scientists and stakeholders. Sweden is probably unique in publishing a series of consultation 

reports as part of this process. This transparency in itself was seen as an aid to the policy’s 

ultimate acceptability to all stakeholders, including the public and to its ultimate successful 

implementation. A strong emphasis was placed on the evidence base and an epidemiologypolicy 

model was developed. 16 expert groups, generating a very thoroughly documented 

database for decisions made, examined the determinants of health. This in turn facilitated 



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the planning of interventions and the setting of goals or outcomes. The final policy shape 

was represented in pyramidal terms. At base was the fundamental goal of health on equal 

terms for all. In turn this constituted 6 overarching guidelines. These were translated into 8 

working goals, a further 50 sub goals and 115 candidate indicators for use in monitoring the 

success or otherwise of the policy. This offers the possibility of wide-ranging action at 

primary care and health promotion level, facilitates inter-sectoral action by clarifying the roles 

and responsibilities of all in achieving outcomes, provides a feasible working framework for 

health impact assessment and facilitates intermediate evaluation. The policy will set out a 

plan of action up to 2010. This process also revealed underlying ideologies and challenged 

politicians in particular to examine their social values in relation to the solution proposed. 

Political patience with the pace of the process was helped in large part by the preparation of 

the need for this approach by the responsible civil servants and others. 

Mike Ponton is a member of the new Welsh assembly and responsible for the new Welsh 

strategy. By contrast with the Swedish experience, the period of policy development was 

short, less than six months, because the need was already established, the challenge lay in 

consulting on the process of implementation. This meant clarity about milestones and a 

means of learning from experience and modifying the agenda accordingly. Better.Wales.Com 

is an all-embracing strategy in many ways, that aims at improving the overall quality of life, 

so that what would emerge was a prosperous, healthy, well-educated country. In this sense 

health impact assessment would be, or indeed had already become, a way of life that 

conditioned thinking not just of politicians, but also of officials. It meant a change in the 

nature of the public servant. Now all heads of function have to work not just to their own 

brief but also as a concerted team. In the case of the public health strategy people had to 

be persuaded of its personal importance to them as individuals, so that agenda setting was 

driven by this. Issues like workplace or housing standards rose to the top in this process. 

There was also a pragmatic realisation that if we do not proactively manage change it will 

happen in some forms anyway. It was not just about reforming the National Health Service 

but re-positioning it. In following this investment for health concept, well-being becomes 

hugely important and community development a key. It was about putting individuals in 

context. 

A major distinguishing feature of this system was the separation out and doing away with, 

layers of bureaucracy. In effect the five regional boards were abolished, with a National 

structure and 22 local authority/local alliances. In this structure it is all-important to improve 

democratic participation in decision making by stakeholder representation. A process of 

listening to what local people were saying was brought about, as well as ensuring local 

accountability for decision making. A means of achieving this has not been finalised but 

statutory partnerships governed by legislation are envisaged. In this sense it is very much a 

bottom up structure, feeding these various local plans into an aggregated national plan. It 

therefore has three hallmarks, a bottom up approach, a framework of health impact 

assessment and means of delivery in place with a system of accountability. This aspiration 

of a “people’s NHS” is an example of progressive management to make a difference. 

Both these National approaches take account of the relevant contribution of expertise and 

the need for meaningful consultation and both contain both top down and bottom up 

elements. However the Swedish model appears to hinge crucially on evidence underpinning 

credibility, whereas the focus in the Welsh model is on the need to involve and deliver. This 

difference in emphasis may be explained by the historical differences between the two 

countries. Both have a strong epidemiological tradition but Sweden has a history of 

participatory action in other sectors whereas this type of process is perhaps more novel in 

Wales. 




Session 3: Measuring progress and impact 

This concerned a description of the WHO supported Verona initiative (4), both in the 

eponymous region of Italy and adapted in the context of Slovenia, that attempts to take 

account of the economic, social and human environment. Verona is a province of 250,000 

people in the North east of Italy. Luigi Bertinato indicated that here had not previously been 

a tradition of inter-action between the health sector and others. An objective of the project 

was to create an arena of debate between various sectors and to compare and discuss 

experience of various health issues. It was intended to create a true European multidisciplinary 

learning and working environment. For instance three themed meetings between 

1998-2000 on macro trends and their relative impact and the positioning of health promotion 

for the 21st century were debates, rather than conferences, with an ongoing chat line system. 

The concept of investment for health was not new to the Verona initiative but had been 

developed over 5-6 years at WHO Copenhagen. It was concerned with planning the political 

process for achieving the necessary changes in population health. This included identifying 

relevant policy attributes, considering factors that might enhance or inhibit policy change and 

identifying what sectors to involve. By contrast with the epidemiological model of study, the 

initiative was concerned with the means of implementing their findings. This meant dialogue 

on how to choose local partners, how to explain it to these and how to win their 

involvement and support. After 3 years of debate the Verona benchmark guidelines were 

produced. These included identification of means of monitoring success, adopting a 

sustained approach, accountability, and putting an emphasis on high priority for health, 

social capital for health and a process of public engagement. This entailed seven system 

characteristics that were hallmarks of good practice. Finally he highlighted and discussed 

concrete initiatives. The process of discussion meant a completely new health promotion 

structure and a new observatory system for the elderly population. The use of an existing 

surveillance system, in this case the international HBSC survey (5), highlighted social 

variations in health behaviours, directly responsible for persuading politicians to fund a 

drugs prevention programme. Challenges include shifting theory to practice, and the need to 

introduce a new vision of public health among health professionals themselves. 

Moyca Grunter Cinc is under secretary for health in Slovenia. This small country of 1.9 

million people has undergone major social, cultural and economic change since its 

independence 10 years ago. Not alone do these changes affect health care sector provision, 

but also the population health. There have been major changes in health status in Middle 

and Eastern Europe in the last decade (6). In 1996 a WHO Euro appraisal was undertaken 

and between 1998-2000 they were participants in an adaptation of the Verona initiative. 

Slovenia joined pilot in Benchmark 2 at local level. Main aims were to assess the readiness 

of administrative areas to implement an investment for health approach and testing an 

appropriate needs identification tool. Main lessons learned included the fact that health is 

perceived as the responsibility of the traditional health sector, with limited existing 

collaboration, a lack of appropriately qualified public health specialists and a lack of formal 

organisational structures. This was balanced by willingness for involvement. Since then 

developments have included a broadening of the minister for health’s title to include health 

care, the establishment of a number of inter-sectoral agencies and the active involvements of 

ministry of health in inter-sect oral action. These two examples therefore illustrated that the 

shared principles of cross-sectoral collaboration and re-oriented health professional practice 

could be applied in two markedly contrasting social and political contexts. 





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References: 

1. World Health Organisation. The Ottawa Charter on Health Promotion. Copenhagen 1986 

2. Kelleher CC. Theories, Values and Paradigms: Reflections on the Fourth World Conference 

on Health Promotion in Jakarta. In: Edmondson R and Kelleher C. Health Promotion. 

New Discipline or Multi-Discipline? Irish Academic Press. Dublin and Portland, Oregon. 

2000. 

3. Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinen A. changes in premature deaths 

in Finland: successful long-term prevention of cardiovascular diseases. Bull World Health 

Organ 1998; 76(4): 419-425 

World Health Organisation Euro Home Page. The Verona Initiative Website. http:// 

www.who.dk/Verona/main.htm 

Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J (eds). Health and Health 

Behaviour among Young People. WHO Policy Series: Health Policy for children and 

adolescents Issue 1. International Report. Copenhagen 2000. 

Kelleher CC. Editorial: Evolution of cardiovascular risk factors-light at the end of the tunnel? 

Wiener Klinische Wochenschrift. The Middle European Journal of Medicine. 2001; 113 (15- 

16): 552-557. 




Forum II: Globalisation, World Trade 

and Health 

The Forum was structured as an enquiry process. Expert witnesses were called to make a 

statement of the facts from their particular point of view to a representative panel of 

stakeholders. Delegates had the opportunity to feed questions into the enquiry process and 

were called upon to actively participate in the open floor debate 

Introduction - Health and Free Trade Conflict or Synergy 

Julius Weinberg 

The possibility that there might be conflict between commerce and health has been 

recognised for many centuries. For several hundred years the only effective measure to 

combat infectious disease was quarantine, a restraint on trade. As the plague swept across 

Europe in the epidemics of past centuries quarantine, the closing of town gates and the 

isolation of communities was a common response. Attempts to regularise the international 

response to infectious disease were the major drive to the development of international 

collaborations in health. However the first International Sanitary Conference in 1856 

foundered for two main reasons, first there was no understanding of the microbial basis of 

infectious disease and secondly because some of the participants, particularly Britain saw 

attempts to control infections disease as infringing free trade. 

Since this time balancing the interests of trade with the interest of disease control has 

proved problematical. The International Health Regulations explicitly state that any measure 

taken should be the minimal appropriate for the control of disease and that there should be 

least possible disruption of trade. 

As International trade and travel has increased and as the problems associated with 

infectious disease have reduced the problems have become more complex. Now the concerns 

include the internationalisation of non infectious threats to health, and the responses to 

those threats. 

The Internationalisation of potential threats to health is associated with trade in food and 

other commodities such as tobacco, pesticides, GM crops; the internationalisation of the 

response is associated with the trade in pharmaceuticals and health related services. 

The essence of the conflict is based upon: 

• That local authorities should be able to undertake appropriate measure to control 

threats to health. 

• That there should be minimal impediments to trade and that there should be a 

“level playing field” in health with regulation of standards. 

These two principals will inevitably be in conflict on occasion. 

There is little in International Law which is primarily concerned with health – the International 

Health Regulations are only concerned with Yellow Fever, Cholera and Plague. Whilst there 

are a large number of International Laws and Regulation in the area of trade – some of these 

might include a health element. 



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World Trade Organisation 

The World Trade Organisation was established under the Uruguay Round of the General 

Agreement on Tariffs and Trade (GATT), passed in 1994. The WTO is a permanent 

institutional structure with provisions beyond the usual area of trade agreements (tariffs and 

quotas) and includes provisions which concern domestic public health, food safety, 

consumer, worker and environmental protection policies. The agreement constrains members 

to “ensure the conformity of its laws, regulations and administrative procedures with its 

obligations as provided in the annexed Agreements.” 

The WTO provisions assert that “domestic health, safety, and environmental policies must be 

designed in the "least trade restrictive" manner and national laws and standards should be 

standardized internationally so as to maximize economic efficiency in cross-border trade.” 

Standards providing more protection to consumers or public health or local communities or 

the environment can be challenged as unfair barriers to trade. The WTO has provision for 

global standard setting, which takes place in international standard-setting institutions, and 

equivalency agreements, 

global standard setting: Specific international standards are set by organisations such as 

the International Organization for Standardization (ISO) in Geneva and the Codex 

Alimentarius Commission (Codex). ISO, which sets product and manufacturing process 

standards, is a private sector organization, funded by industry and largely comprised of 

industry representatives. Codex, consists of governmental representatives, but with an 

important formal role for industry. Participation by health or consumer groups in both is 

limited. 

equivalency agreements, Regulatory systems and standards in other countries can be 

declared "equivalent" to domestic regulatory systems. Once a foreign system is declared 

"equivalent," it must then be treated as if it were a domestic system. Mutual Recognition 

Agreement (MRA) is a reciprocal agreement between nations which allows one nation to rely 

on the other's verification that a product meets a required standard. 

"Codex Alimentarius" . The Codex Alimentarius Commission (Codex) is recognized by the 

WTO for setting global food standards. It was established as a voluntary standard-setting 

body in 1962 by the World Health Organization and the U.N. Food and Agriculture 

Organization, to facilitate international trade of food and agriculture products. Codex is 

officially comprised of government representatives, with active and formal assistance from 

official industry advisors, who serve as actual members on country delegations. A 1993 study 

showed that over four-fifths of the nongovernmental participants on all delegations to Codex 

committees represented industry, while only one percent represented public interest 

organizations. 

International Organization for Standardization. The International Organization for 

Standardization (ISO) in Geneva is a private, industry standard-setting body. The ISO has 

been recognized by the WTO as the presumptively-legal international standard setter for all 

non-food products. ISO started in the 1950s to standardise sizes for consumer products to 

help industry expand markets (i.e. batteries). ISO's areas of interest have expanded and 

now include standards for environmental products, eco-labels, and humane fur trapping 

standards, ISO is now developing additional standards that focus on management practices. 

Disputes 

Disputes under the WTO are decided by tribunals comprised of three trade experts, chosen 

on the basis that has been criticised as ensuring that panelists will have a favorable view of 




current trade rules. For example, to qualify for a WTO tribunal a person must have worked at 

the GATT or WTO or represented a country there, with limited exceptions. 

General Agreement on Trade and Services 

Since the meeting on international trade rules in Seattle in 1999 talks have begun to 

strengthen one of the 28 agreements overseen by the WTO – the General Agreement on 

Trade in Services, GATS. GATS covers sectors of the economy like banking, construction, 

education, insurance, retail, telecommunications, tourism, health or waste disposal. 

Via GATS, private companies can insist on being allowed to enter the market for publicly 

funded services. In the countries of the OECD public expenditure on health services and 

education accounts for 13% of GDP. Much of this goes to public or voluntary bodies but 

could end going to for-profit groups. As of 1998, 59 countries had put one or more aspects 

of their professional (medical, dental, veterinary, nursing, midwifery, physiotherapy) services 

or health-related and social services (including hospitals) under GATS. 39 countries had 

agreed to open up hospital services to foreign suppliers. 76 countries have made financial 

services sector, including health insurance commitments. 

“We believe we can make much progress in the [GATS] negotiations to allow the opportunity 

for US businesses to expand into foreign health care markets . . . Historically, health care 

services in many foreign countries have largely been the responsibility of the public sector. 

This public ownership of health care has made it difficult for US private-sector health care 

providers to market in foreign countries.” The US Coalition of Service Industries. 

TRIPS 

The WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) covers 

a wide range of subjects, copyright and trademarks as well as patents. A patent on a 

pharmaceutical product can cover the product or the manufacturing process if these can be 

shown to be novel. The aim of the patent is to reward the inventor and enable research 

costs to be recovered. Once the patent has expired, other companies can make the drug – 

these “generics” are often cheaper as they do not have to cover the research element, 

furthermore competition lowers the price. 

TRIPS standardises the use of patents, so that all WTO members have to grant patents for 

twenty years, previously some countries had shorter periods and could therefore permit the 

production of generics. All countries including those which had not had patent processes will 

be expected to implement the provisions of TRIPS 

There is concern that the attempt to balance the interests of public health with the interest 

of innovators is tilted towards the pharmaceutical industry and that without access to 

generics new drugs will remain too expensive for poor countries. Furthermore the generics 

manufacturers in developing countries will be adversely affected. TRIPS also allows for action 

to be taken against countries with patent laws which are perceived to be inadequate. 

The are some safeguards for protecting Public Health interests within TRIPS. 

Governments can set justifications for compulsory licensing which could include a “national 

emergency”, however this is not clearly defined. The TRIPS Agreement says products made 

under compulsory licences should be “predominantly for the domestic market” however 

some countries may not have the capacity and wish to use compulsory licenses for import. 

Parallel imports are also allowed and this may keep process down however there is concern 

that this might lead to re-export of cheaper products. 



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Key Issues 

There are a number of key issues that are of concern 


• The relationship between objectives which further trade and those that serve public 

health objectives – to what extent are they in conflict. 

• Does trade liberalisation improve health and reduce inequalities in health 

• What are the respective rights, responsibilities and capacities of the private and 

public sector 

• Should international standards serve as a ceiling or as a floor that all countries 

must meet. 

• What assessments have we got for the efficacy of service liberalization. 

• A major challenge is to strike a balance between the need to provide incentives for 

innovation and the need to enable all people to benefit from innovation. 



The stakeholders - Statements on organisational and professional 

interests 

Nina Hvid 

Statement not available 

Mehtab Currey 

Statement not available 

Mihaly Kökeny 

As a former Minister of Welfare of Hungary, - a country which has experienced what a 

government can and cannot do for placing health higher on its agenda, under economic 

pressure while in transition, -I feel that the socio-ecological perspective of health is not well 

recognised in the countries of Central and Eastern Europe. 




Health is not the most prestigious one of ministries compared with finance or defence and 

tend to be dominated by the medical model. As this model is based on the challenge of 

disease rather than the challenge of health, the task is seen as medical care of the sick, 

rather than reducing the disease burden. The impact of globalisation on health and the 

increasing globalisation of certain diseases as well as health damaging practices have only 

recently been gaining the attention they deserve. 

Environmental degradation, BSE and the dioxin crisis have all contributed to the 

reinforcement of the focus on health within the EU and to clarifying the need for Europe to 

have an unambiguous and evidence based common public health platform. 

However, much has to be done until the public health mandate of the European Community 

is fully implemented and the enlarging EU takes health responsibilities seriously. If the 

accession countries observe the dichotomy that Brussels spends “pocket-money” on anticancer 

programmes on one hand and more than a billion euros subsidising tobacco farmers 

on the other, they will not be prepared to meet public health policy obligations. Such an 

experience suggest that in spite of rhetorics EU marginalize health problems during the 

enlargement. 

I would like to see and work for a vigilant and demanding health policy position from the 

European Union, serving the creation of a global health arena in which old and new actors, 

governments and NGOs, businesses and policy networks are jointly coping with transnational 

influences on health. A number of invaluable lessons have been learned on public health. 

The most important one is still to be fully understood, that various forces interested in 

health gains, can withstand and fight disease effectively and efficiently only if they are 

united. 

Ron Labonte 

The EPHA and IUHPE do not oppose liberalized global trade and investment per se, nor 

changes in tariff structures and other national regulations that impede such trade and 

investment, provided the effects of trade/investment liberalization are ecologically sound, 

lead to a fairer distribution of goods (including income) within and between nations and 

generally improve the goals of human development as articulated in numerous UN and 

multilateral declarations and accords. Liberalization proponents claim that open markets are 

both necessary and sufficient to accomplish these ends. Twenty years of experience with 

Structural Adjustment Programs and other forms of market liberalization do not empirically 

support this claim. Strong, internally developed and saturated economies benefit by 

liberalization; poorer domestic economies rarely do. Given the growth of income inequalities 

between rich and poor nations, and the ecological impossibility of fossil-fuel based 

development of poor nations to the existing level of rich ones (which would require, by one 

estimate, an additional four planets to exploit), human development on a planetary scale 

demands a global re-distribution of wealth from rich to poor. This is an inescapable fact, and 

one that cannot be resolved by trade or investment liberalization and, indeed, is exacerbated 

by it under present liberalization rules. If the WTO is to uphold its promise of creating a 

"rules-based trading system" that will help weaker participants offset the economic power of 

stronger participants, its basic premises of the relationship between trade liberalization and 

human development must be reversed. Its Agreements need to be subordinated to human 

development and environmental sustainability goals, and not allowed to overbear them. 



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Decision-making on trade and human development needs to be opened to a wider range of 

multilateral and civil society actors. Assistance and resources for more equitable participation 

in the emerging network of global governance must be made available to poorer 

populations, generally and poorer nations in particular. 

Regarding the GATS, the existing Agreement should not be extended or deepened at this 

time. GATS could increase the already substantial migration of skilled professionals, including 

health professionals, from poorer to wealthier nations. GATS may also increase privatization 

of and decrease access to many public services (health, education and so on) essential to 

health and well-being. Individual countries remain free to exclude such services from the 

Agreement, but the GATS built-in principle of "progressive liberalization," and the difficulty in 

foreseeing all possible future implications of services liberalization when specifying 

exemptions or modes of service delivery, renders such assurances questionable. Moreover, 

EU countries have already committed most of their health services to the GATS. It is 

important to recognize that the major force behind the GATS are private sector interests, 

such as the US Coalition of Service Industries and the European Services Forum. They are 

primarily interested in increasing private access to the public service market, i.e., the global 

health care market (worth US $3.5 trillion annually), education market (worth US $2 trillion 

annually) and water market (worth US $1 trillion annually). 

Regarding TRIPS, intellectual property rights similarly entered the world trading system at the 

behest of corporate interests. Unlike other WTO Agreements which require nations to remove 

trade protections, TRIPS requires that they extend protections, specifically corporate 

monopolies over drugs, foods (seeds) and other "intellectual property." TRIPS provisions 

(which are enforceable) currently contradict other multilateral Agreements, such as 

commitments to technology transfer, the right to food and health, and the Convention on 

Biodiversity (which remains unenforceable). TRIPS provisions also allow increasing 

"biopiracy," the patenting of traditional medicines and other indigenous knowledge by 

corporations based in wealthier nations. TRIPS, alongside TRIMS, is cited by the UNCTAD 

Director-General as the two WTO Agreements most potentially harmful to the abilities of least 

developed countries to develop their own internal economies. The TRIPS Agreement needs to 

be re-negotiated to reduce its extended patent protections, and to exclude property rights on 

life forms per se. This ban should extend to "micro-organisms" and "microbiological 

processes," which are currently allowed patent protection. Substances found in nature are a 

discovery and not an invention; they should not be patentable. There is also a presumption 

that decreasing the patent reach of TRIPS will lead to a retreat from scientific research and 

progress. Yet there were not generous patent protections in place when many of the great 

discoveries of the past century occurred. There is little evidence that generous patent 

protections lead to increased scientific research and progress (and certainly not for diseases 

affecting most of the world's poorer peoples), while there is substantial evidence 

that it is increasing drug costs. In public systems, this reduces the funding available for 

primary and public health care services of great importance in early disease intervention and 

disease prevention. Moreover, much of the research on new drugs, particularly antiretrovirals, 

is supported by public grants or tax deductions, rendering the distinction between 

private and public investment, and hence private and public "ownership," moot. Finally, 

Fortune magazine has just named the drug industry as "more profitable than any other." The 

industry was also rated the most profitable industry last year and has been consistently 

ranked number one or two by Fortune over the past few decades, including periods when 

patent protection was not so generous. 

In the case of both Agreements, how much profit is enough? At what cost to public health, 

both within and between nations? 




Maurice Mittelmark 

The International Union for Health Promotion and Education (IUHPE) is an independent 

professional association of individuals and organisations that for nearly 50 years has been 

committed to improving the health of the people of the world through education, community 

action and the development of public policies. With more than 2,000 members in over 90 

countries, the IUHPE is the only global non-governmental organisation that provides an 

opportunity to build an international network to encourage the free exchange of ideas, 

knowledge, technical skills, and experience. 

The mission of the International Union for Health Promotion and Education (the IUHPE) is to 

promote global health and to contribute to the achievement of equity in health between and 

within countries of the world. 

The IUHPE fulfils its mission by building and operating an independent, global, professional 

network of people and institutions to encourage the free exchange of ideas, knowledge, 

know-how, experiences, and the development of relevant collaboration projects, both at 

global and regional levels. 

In line with its mission, the IUHPE has three major goals: 

a) Advocate for health - to advocate for actions that promote the health of 

populations throughout the world. 

b) Improve effectiveness - to improve and advance the quality and effectiveness of 

health promotion and health education practice and knowledge. 

c) Build capacity - to contribute to the development of capacity in countries to 

undertake health promotion and health education activities. 

The IUHPE pursues these major goals by: 

• advocating for investment in health promotion and health education by 

governments, inter-governmental organisations, non-governmental organisations 

and the private sector; 

• undertaking activities that contribute to the development of knowledge and practice 

that further the field of health promotion and health education; 

• disseminating evidence-based knowledge and practical experience in health 

promotion and health education; 

• providing mechanisms for the exchange of ideas, experience and knowledge that 

promote health; 

• providing a global forum for mutual support and professional advancement of its 

members; 

• building alliances and partnerships amongst all sectors, based on agreed ethical 

principles, mutual understanding and respect; 

• strengthening the capacity of the Organisation to fulfil its mission. 



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The expert witnesses: European Trade policies and their impact upon 

health 

Paul Strickland 

Introduction 

• Seattle – concerted attack on patented pharmaceuticals. Main message being that 

patents make drugs excessively expensive. An eye–opener for the industry and 

international organisations, including the European Commission. 

• Since the beginning of 2000, DG TRADE of the European Commission has held 

regular meetings open to all non-governmental organisations and the 

pharmaceutical industry with a view to defining and analysing perceived problems 

in connection with intellectual property rights, medicines and health. Parallel 

bilateral meetings with major stakeholders have also contributed to trying to 

solve these problems. Commissioner Lamy has also regularly met with the NGOs 

and the industry. All this has contributed to an open, and to a certain extent, 

creative discussion. 

• The outcome of this ongoing procedure is that a lot of issues have been listed as 

problems in connection with access to medicines and health care. Patents may 

add to the total cost of medicines but this is only one issue among many. 

• Poverty - the major obstacle to the lack of health, health services and medicines. 

Poverty means that people are more prone to communicable diseases due to lack 

of proper nutrition and poor hygiene. In addition, a lack of education creates 

difficulties in terms of setting up prevention schemes. Most poor countries have 

no social security nor any other reimbursement system in force, i.e. the patients 

have to pay the full price of medicines out of their own pockets and not many 

can. 

• It is clear that the pharmaceutical industry in Europe and US charge very high 

prices in our markets. Why? Our social security systems (whether based on public 

or private insurance) can afford them even though the debate on cutting public 

expenditure is growing. I guess this discussion will continue. 

• One of our aims is to get the pharmaceutical industry interested in supplying 

medicines at heavily discounted prices in developing countries. This may involve 

trying to prevent cheap products from being diverted from the markets they are 

intended for. The industry has been requesting the European Community to 

reinforce the regulation system in the EC to ensure the continuance of market and 

price segmentation. At the same time, importing countries should also make all 

possible efforts to ensure the medicines are consumed by their sick population, 

and not diverted. There is a common interest that this is done, otherwise 

investment in R & D in non-profitable diseases could further decrease. 

• The debate on access to medicines also touches upon Human Rights and 

intellectual property as well. This year the Sub-Commission on Human Rights of 

the UN Economic and Social Council commissioned a report on a Resolution that 

protection of IPRs as embodied in the TRIPs agreement conflicts, in one way or 

another, with a number of Human Rights. The EC and its Member States consider 

that Human Rights and IPRs are, in many ways, complementary and that their 




EC positions 

objectives, if considered to be in conflict, can be reconciled – private rights are 

human rights too, if it comes to that. Again, the lack of access to medicines in 

general in the developing countries is primarily a result of poverty, lack of 

research into non-profitable diseases, poor infrastructure of health care systems, 

prevention and distribution systems. 

• On 20 September 2000, the Commission adopted the Communication on 

Accelerated Action targeted at major communicable diseases within the context of 

poverty reduction. It focused on the need for immediate action targeted against 

three major diseases namely Malaria, Tuberculosis and HIV/AIDS. 

• The Communication constituted the basis for consultations with the widest 

possible number of interested parties at the Round Table which took place in 

Brussels on 28 September, 2000. The Round Table expressed a clear and 

unambiguous message, namely the urgent need for a joint action to achieve 

results in the fight to help the sick in developing countries hit by infectious 

diseases. 

• On 21 February 2001 the Commission adopted a follow up to the September 

Communication in the form of a Programme for Action: Accelerated action on 

HIV/AIDS, Malaria and Tuberculosis in the context of Poverty Reduction" (COM 

(2001) 96) setting out the activities that should be pursued by the EU during the 

next five years. The Programme outlines the actions to be taken within the next 

five years concentrating mainly on: 

- optimising the impact of health, AIDS and population interventions 

- strengthening of pharmaceutical policies and capacity building 

- developing capacity for local production of pharmaceuticals 

- establishing a global tiered pricing system for pharmaceuticals 

- reducing tariffs and other costs on pharmaceuticals 

- supporting WTO developing country members in implementing the TRIPs 

Agreement and promoting an international discussion on the link between 

the Agreement and public health protection issues 

- strengthening and increasing support for research and development 

including capacity building and incentives for development of specific 

global goods. 

Work in Progress 

• The EC considers that the supply of key medicines at differential or tiered prices 

seems to be the most realistic and feasible means to deliver results on a short 

term basis. For that we need firm and long-term commitments from both the R&D 

based and the generic industries to sell at lowest possible prices covering at least 

medicines against the three diseases targeted in our Communication. 

• Tiered pricing is not a new concept. It has been applied for decades in respect of 

vaccines and contraceptives. Applying the principle also to the most sophisticated 

drugs on the market (i.e. antiretrovirals against AIDS/HIV) does complicate the 

issue. The need for long-term medical care and supervision in connection with 

medication of this kind does put heavy pressure on already weak health systems. 

Reinforcement of health care and prevention are therefore of utmost importance. 



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• The R&D based industry claims it is efficiently applying differential or tiered 

pricing by participating in the Accelerated Access Initiative, consisting of offers to 

supply antiretrovirals against HIV/AIDS from several large pharmaceutical 

companies in co-operation with UNAIDS, WHO and other UN offices. Until now 

arrangements have been concluded with approximately 10 African countries plus 

Romania. Around 35 countries have expressed interest in participating. Clearly this 

initiative is insufficient as it only reaches a maximum of a few thousand patients. 

• This year we have seen a number of individual offers from the industry including 

some generic producers. CIPLA, the main generic manufacturer in India, which is 

producing antiretrovirals legally due to lack of IP legislation, has announced that 

it is offering AIDS antiretrovirals at heavily discounted prices to all African 

countries. To avoid patent conflicts, CIPLA has asked the R&D industry to issue 

licences in the countries where the products are patented. These requests have 

not been replied to but the R&D based industry has followed suit with some very 

low-priced offers which points in the right direction. However, in spite of these 

offers we see no increased supplies of essential medicines to poor countries! 

• The European Commission is addressing tiered pricing in a global setting trying to 

set out the principles for a system based on voluntary and long term 

commitments from producers – a paper is in preparation. In this connection the 

need to address possible increased measures to prevent re-importation into the 

European Union has to be addressed. This will most probably become an 

important issue if exports of cheap medicines increase significantly. (The European 

Commission might at such a stage propose a separate regulation addressing this 

issue.) 

• The European Commission is also concerned about some importing developing 

countries application of relatively high tariffs and other taxes and fees. We are 

looking into this matter with a view to, if necessary bringing the discussion on 

tariffs to the WTO. 

• Local production of medicines may well be a valuable instrument in the long term. 

It is important that both the R&D based and generic industries are forthcoming in 

making long term commitments in terms of technical transfer, possibly supported 

by aid programmes. (TT more likely if a patent regime is in place.) The first step 

should be, however, to ensure standards and capacity of existing manufacturing 

facilities in developing countries. 

• Need for increased research into diseases that are unprofitable is another key 

issue. It is important to boost public funds and create co-operation opportunities 

between private and public facilities to provide incentives for research into 

diseases common in developing countries. The Commission has published calls for 

proposals focusing on these diseases and will shortly be reviewing the new multipartner 

project proposals received. In order to increase the amount and the level 

of co-ordination of testing of new drugs and vaccines in developing countries, the 

Commission is currently supporting initiatives in order to set up a specific trial 

platform with Member States. 

• The EC has called for an accelerated response, and for new approaches to deliver 

more effective aid. The establishment of the Global AIDS and Health Fund (GAHF) 

is one such welcome development. A Transitional Working Group has been 

established and a Technical Support Secretariat (set up in August in Brussels) is 

tasked with defining the modus operandi of the Fund by the end of the year. The 

transitional working group is chaired by Minister Crispus Kiyonga of Uganda and 




the support secretariat is headed by Paul Ehmer from USAID. Work will include 

governance and management structure, fiduciary arrangements, eligibility criteria, 

country processes, implementation options, monitoring and evaluation, 

procurement, resource mobilisation and communication strategies. 

• Pledges to the Fund have now reached US$1.8 billion from about 40 donors. The 

Fund has received broad support from governments and to a lesser extent, from 

the private sector. The EC has contributed 120 million Euro for year 2001. The 

Transitional Working Group is expected to define clear guidelines and working 

methods by end of the year and for the first funds to flow in first half of 2002. In 

terms of drugs purchasing, expectations are high always subject to preferences of 

recipient countries. 

Role of IPRs in an international setting 

• The importance of a strong IPR system in order to secure future research and 

investments in medicines must be stressed. On the other hand, the protection 

should not provide excessive benefits to right holders. The TRIPs Agreement 

provides an adequate minimum level of protection, the balance of which should 

not be altered. TRIPs is not so much part of the problem, as part of the solution. 

• The EC view is that TRIPs offers a significant degree of flexibility including the 

right to apply compulsory licensing in accordance with the conditions set out in 

article 31 of TRIPs. Discussions as to whether or not national health concerns and 

in particular access to medicines are adequately addressed in the TRIPs 

agreement, are being pursued in the TRIPs Council. In particular, Articles 6 

(exhaustion and parallel import), 7-8 (objectives and principles) and 31 

(compulsory licensing) are targeted in this debate. 

• The discussion in the TRIPs Council on access to medicines has now taken place 

on three occasions. Positions are relatively well established. Presently (end 

September 2001), work goes on to negotiate a text for a declaration in 

preparation for the Doha Ministerial meeting of WTO members. 

Such a declaration should address the political fundamental requisite that TRIPs should 

not prevent members from implementing their national health policies and also address 

certain key provisions that need clarification. Discussions continue, and the EC hopes for 

a positive (not minimalist) declaration at Doha in November. 

The role of international agencies in health protection and in 

developing health positive trade policies 

Robert Beaglehole 

The World Health Organization is the main intergovernmental agency responsible for the 

prevention of disease, disability and injury and the promotion of health at the global level. 

The context for this relatively new programme of work by in the Department of Health and 



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Development is the new global environment for public health practice: health is now firmly 

on the global policy agenda; achievements in health are critical to the fulfilment of 

international development goals; and domestic action alone can no longer ensure people’s 

health locally. The dangers, for population health from this new environment are numerous, 

for example, exclusion/disconnection from global markets; increasing private ownership of 

knowledge with potential impact on technology transfer and access to drugs; the continuing 

migration of health professionals; cross border transmission of disease (infectious and 

noncommunicable such as tobacco caused); environmental degradation; and increased 

conflict. The opportunities for public health are increasingly recognised and arise from: the 

new levels of interconnectedness; the new market incentives for research and development 

for diseases of the poor; the new and major resources promised to scale up existing effective 

interventions; the wider dissemination of knowledge of effective interventions; and the new 

global health rules to control cross border and global risks. 

The strategies being used by WHO to assist member states take advantage of these 

opportunities include: expanding and sharing knowledge on the effects of globalization on 

health; continuing to act as an independent provider of knowledge and evidence; developing 

appropriate policy responses; strengthening national negotiating capacity to place public 

health interests higher on the trade, investment and development agendas; supporting the 

control of public health bads and the production and access to public health goods. Specific 

areas of work include: analysing the impact of globalisation on health (risks, opportunities 

and responses); documenting the public health implications multilateral trade agreements; 

promoting new avenues for international financing for health development; assisting the 

processes of managing interdependence for health and negotiating across boundaries; 

analysing the implications of global public goods for health; exploring opportunities for 

strengthening global health governance. 






The role of health issues in multilateral trade agreements 

Rolf Adlung 

Presentation was based largely on an article previously published in Issues in European 

Health Policy, 5th Issues, July 2001. 

THE GENERAL AGREEMENT ON TRADE IN SERVICES: 

APPLICATION TO THE HEALTH SECTOR 

The General Agreement on Trade in Services (GATS) is the multilateral trade agreement in the 

area of services. Its entry into force in 1995 was one of the major achievements of the 

Uruguay Round of trade negotiations (1986-1993) and a landmark event in the history of the 

trading system, comparable to the inception of the General Agreement on Tariffs and Trade 

(GATT) in 1948. While the GATT was initially conceived as a framework for merchandise trade 

between the post-war economic powers, it has since achieved almost global coverage. The 

World Trade Organization – its successor since 1995 – has 141 Members at present, including 

some 80 developing countries and close to 30 least-developed countries. The WTO 

comprises the GATT, as amended in eight successive rounds of trade negotiations, the GATS, 

and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). All WTO 

Members participate in, and have assumed obligations under, all three Agreements. 

Despite many significant reforms since the late 1940s, core elements of the system have 

remained unchanged. These include the consensus principle – i.e. no decision is taken as 

long as even one Member objects – and Most-Favoured-Nation (MFN) treatment, i.e. a 

requirement on all Members not to discriminate in their trade regimes between products and 

producers of different foreign origin. The commitment to MFN treatment reflects not only 

economic efficiency considerations but, more importantly, the system's exclusive reliance on 

rules- as against power-based policies. All goods and services imported from abroad must 

be accorded the same treatment, regardless of the economic clout of the originating country 

and any specific policy considerations. 

For decades, the non-existence of a services agreement had not been viewed as a 

particularly pressing problem. Apart from international transport and communication, 

services have predominantly been considered as domestic activities, requiring the 

simultaneous presence of supplier (e.g. banks, hotels, hospitals and their staff) and 

consumer (depositors, tourists or patients). However, this view has changed significantly in 

recent years as a result of technical developments, including new communication 

technologies enabling e-banking or tele-health services, as well as economic reforms that 

have increased the "openness" of many services sectors. Although cross-border trade in 

services is still dwarfed by merchandise trade, accounting for no more than 20 per cent of 

total exchanges, it has grown faster over the past two decades. 

While the emphasis of the Uruguay Round was on creating a comprehensive set of trade 

rules, the liberalizing effects of GATS have remained limited to date. Most WTO Members 

have confined their access commitments to binding status quo conditions in a limited 

number of sectors. The ongoing services negotiations, launched in January 2000, offer them 

a new opportunity to consider the advantages of internationally guaranteed, more open 

access regimes. Increased foreign presence in a sector may help, for example, to fill 

domestic supply gaps; to broaden a country's resource base (including capital and 

expertise); to promote efficiency through competition; and, in infrastructural sectors such as 



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communication, transport or finance, to strengthen economic links with external suppliers 

and customers. 

The implications of the GATS for any individual service sector depend mainly on three 

parameters:10 

The institutional structure of the sector 

The GATS excludes all public services, i.e. services provided in the exercise of governmental 

authority. This carve-out applies whenever a service is provided neither on commercial basis 

nor in competition with other suppliers; free medical treatment in public facilities is a case 

in point. Such services are not covered by the Agreement, and will not be made subject to 

future negotiations. Although it has been alleged that WTO Members "decided" that the 

relevant provision needed to be interpreted narrowly and did not cover the whole sector, no 

such decision exists.11 

General obligations under the GATS 

Trade in virtually all other services is governed by some general, cross-sectoral rules. 

Foremost among them is MFN treatment. WTO Members are thus not allowed to discriminate 

between like services offered by different trading partners. Whatever the trade regime in a 

sector – whether free access, closed markets or something in between – it must be the same 

vis-à-vis all foreign suppliers. 

The scope of market access and national treatment commitments 

Each Member must submit a schedule of specific commitments under the GATS. This lists 

the sectors, and any relevant limitations, in which the Member grants market access and 

national treatment. Full market access would imply, inter alia, the absence of quantitative 

restrictions, while full national treatment would guarantee foreigners the same competitive 

opportunities as those enjoyed by domestic suppliers. All commitments are specified for 

four modes of supply, reflecting in many services the need for physical proximity between 

provider and consumer. The modes relate not only to the traditional concept of cross-border 

trade (mode 1), but to the consumption of services abroad by nationals of the scheduling 

Member (2), to the supply of services via foreign commercial presence (3) and to supplies via 

presence of foreign natural persons (4). 

In any sector included in a schedule, Members are free not to commit on a particular mode, 

i.e. to leave it "unbound", or to further condition their commitments. Typical conditions 

("limitations") scheduled for health services specify maximum numbers of doctors or 

hospitals, the non-eligibility of foreign hospitals for subsidies or their exclusion from public 

insurance schemes. However, non-discriminatory public policy requirements, e.g. obligations 

on private hospitals to reserve some capacity for the poor or to train more staff than needed 

for own purposes, are compatible with relevant GATS provisions and do not have to be listed 

as limitations. 

Country schedules vary widely in their sector and modal coverage. While some Members 

have scheduled less than a handful out of a total of some 160 services sectors, others have 

included 100 and more. Health services have not proved very popular in this context. For 

instance, more than 90 of the WTO's current 141 Members have not undertaken any 

10 For more details see R. Adlung and A. Carzaniga, Health Services under the General Agreement on 

Trade in Services, Bulletin of the World Health Organization, 2001, Vol. 79, No. 4. 

11 See A. M. Pollock and D. Price, Rewriting the regulations: how the World Trade Organization could 

accelerate privatisation in health-care systems, Lancet, 2000, Vol. 356. A reply is given on the WTO 

Website. 




commitment on hospital services, i.e. these countries are free to operate in this sector, 

subject to the MFN principle, whatever restrictions they deem appropriate. The European 

Communities' schedule does contain, however, some significant commitments. For instance, 

for hospital services not provided by public utilities, it guarantees foreign investors full 

market access and national treatment in Denmark, Germany, Greece, Ireland and the United 

Kingdom. 

Health Services: Country Pattern of Commitments (July 2000) 

Sub-sector Members with commitments 1 

Total 

Medical and dental services 54 36 

Services provided by nurses, midwives, 

physiotherapists 

29 12 

Hospital services 44 29 

Other human health services (ambulances 

etc.) 

17 15 

Developing 

economies 

1 The scope of individual commitments varies as a result of mode-specific exemptions 

or limitations. 

Source: Adlung and Carzaniga, op. cit. 

The reticence of many Members to undertake commitments in the Uruguay Round might have 

been due, inter alia, to lack of information or negotiating interest, absence of coordination 

links between competent ministries or fears that commitments might jeopardize basic quality 

and equity objectives. However, such fears are not justified. The GATS creates a framework 

for the conduct of services trade, but does not undermine a government's ability to regulate. 

The Preamble to the Agreement explicitly recognizes "the right of Members to regulate, and 

to introduce new regulations, on the supply of services within their territories in order to 

meet national policy objectives". National regulations may specify, for example, certification 

requirements for doctors and hospitals, or minimum availability standards ("universal service 

obligations") for the services rendered. 

There are claims, nevertheless, that legal test are under consideration that would outlaw the 

use of non-market mechanisms such as cross-subsidization, universal risk pooling, solidarity 

etc.12 Such claims are patently absurd. The relevant negotiations, pursuant to Article VI:4 

of the GATS, are confined to developing disciplines that would prevent qualification 

requirements and procedures, technical standards and licensing requirements from 

constituting unnecessary barriers to trade. The relevant mandate is closely circumscribed 

and does not call into question governments' ability to determine regulatory objectives and 

content. Any modification would presuppose an amendment to the Agreement itself which, 

in turn, would require Parliamentary approval in many countries (for example, the European 

Parliament and the Parliaments of all EC States would need to be involved). 

12 Pollock and Price, op. cit. 



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Schedules are not cast in stone. A government may modify or withdraw any specific 

commitment it feels unable to live up to. Such modification or withdrawal does not depend 

on any other government's approval. However, in order to discourage excessive use and 

protect the overall level of commitments, the relevant Article provides for negotiations on 

compensation with affected trading partners. Moreover, under a general exception clause 

contained in Article XIV of GATS, Member governments are entitled to take any measure, 

regardless of their obligations under the Agreement, that is necessary to protect human, 

animal or plant life or health. A recent dispute settlement case has confirmed the relevance 

of this clause.13 

To date, in the context of the new services round, some 40 WTO Members have specified 

their negotiating interests in the form of written proposals. Like other relevant documents, 

these are available on the WTO Website (www.wto.org). However, among the 90-odd 

proposals received, none refers specifically to medical or hospital services. 

All views are those of the author and should not be attributed to the WTO. 

The role of commercial enterprises in health 

Petra Laux 

At GlaxoSmithKline - one of the world's leading research based pharmaceutical companies - 

we want to improve the quality of human life by enabling people to do more, feel better and 

live longer. But developing new medicines is not enough if the patients who need them are 

denied access. We are acutely aware that millions of people in developing countries do not 

have access to even the most basic healthcare services, including safe and effective 

medicines, that are taken for granted in the developed world. 

This has led to a global healthcare crisis, in which life threatening diseases such as 

tuberculosis, malaria and HIV/AIDS are spreading unchecked in countries that have neither 

the resources nor the facilities to deal with the epidemics. 

Poverty is at the root of the issue. Large parts of the populations of developing countries 

often do not have access to food and clean water, let alone healthcare services. If the health 

of the developing world is to improve, then all sectors of our global society - governments 

and international agencies, as well as the private sector - must work together in partnership. 

GlaxoSmithKline is committed to playing a full part by taking an innovative, responsible and 

above all, sustainable approach to meeting the healthcare challenges of the developing 

world. There are three key areas in which we believe we can contribute: 

1. Continuing our investment in the research and development of diseases that affect 

the developing world in particular. 

We are the only pharmaceutical company that is conducting R&D into both prevention 

and treatment of all three of the WHO's top priority diseases - HIV/AIDS, malaria and TB. 

However, the fundamental framework on which medical advances depends, and which 

13 See reply to Pollock and Price on WTO Website. 




has led to sustained investment in research and development, requires intellectual 

property protection. 

2. Offering sustainable preferential pricing arrangements in Least Developed Countries 

and sub-Saharan Africa for currently available medicines that are needed most. 

We have done this with our vaccines for nearly 20 years and our HIV/AIDS medicines for 

the past four years - we will extend this programme. 

3. Taking a leading role in community activities that promote effective healthcare. 

At a corporate level, GSK is currently involved in community partnership activities in 96 

countries, with additional donations at a local level. And we run the world's biggest 

donation programme to eliminate lymphatic filariasis. 

We strongly believe we are making a real difference to healthcare in the developing world. 

We believe this is both an ethical imperative and key to business success. It is our intention 

to make access to medicines a continued priority of our company. If we provide the 

medicines society needs, and help solve the problems of access to those medicines, then we 

will demonstrate what it truly means to be an industry leader 



Summary Report of Forum II 

Julius Weinberg 

1. Workshop Description 

The workshop was organised along innovative lines and addressed the question of whether 

the impact of the flows of capital, goods, ideas and peoples across borders, and the 

institutions and rules established to regulate them was good or bad for health. 

First an introductory talk set out the history of the relationship between globalisation and 

health. This talk also described the roles of relationships between the various international 

agencies and the “language of globalisation”. 

Following the introductory talk a number of experts drawn from International Organisations, 

the Pharmaceutical Industry and Non-Governmental Organisations made presentations. The 

presenters were then questioned by a panel of experts, following which discussion was 

opened to the audience. 

The panel of experts then summed up the contribution of the presenters and the responses 

to the questioning, drawing together the issues that had been raised. 

Presentations were made from the point of view of: 

• The World Trade Organization 

• The World Health Organization 

• The European Commission 

• The Pharmaceutical Industry 

• The panel of experts were drawn from a variety of stakeholders. 



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It was agreed that globalisation had an impact on national policy and there was potential 

loss of national autonomy. There was a probable impact on health risks and an impact on 

household incomes and their distribution. 

2. Workshop Progress 

Some key areas of disagreement and concern were identified. It was commented that the 

voice of developing countries was inadequately represented in the debate. 

2.1 Issues 

There was no consensus over whether the arrangements for international trade were 

beneficial for health or not. Nor was there agreement over the relationship between trade, 

health and economic growth. There was some debate about where the major problems lay – 

patents and trade were considered by some contributors to be a side issue, the real problem 

being poverty. 

There was agreement that the evidence on the relationships between the impact of trade, 

changes in inequalities and health outcomes was inadequately understood. 

There were concerns that there had been little input from health experts, and those with an 

interest in public health in shaping the various international trade agreements. It was agreed 

that the possible impact of the General Agreement on Trade and Services was unclear, and 

there was no common understanding of whether Public Health services would be protected 

by exemptions under the GATS agreements 

There were increasing concerns that patents make drugs unacceptably expensive, and there 

was increased sensitivity to the problem of the affordability of pharmaceuticals in the 

developing world. The major R&D areas are not relevant to developing world and the 

argument that patent protection was essential for innovation did not seem clear. Much 

innovation seemed to be curiosity driven in Universities. 

2.2 Data and Research 

There was no good data upon which to base sound arguments, elements were taken out of 

context and inappropriate conclusions drawn. There was urgent need for good research into 

the relationship between trade and health. 

2.3 Advocacy 

Health experts had not been present in many of the policy decisions and needed to make 

their voice(s) heard. This meant understanding the language and issues. There were 

problems over how this was to be funded. Ministries of Health were weak in this area – 

work needed to be done in developing “Health Impact Assessments” of economic policies 

and in understanding the policy making process. 

Decision making was not transparent within the International Agencies and Public Health 

advocacy for open policy making was important 

Attention needed to be given to the widening inequalities gap. 

2.4 Governance and Accountability: 

There was need for better systems of global governance, where the various stakeholders are 

better represented, and where the less well resourced are supported so as to be able to 

contribute to the debate. 

The developing role of Health Impact assessment of economic policies was considered 

important 




Accountability of decision making was not always clear. Many of the International agencies 

do not have a health mandate. There seems to be unbalanced accountability towards the 

needs of trade. 

Health is central to global development goals and on the WHO Policy agenda. 

2.5 Intellectual Property Rights 

Lack of access to medicines is primarily due to 

• Poverty 

• Lack of research into the disease of the poor 

There was no agreement over the impact of TRIPS, the international agreement on 

Intellectual Property Rights. The debate polarised between a view that patent protection was 

essential to reward and promote innovation and a view that it meant that essential 

medication was too expensive for poor countries. There was extensive debate over the 

effectiveness or otherwise of the safeguards present in the TRIPS agreements. 

It was suggested that amendments to the TRIPS systems with tiered pricing systems and 

stronger links to public health could make TRIPS work more effectively, with better 

management of knowledge dissemination. 

Pharmaceutical industry is to make a profit, but needs to have a sense of social obligation 

and is part of civil society, there needs to be reasonable and proper balance between the 

interests of the poor and the need for profitable private industry 

2.6 Summary Comments from Expert Panel 

Around globalisation, facts disappear and prejudice dominates the discussion. The language 

of the international regulatory agencies is opaque and difficult. Many people feel excluded 

from the discussion and become alienated. There was concern that although there were 

protective mechanisms available for countries it was unclear how they could be used in 

practice – there was not a “level playing field” for countries in their ability to influence and 

use the international agreements. 

3. Consensus 

Areas where consensus was reached: 

• International trade rules should contribute to increased health for all. 

• There is a need for increased R&D in innovative medicines relevant to the 

problems of the poor in under-developed countries – patent law does not seem to 

have achieved this. 

• Lack of treatment is not just due to price. 

• All stakeholder in the healthcare business recognised that the implementation of 

just international trade rules is pivotal for the promotion of health care in the 

poorest countries. 

• Co-ordinated sustainable solutions to the major threats to health in the least 

developed countries were strongly supported. 

• Multilaterality and rules based systems are the only way to avoid the “bully on the 

block”. 

4. Not consensus 

Areas where consensus could not be reached: 

• Does globalisation and international trade promote health, or not? 



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• Should public health concerns prevail over trade rules – ends and means? 

• Does the debate discourage the pharmaceutical industry from entering research 

market? 

• Is the TRIPS agreement flexible enough? 

• The role of IPR in promoting new drug development. 

5. Recommendations 

5.1 Research Agenda 

• Health effects of globalisation/international trade and trade agreements on the poor 

• EU research framework to support the development of methodologies for research 

on trade policies in health 

• Need to bring researchers together - nationally and internationally – meetings and 

fora 

5.2 Training Priorities 

• Influence the policy debate/Advocacy – Intense training on trade policy law / core 

ethics training for IOs NGOs national Level 

• Develop Workshops on specific issues 

• Train the Public Health Workforce on the linkages between health and trade 

Simultaneously look at burden of disease in global context 

• Training for purpose: targeted training on policy influencers 

• Public Health Legal Base 

5.3 Advocacy/Communication Priority 

• Need to know what we are advocating for 

• Advocacy for accountability at national level, at wider numbers of stakeholders, for 

resources. 

• Greater balance between the stakeholders to ensure plurality of balance of 

representation in trade rounds 

• The EU is asked to provide technical assistance to least developed countries and 

ensure transparency 

• Promote public understanding of health issues ensuring shared language and 

practical ability to participate 

5.4 Governance 

• Need for a coherent system of global governance which is health promoting 

• Fill the gaps in power and the gaps in knowledge 

• Health impacts of international trade and trade agreements should be taken more 

seriously. 

• Health and human development goals should be integrated into discussions on 

Trade negotiations, ensuring plurality of interest and transparency of all those 

involved. 






Forum III: Health and the Single 

European Market 

Introduction: The European Union and health care 

Philip Berman 


The labour market for doctors and nurses 

Bie Nio Ong 

Background. 

As one of the largest employers in Europe, health services, clearly, have the potential to be 

affected by the impact of labour mobility on the demand for and supply of doctors nurses, 

and other health professionals. Health service workforce planners in Europe have 

traditionally overlooked this potential impact. Integrated workforce planning that adopts a 

European dimension is an undervalued but increasingly important process. 

Taking the UK as the main example we present a description and analysis of the labour 

market for doctors and nurses in the EEA. The European dimension to workforce planning is 

important not least in terms of the Government’s Comprehensive Spending Review 

(Department of Health, 1998) and the announcement of an increase of 7,000 more doctors, 

15,000 nurses and 6,000 more nurse training places for the NHS. This announcement must 

be considered in parallel with identified pressures that the British health service has recently 

faced (Buchan, 1998; Jinks et al. 1998; Lambert and Goldacre, 1998; Snell, 1998; Friend, 

1998; Lyall, 1997). These pressures include, for example: 



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• major domestic nurse and doctor recruitment and retention problems 

• a change in gender balance to the UK Physician workforce. This has led to a rise in 

the number of UK physicians seeking part time employment 

• a trend towards early retirement 

• specific concerns about recruitment difficulties for general practice 

In the past, the above pressures have been moderated by the supply of doctors from both 

overseas and the EEA. For example, EEA qualified doctors contribute significantly to the 

Senior House Officer cadre (SHO). Recent figures show that ten percent of SHOs in England 

and Wales are from the EEA (Jinks et al, 1998). The potential impact of labour mobility thus 

becomes apparent when new registration figures from the General Medical Council are 

examined. These figures indicate that the number of new full registrations of doctors from 

other EEA member states are in decline. See Figure 1 below.

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Figure 1. New full GMC registrations of EEA, UK and Overseas doctors (1988-1999) 

Figure 1 suggests that European junior doctors are now less likely to come to the UK to train. 

This decision could be affected by employment opportunities in their host country. Indeed, a 

recent study undertaken by the Permanent Working Group (PWG) of European junior hospital 

doctors (PWG, 1996) has indicated that medical unemployment on the continent will continue 

to fall well into the early part of this century. This trend has clear implications for policy 

makers both in the UK and on the continent and, thus, presents important research 

questions: to what extent are people moving; what are the factors that facilitate or prohibit 

mobility; and, what are the implications of mobility for health services? 




Policy Framework for Free Movement of Individuals 

The Treaty of Rome lays the foundations for the free movement of labour within Europe. Key 

articles that facilitate freedom of movement are illustrated below in table 1. 

ARTICLE NUMBER DESCRIPTION 

48 Freedom of Movement for Workers 

52 Freedom of Establishment in another Country 

59 Freedom to Provide Services 

07 Prohibition 

Nationality 

of discrimination based on 

57 Mutual Recognition of diplomas, certificates and 

other evidence of formal qualifications 

Table 1: Articles from the Treaty of Rome (Mobility of Labour) 

The above policy framework facilitates the free movement of doctors and nurses across the 

EU as there is mutual recognition of qualifications. Furthermore, language ability does not 

have to be proven. Doctors who wish to work in the UK need to register with the General 

medical Council, while nurses UK need to be registered with the United Kingdom Central 

Council. 

One example of how EU policy on the freedom of movement has had a direct impact in the 

UK can be seen from recent changes to postgraduate and specialist medical training. In the 

early 1990s, the European Commission queried the way in which the UK issues certificates to 

its own specialists and the way it recognised specialist medical qualifications issued in other 

countries. 

In 1992, the British Government responded to pressure from the EU by establishing a 

working party to advise on how Britain could be brought into line with the EU directives. 

The working party made a number of important recommendations, (the Calman proposals), 

including, for example: the introduction of a Certificate of Completion of Specialist training 

(CCST). This is awarded to a doctor when the relevant medical Royal Colleges considers that 

training has been satisfactorily completed to a level of competence compatible with 

independent practice and eligibility for consideration for appointment to a consultant post. 

Another important recommendation was the unification of registrar and senior registrar 

grades to a new grade of Specialist Registrar. 



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Identifying EEA Doctors and Nurses in the UK NHS. 


The policy framework that underpins the movement of health care professionals has been 

defined. The next question, therefore, is to what extent are people moving ? Previous 

studies on labour mobility (Buchan, Seccombe and Ball, 1992, Hurwitz, 1990) are rare. The 

lack of previous research into labour mobility among healthcare professionals in Europe is 

not surprising when considering the inherent challenges in doing so. 

Investigations for this study support earlier observations, (McKee, 1993), that there is little 

systematic collection of the numbers of people moving throughout the EU. Comprehensive 

and consistent national data on the number of EEA qualified doctors in the UK and, 

importantly for workforce planners, their whereabouts, is missing. 

Figure 2: New full GMC registrations of EEA doctors per year by country of qualification 

(1996-1999). 




Figure 2 supports data from the GMC that the numbers of EEA doctors coming to the UK are 

in decline (a total decline in England by 227 between 1996 and 1997). A shift in the profile 

of doctors between grades is also evident. For example, there has been a rise in the 

number of EEA doctors at Consultant or Specialist/Senior Registrar grade; and, a decline in 

the number at Registrar grade. Importantly, there is also a decline in the number of EEA 

doctors at SHO and HO grades. Traditionally, EEA doctors embark on training programmes in 

the NHS at SHO grade. This is where the greatest decline in the number of EEA doctors 

practising is seen - a decline in number of 207. The number of UK SHOs has, however, 

increased between 1996-7 by 330. 

The mobility of nurses can, at present, only be traced at a national level. No systematic data 

collection takes place at regional or local level and even if Trusts record country of origin, 

there is no consistency across different organisations. Thus, we only present national level 

data here. 

Table 2: Initial registration of nurses and midwives. 

Year EU countries Other countries Overseas total 

94/95 798 1,654 2,452 

95/96 763 1,999 2,762 

96/97 1,141 2,633 3,744 

97/98 1,439 2,861 4,300 

98/99 1,412 3,568 4,980 

99/00 1,416 5,945 7,361 

Source: UKCC press release, 14/6/00 

Table 2 demonstrates the rise in EU nurses in 1996, with a more modest increase in 1997 

and then the levelling off of this trend. In contrast, the rise of nurses from other countries, 

notably South Africa, Australia, Philippines and the West Indies has been considerable. 

Buchan (2000) argues that this differential rise is due to the importance of communication 

with patients, advantaging staff from English-speaking countries. 

A more detailed breakdown of nurses registered with the UKCC as to the EU country of origin 

is provided through an analysis of trends in the number of European nurses and midwives 

coming to the UK. For example, in 1998/99, 5.42 per cent of the total number of admissions 

to the UKCC’s professional register were from practitioners qualified in other EU countries. 

Figure 3 illustrates how admissions of practitioners from EU countries compare with 

admissions from elsewhere. 



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Figure 3: Nurses registered with the UKCC (1996-1999) 


Figure 4: New admissions to the UKCC via EC arrangements by country of qualification 

(1996-2000). 




The number of admissions of EU practitioners to the UKCC professional register rose for the 

first time between 1997 and 1998. The greatest number of new admissions in this time were 

from practitioners who had qualified in Sweden and Finland. The number of admissions of 

EU practitioners to the register has, however, recently fallen from 1,239 between 1997/98 to 

1,165 between 1998/99. Admissions of practitioners from Sweden and Finland have fallen, 

whilst the admissions of practitioners from Germany and Spain have risen. 

It is important to bear in mind when looking at the figures that registration with the UKCC 

does not necessarily mean that the nurse in question is working within the health system. 

Conversely, nurses might work in the UK as auxiliaries during a period of adaptation before 

being accepted onto the UKCC register (Buchan, 2000). 

Case study. 

In order to investigate in more detail the movement of doctors, the reasons behind mobility 

and the perceptions of key personnel involved in their training and overall guidance the UK 

team undertook a survey of EEA doctors in the North West of England. The Region’s 

Postgraduate Dean’s medical staff database was used to identify a sample frame of EEA 

doctors. A total of 167 EEA doctors were identified (110 SHOs, 48 SpRs and 9 GP Registrars). 

Each EEA doctor was sent a short postal questionnaire. Pre-paid return envelopes were 

provided. A reminder (including a second pre-paid envelope) was administered after four 

weeks. There were 17 exclusions due to “addressee unknown”. An adjusted response rate 

of 53 % was therefore achieved. 

The survey aimed to: 

1. Identify EEA doctors in the area covered by the Manchester Deanery 

2. Investigate the reasons for labour mobility and, therefore, coming to the UK 

3. Investigate the process of registering to practice in the UK and actually practising in 

the UK. 

4. Investigate the experiences of training in the UK and satisfaction with training 

progress. 

5. Identify EEA doctors career intentions. 

6. Identify a sample of doctors for interview. 

The role of Clinical Tutors is important in the selection and monitoring of junior doctors, and 

thus, EEA doctors fall within their remit. Seven Clinical Tutors from the NW region were 

selected, representing the full range of hospital settings (general and teaching hospitals) and 

geographical locations. The purpose of the semi-structured interviews was to explore the 

specific issues pertaining to EEA doctors in comparison to both UK and overseas doctors. 

The interviews took a chronological format and also considered experience with EEA doctors 

against both EU regulations and the doctors’ impact on the UK health care system. 

Interviews were either conducted face-to-face (tape recorded and then fully transcribed), or 

via telephone format on prepared schedules. The interviews lasted between 30-60 minutes. 

From the EEA doctor survey a stratified sample was drawn consisting of twelve 12 doctors 

reflecting the composition of the overall sample in terms of grade and nationality. The 

purpose of the follow-up telephone interviews was to explore the issues covered in the 

sample in more depth in order to get a better understanding of the perspectives and 

experiences of EEA doctors. All doctors were asked to provide times, which suited them to 

be interviewed. Notes were taken during the interviews on prepared schedules and after the 

interviews they were transcribed. The interviews lasted between 30 - 45 minutes. 



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Selected findings. 

The survey. 

The main reason for labour mobility reported by doctors who responded to the survey is 

related to labour market conditions in EEA doctors’ home country. Medical unemployment or 

lack of specialist training posts were most frequently sited as the reason for leaving the host 

country and coming to the UK. A higher standard of training in the UK was also a commonly 

sited reason. 

When asked how easy or difficult it was to obtain permission from UK authorities to train or 

practice in the UK, an overwhelming majority of respondents, (89% in total), found it was 

very easy or easy. A smaller number, jut over half, found it easy or very easy to obtain an 

actual training position once here (total 51%). A very small number of EEA doctors who 

responded to the survey found obtaining permission to train in the UK to be a difficult 

process. However, the number of those respondents who found it difficult or very difficult to 

obtain an actual training position was much larger. Of those doctors who expressed difficulty 

in obtaining a training position, 37% were Greek, 18% German, 18% from the Netherlands 

and 9% each from Ireland, Poland and Spain. 

When asked whether satisfied with their current training programme the majority of answers 

were favourable. However, 9 % stated that they were dissatisfied and 20 % were neither 

satisfied or dissatisfied. 

In relation to the issue of whether patients accepted them as they would accept a UK doctor, 

the overwhelming majority (90%) of respondents felt that they were accepted on an equal 

basis. Only 8% felt that they were not accepted by patients as UK doctors would be. Asking 

a similar question with regard to whether they felt UK doctors accepted them as they would 

accept other UK doctors, the number who responded “no” was much higher than above 

(18/79 or 23 per cent). The number of respondents who did feel accepted as a UK doctor 

would be accepted was 59/79 (75 per cent). 

EEA doctors were asked about their career intentions and; whether, or not, they intended to 

remain in the UK. These findings are of particular interest. Only a quarter of those who 

responded intend to remain long term in the UK with over a half intending to leave in the 

short and medium term. The data highlight the considerable amount of uncertainty among 

EEA doctors who responded to the survey. 16 per cent of SHOs and 17 percent of SpRs are 

currently undecided as to whether or not to remain in the UK. Furthermore, the majority of 

SHOs stated that they intend to remain only in the medium and short term (32 per cent and 

26 per cent respectively) rather than in the longer term (21 per cent). Those who intend to 

leave in the short term will do so, for example, “after obtaining MRCP qualification.” 

More SpRs than SHOs stated that they intend to remain here in the long term and qualified 

this statement with, for example, “until retirement” and “indefinitely”. Twenty three per 

cent of SpRs also indicated that they intend to stay only in the short term: and, on 

completion of specialist training they intend to leave the UK. It is possible to assess the 

intentions of EEA doctors to stay in the UK by country of qualification. It is interesting to 

note that overall, Greek doctors, in particular intend to remain for short periods in the UK 

(1/12), with an even number of German doctors intending to stay for short and long periods. 

Only 2 of 12 Irish SpRs anticipate long term stay. 

The interviews. 

We present the selected findings of both the doctors’ and Clinical Tutors’ interviews 

together: 




In terms of supply factors EEA doctors come to the UK because the job situation in their own 

country is tight with an over-supply of doctors limiting the choice of options and career 

progression - together with hierarchical systems in some countries. Factors specific to the 

UK are the reputation of the UK training and that English is taught in most European 

countries as the second language. 

Two main routes into the application process were mentioned. First, through friends who 

alerted EEA doctors to adverts/vacancies and second, through specialised employment 

agencies. The latter route was seen as the more comprehensive and easy, because the 

individual was guided through all the stages of the application to the acceptance of a job 

offer. This was considered particularly useful in relation to validation of qualifications by the 

GMC, which included the proper translation of documents. 

The Clinical Tutors admitted that there is no separate policy for dealing with the induction of 

EEA doctors and that they are treated the same as other junior doctors. Apparently are only 

a handful of organisations with large numbers of EEA doctors have a tailor-made programme. 

It was suggested that hospitals could get together, or that such a programme should be 

offered at regional level. 

In theory the career opportunities for EEA doctors are the same as for UK graduates. In 

practice the picture is more complex. On the one hand there are doctors who testify that 

they are satisfied and feel that there is equality of opportunity. They state that they are 

treated the same as the UK graduates and that they feel well integrated and accepted. On 

the other hand, a number of doctors expressed doubts as to whether an implicit hierarchy is 

in operation, which goes as follows: 

“First, British doctors, then EEA doctors and then Indian doctors. It all appears to depend on 

skin colour” (SHO) 

When comparing the EEA doctors’ perspectives with the opinions of the Clinical Tutors 

interesting issues arise. At the formal level mutual recognition of previous training exists, 

but in practice the Clinical Tutors describe concerns that they themselves and their 

colleagues within the health service have about equivalence. The comments from the EEA 

doctors and the Clinical Tutors point towards a problem of perception about the role of EEA 

doctors and their aspirations. They all express the wish to take advantage of the same 

career opportunities as UK doctors, yet do not all feel that these are available to them. This 

can lead to an under-investment in professional development with possible negative 

consequences for individual EEA doctors and the quality of the service provided by them. 

The long-term career intentions of the EEA doctors differed between individuals and no clear 

pattern could be ascertained in terms of nationality. The factors which determined whether 

individuals wanted to pursue a career in the UK or at home were a combination of personal 

considerations such as marriage and family, structural considerations such as changing 

employment patterns and professional choices such as moving into new territories such as 

practicing in developing countries. 

Specific issues warrant further discussion. First, there was considerable confusion whether 

qualifications such as CCST obtained in the UK would be recognised in the home country. 

Most German and Greek doctors were confident that their UK CCST was recognised, while the 

Dutch, French and Spanish doctors appeared uncertain. This is somewhat surprising given 

that these doctors have embarked on training programmes and invested time and resources 

in something that they do not know whether it will pay off in the long term. 

Second, most of the German doctors want to stay in the UK, not only because of the poor 

job prospects in Germany but primarily because they feel that they have been trained for the 



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UK context and therefore their career is geared towards the needs of the British health 

service. 

Conclusions. 

EU regulation with regard to free movement of labour has resulted in easy registration for 

EEA doctors with UK authorities to train and practice in the UK. Obtaining registration with 

the GMC was not considered difficult, but finding an actual training position could sometimes 

be more problematic. There is evidence in our study that a relationship with how prior 

qualifications are interpreted exists. Whilst qualifications are formally recognised by the GMC, 

and Trusts do generally not demand proof of qualifications, the recognition in practice is less 

straightforward. The local medical establishments appear to perceive non-UK qualifications in 

paradoxical ways: on the one hand formal recognition is espoused, but on the other hand a 

lack of confidence in community-wide standards of basic medical and postgraduate 

education becomes apparent when judging individual candidates. This leads to inconsistent 

assessment of candidates’ suitability for training posts, with distinction made between 

educational qualifications from Northern versus Southern European countries. The effect of 

these localised, unsystematic judgements is a potential inequality of training opportunity for 

certain EEA doctors. 

The second issue relates to information concerning the training structure. The European 

Commission’s Green Paper on Transnational Mobility (European Commission, 1996) and the 

subsequent EU action plan on Free Movement of Workers that was adopted in 1997 

emphasise this, because insufficient information in the member states can create obstacles 

to mobility. At a local level this could be adapted to the needs of EEA doctors through 

information sharing strategies, including regional booklets, Internet based material, induction 

videos and so on. At a more personal level support networks for EEA doctors could be 

helpful in breaking isolation, sharing information and experiences and possibly providing 

guidance to local medical establishments about educational qualifications gained in EEA 

countries. 

In general terms, it is clear that the EU directives have influenced the UK health service in 

that the free movement of labour allows the mutual acceptance of qualifications and thus the 

uptake of training places for medical personnel. The reputation of British training and the 

status of English as the dominant international language results in Britain being primarily an 

importer of personnel. However, the attraction of the UK appears to be lessening for EEA 

doctors while doctors from other English speaking countries (esp. South Africa and Asia) are 

on the increase. 

EU-wide policies and directives are in place and have been transposed in most countries, but 

the key question now lies in their implementation at country-level. The UK case study has 

illuminated the tension between formal and ‘real life’ recognition of medical qualifications, 

and the lack of guidance throughout the training period for EEA doctors in the UK. It is vital 

that the implementation discrepancy between formal and informal recognition and access to 

information are tackled if equal access to medical training is desired as envisaged in the 

Medical Directive 93/16/EEC. 

Related to this is also the question of the quality of medical and nursing training. Even 

though formal recognition exists, there is uncertainty as to the comparability of actual skills 

and competencies. The differences in national curricula are difficult to ascertain because they 

depend on a multitude of factors: clinical knowledge and content of educational 

programmes, training context, cultural expectations, roles and responsibilities in different 

health care systems and so on. Judgements as to what constitutes appropriate quality are 




problematic and contingent upon specific structural and cultural conditions. An argument 

could be made for the development of a minimum competency framework to be adopted 

across the EU. 

The (implicit) assertion underlying the EU legislative framework is that labour mobility is ‘a 

good thing’. Clearly, in an economically and socially homogeneous Europe, which is a supernational 

political entity, such mobility is likely to be considered as a basic human freedom. 

This study highlights the positive aspects of mobility which are both at the individual level in 

terms of widening experiences and opportunities, and at the institutional level where 

organisations are enriched through a wider range of cultural and educational inputs. 

Yet, in a Europe ‘at the crossroads’, there may be unpredictable effects upon individual 

countries. If, for example, doctors are in shortage Europe-wide or in certain economically 

better-off countries, then free mobility may lead to shortages in economically poorer 

countries. The migration of doctors from Greece to the UK would be a case in point. The 

situation could be the other way round: surpluses in better-off countries could aid poorer 

countries, or countries with shortages, or both. The recent (only temporary) surplus of 

German doctors is a case in point. 

What is clear, however, is that national manpower planning in the public sector may often be 

inadequate to achieve its goals in the context of unpredictable international mobility. As a 

result, there may be a politically difficult choice to be made between developing a European 

manpower planning strategy for substantially publicly funded provision (e.g. of doctors); the 

maintenance or even increase in regulatory restrictions on mobility to prevent national 

strategies for being undermined; and the increasing privatisation of public planning (e.g. 

leaving the supply of doctors to the private market with individuals investing in their own 

training). The last is likely to be unattractive and inequitable – for poorer individuals and 

also poorer countries. The second option goes against the grain of developing EU policy. Yet, 

the first option is an attack upon subsidiarity within the EU as currently understood. 

This overview on four EU countries has not begun to investigate these matters in any depth. 

Yet, the pervasiveness of ‘informal’ barriers to implementation of free mobility perhaps 

suggests that – in the absence of clear European policy compatible with member states’ own 

policy and reality – member states will use informal policy, or barriers, to render national and 

EU directives superficially compatible. 



References 

Buchan, J., Seccombe, I. and Ball, J. (1992) The International Mobility of Nurses, A UK 

Perspective. 230, Institute of Manpower Studies. 

Buchan, J. (1998) Your Country Needs You. Health Service Journal 22-25. 

Buchan, J. (2000) Pressure is on, Health Service Journal, 26-27. 

Davies.J. (2000) The devil is in the detail, Health Service Journal, June 1, 18-21. 

European Commission (1996) Education, training, research. The obstacles to transnational 

mobility, Brussels, COM(96)462 final. 

European Observatory on Health Care Systems (2000) Health care systems in transition – 

Germany, written by R. Busse. Copenhagen: European Observatory on Health Care 

Systems (in print) 



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Hurwitz, L. (1990) The Free Circulation of Physicians within the European Community, 

Aldershot: Avebury. 

Jinks, C., Ong, B.N. and Paton, C. (1998) Catching the Drift. Health Service Journal 24-26. 

Lambert, T.W. and Goldacre, M.J. (1998) Career destinations seven years on among doctors 

who qualified in the UK in 1988: Postal questionnaire survey. British Medical Journal 

317, 1429-1431. 

Lowry, S. (1996) Certify a Specialist. British Medical Journal Career Focus, 2-3. 

Lyall, J. (1997) Doctors' Orders. Health Service Journal 12-12. 

McKee, M. (1993) Workshop Discusion Report. In: Normand, C. and Vaughan, P., (Eds.) 

Europe without Frontiers. Implications for Health, pp. 105-110. Chichester: John Wiley 

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Manpower in Europe by the year 2000. From Surplus to Deficit. Copenhagen: PWG. 

Annette Kennedy 

Introduction 

I am speaking on behalf of the PCN Standing Committee of Nurses of the EU, which is the 

only independent EU organisation representing 750,000 nurses across the EU. The 

concentration in this session so far has been on the mobility of doctors. I will try and 

represent nurses in the EU. 

Despite the growing concern across Europe about the nursing manpower shortage, the 

continually increasing international mobility of nurses and the ensuing difficulties in 

healthcare planning and manpower determination, there is a lack of data on the nursing 

resources at national, European and international level. This remains the greatest difficulty 

in predicting nursing manpower requirements and in planning for the provision of the most 

effective and efficient utilisation of the nursing resource. 

There is a lack of basic information in all EU countries about the number of nurses: 

registered in full-time employment / part-time employment; in other employment; 

unemployed; immigrated; on leave for educational / family purposes and there is no accurate 

information on the age profile or turnover of nurses. 

Verbal reports from national nursing representatives across Europe would indicate that 

countries likely to be recruiting nurses internationally have evidence to show that there may 

not be shortage of qualified nurses, but insufficient numbers of registered nurses working as 

nurses in the health service, e.g. Norway, Ireland and the UK. 

Sufficient numbers of nurses have trained and registered over the last decade, but have 

sought alternative employment, have immigrated or have decided not to return to work. 

Many countries portraying a surplus of nurses or unemployed nurses may have shortages in 

specialist areas, country areas or may not have filled nursing vacancies. 

There are many difficulties in compiling data in order to make predictions for the future, both 

nationally and at an EU level. These include: 




1. Different levels of aggregation of figures; 

2. Differences in definitions; 

3. Difficulties interpreting figures on staffing norms; 

4. Diversity of health service delivery; 

5. Statistics not drawn from – a) similar sources, b) similar years. 



113 

OECD figures for 2000, which are regarded as the most accurate, relate in many countries to 

head count as opposed to whole-time equivalents (WTE’s). 

• What does head count mean? The number of nurses, irrespective of the 

number of hours each nurse works? 

The manpower data on medical and nursing staff is collected from professional registers in 

most countries. 

This register indicates that a nurse/doctor is registered as a nurse/doctor in that country, but 

will not indicate if that nurse or doctor is in active full-time employment. 

The Nurses’ Register in Ireland is a case in point. There are 57,000 nurses on the Register, 

which, if this is accurate, would indicate that we have a surplus of nurses. However, we 

estimate that only approximately 35,000 nurses are actively working in the health services. 

This is equally true for other European countries. 

THE QUESTION THAT MUST BE ASKED IS: WHY HAVE SO MANY NURSES OPTED OUT OF 

NURSING? 

European countries have extreme diversity in the delivery of healthcare and of those involved 

in the delivery. The term ‘nurse’ may relate to a variety of workers, which may not be 

compatible – 1st level nurse, 2nd level nurse, state enrolled nurse, nurse assistants, etc, which 

has major implications for the collection of data on staffing norms. 

Seeking data from individual countries is very difficult, not only in relation to aggregation 

and definition, but also in relation to the source. 

The sources may include Professional Registers, Departments of Health estimations, public 

and private figures or separate figures, most of this data is out of date, being years older 

than the survey, which has major implications on the accuracy of the research, particularly in 

times of major changes. 

The data on nursing manpower is extremely deficient. A study undertaken by the EU in 1995 

in relation to nurses / midwives across Europe relied on data from sources compiled in 1990, 

1991, and 1992, depending on the country of origin. No one year could be used across 

Europe, as the data for that year may not have been in existence. 

However, many predictors of such difficulties were in evidence ten years ago, but we failed 

to pick up on the ensuing problems.

114 


Although most countries, as can be seen in the table, had sufficient numbers of general 

nurses, there was a shortage of nurses in speciality areas. In Ireland and the UK, two of the 

countries currently with the greatest problems in relation to shortage of nurses, had an 

oversupply in 1990 / 92. 

However, Ireland did not have sufficient training places for specialist nurses and was reliant 

on the UK for nurses to undertake specialist education. In all countries entry places for 

nursing was restricted and countries indicated that there was a decreasing interest / 

attractiveness in training for nursing. 

• On what basis did countries decide on the number of training places 

required to meet service needs and to meet changes in the workforce 

movement, e.g. retirement, emigration, education, shorter hours, different 

opportunities? 

There is no evidence to suggest that training places for either nurses or doctors were based 

on accurate research data of service needs or changing workforce requirements. 




As you can see from the chart, all the countries who ten years ago had sufficient nurses, now 

have a shortage, except Germany and Spain. 

These countries currently have an oversupply. Germany did have a shortage about 7 years 

ago. However, rationalisation of the health services in Germany has increased the number of 

nurses unemployed. 

In Spain information from the National Nursing Association suggests that, although there is 

an oversupply and unemployment of general nurses, there is a shortage of specialist nurses 

and of nurses working in remote / country areas. 

The Problem is Global 

The problem of shortage of nurses and other health professionals is global, not just 

European. It would be wise to take this into account in any strategy that may be developed 

in the EU. Countries are currently competing in the recruitment stakes. The EU, America, 

Canada and Australia have joined in recruitment and are all recruiting from the same sources 

which are finite. 

• What does that signify for nursing and medicine worldwide? 

It is clear that recruitment from other countries is not the answer. We are “robbing Peter to 

pay Paul”, or in other words, recruiting from each other, recruiting nurses / doctors from 

developing countries, taking the more experienced professionals from countries who have 

surplus, but need these most experienced nurses to develop their own health service. This 



115

116 


is not the solution and is, to say least, unethical, and in many cases that surplus may be as 

a result of an under-resourced and underdeveloped health service, e.g. India, Africa, Eastern 

Europe. 

How Did The Crisis in Nursing and Medical Manpower Arise? What went wrong? 

The most common reasons cited by all EU countries include: 

1. Lack of manpower planning 

2. Decreasing attractiveness 

3. Low pay 

4. Poor image 

5. Restricted / reduced entry numbers 

6. Increased career choices 

7. Inflexible working arrangements 

8. Lack of career progression 

9. Perception of being undervalued 

10. Poor conditions of employment 

11. Heavy workload 

12. Stress 

As already stated, the single most common reason in all countries in relation to the current 

labour crisis in all health professional groups was a lack of information in respect of the 

number of health service employees and the future healthcare needs. There was no 

monitoring of a changing climate among these workers. 

An increase in the gender balance among junior doctors saw more women in medical practice 

who would require time out for family reasons, job sharing, part-time work, who would have 

more difficulty in career advancement and who were likely to change career or retire from the 

service because the conditions of employment did not suit family responsibilities. This is 

equally the case for nurses. The greatest influencing factor in decreasing attractiveness for 

prospective students taking a career in healthcare is low pay, stress, workload, poor image 

of the profession and shift work. Students over the last decade have been given a range of 

very attractive career choices, which give them better pay for a less stressful occupation, 

regular hours and better conditions of employment. 

Changes in medical care: e.g. increasing technology and intervention, more dependant 

patients, increasing elderly, changing health needs, e.g. road accidents, AIDS, unhealthy 

lifestyle, drugs, smoking, alcohol abuse has led to a greater demand for healthcare and, 

consequently, the need for more doctors and nurses. 

Reasons for Mobility of Nurses: 

1. Economic / Employment 

2. Recruitment 

3. Travel 

4. Education 

5. Migration / Emigration 

6. Career Advancement 

7. Greater Opportunities 

The single greatest reason for mobility of large numbers of nurses is economic i.e. improved 

pay and conditions of employment. Nurses moved from Ireland to the UK, the United Arab 

Emirates, USA, and Australia in the 80’s primarily to make money, and secondary to travel. 

Many workers left Ireland for employment and economic reasons. However, when the 

economic climate in Ireland improved the pattern changed and Irish people returned to the 




country. Now Irish nurses, having trained in the UK are returning to Ireland. The nurses who 

choose to emigrate are going to Australia primarily to travel and see the world. 

Nurses have always travelled by choice to other countries; it is one of the attractions and the 

marketing strategies for recruitment to nursing. Generally, nurses who are English-speaking, 

travelled to English-speaking countries and, likewise, within other EU countries as speaking 

the language of the country was an important factor. Now we see a major change, 

recruitment agencies undertake to provide language education to nurses who wish to travel 

to other countries to work. 

In relation to doctors and mobility, it would appear to be related to education and career 

advancement. 

Nursing Registration 



117 

This bar chart reflects the situation over the last nine years in relation to the mobility of 

nurses.

118 


However it must be emphasised that these are registration figures and not actually nurses in 

active employment. Both the EU and non-EU registrations have increased dramatically. The 

EU registrations have doubled in five years from 700 to 1400 and non-EU registrations from 

200 to around 1,000, and these figures have further increased in 2001 with active 

recruitment. 

It must also be noted that the highest figures for Irish nurses registering was in 1996 with a 

gradual decrease since. Now all new graduates will register on the Irish Nursing Register, but 

may choose to work in another country, work part-time or study. 

The UKCC figures show an increase of 20% of overseas nurses on their Register and a 

significantly greater increase in the London area hospitals, which have 3% overseas nurses. 




Problems Associated with International /EU Recruitment: 

1. Language 

2. Culture 

3. Emigration / Migration 

4. Education 

5. Cost 

6. Retention. 

The problems associated with international recruitment have led to PCN and ICN and 

individual countries examining the issue with the objective of drawing up ethical guidelines 

for the recruitment of nurses. PCN has held two workshops in Dublin with the aim of sharing 

good practices in recruitment and retention at a national and European level. 



119 

Ethical Guidelines for best practice recruitment should include the following broad 

categories: 

1. Protocols for Recruitment Agencies 

2. Information on the Country Recruiting and Employment Practice / Laws of that 

Country 

3. Rights of Employees 

4. Details of Orientation / Induction Programmes 

5. Integration Process 

6. Support for Overseas Nurses both socially and within workplace. 

This is where the Single European Market can assist countries to collaborate in good 

recruitment practices. Information can be shared on disreputable recruitment agencies, 

aggressive recruitment practices, recruitment from developing countries, unethical practices 

of recruitment and poor or no support for overseas recruits. 

Strategies for Retention: 

A number of strategies for the retention of nurses have been discussed by PCN-member 

associations and these are follows: 

1. Nursing pay is too low – systems promoting equal pay for equal work are valuable 

– organisations should work towards promoting a level of pay reflecting workload 

responsibilities. 

2. National Nursing Associations to work with local Government seeking favourable 

pay and conditions of work – pay is a priority in retaining nurses. 

3. Consideration be given to funding career opportunities for older nurses. 

4. Implement strategies to attract returnees to the profession – back-to-nursing 

courses. 

5. Support returnee nurses in the clinical areas. 

Nursing is predominantly a female profession with a high proportion of members in 

childbearing and childrearing years. These issues need to be addressed by: 

1. Introduction of family-friendly initiatives; 

2. Provision of adequately staffed childcare and crèche facilities; 

3. Flexibility in hours of work; 

4. Marketing initiatives to recruit mature students; 

5. Continuing professional development as a means of retention;

120 


6. Create ways to assist nurses undertaking further study – study leave, 

reimbursement of fees and expenses incurred. 

Development of management tools to assist nurse managers in terms of pro-actively 

planning recruitment and retention strategies. 

Recruitment of nurses from other countries could be supported by – 

1. Nationally agreed protocol on good recruitment practices; 

2. Efficient national registration system for foreign nurses; 

3. Recruitment using telephone 24-hour help line. 

4. Orientation and induction programmes for overseas nurses; 

5. Nurses from other countries have their education and experience gained recognised 

in terms of pay and conditions. 

Where To From Here? 

It is inherently obvious that co-operation and collaboration is required, both amongst 

countries within the Single European Market and the Eastern European Association (EEA). 

Whilst recognising the difficulties encountered by EU countries in relation to nursing 

shortages, PCN and its member-associations have concerns about recruitment practices which 

militate against finding solutions, within individual countries, to the nursing manpower 

shortage. 

Policy implications should include: 

• Collaborative research into the nursing and medical resource across the 

EU, future health service needs and recruitment practices in order to make 

future predictions. Countries should be assisted / encouraged to collate 

good quality data at local level first and then at national level. Guidelines 

on the aggregation of data should be provided and research should be 

both quantative and qualitative. 

• Setting up of an EU / National Manpower Forum. 

• Identification of successful recruitment and retention strategies and the 

evaluation of their transferability across Europe. 

• Encouragement of countries to set up partnerships. 

• Ongoing monitoring of: 

� Health Service Needs 

� Employment Needs 

� Global / EU 

� Impact of Manpower 

� Changes for the Retention of Nurses 








121 

Public procurement of goods and services: a legal analysis of the 

Spanish case: 

Fernando Silio 

1.Background 

It is estimated that up to 15 per cent of the European Union's Member States economic 

activity originates in the public sector to fulfil needs such as the execution of public works 

and supply and services demanded by the public administration. Public procurement, as 

well as being one of the essential tools of each administration for its own functioning, has a 

great deal of influence in the evolution of the industrial and commercial structure of society. 

For this very reason the inclusion of Spain in the European Community has provoked a 

substantial change in the way public procurement is regulated. The legislative process was 

begun in 1986 and concluded with the enforcement of the 13/1995 Public Procurement Act of 

May 18th. 

One of the backbone policies of the European Union in the construction of a single internal 

market aims to "effectively open the public markets" with the purpose of ensuring 

transparency of information and contract award procedures. This enables both suppliers 

and businesses greater opportunities to develop and carry out their activities in the 

community. The market expansion allows the reduction of cost through scale returns and 

improved efficiency thanks to the positive effects of competition. Also, the diverse public 

administrations benefit from greater choice which allows important budgetary savings. 

Finally, consumers and users benefit from services at better value for money14. 

The basic principles of public procurement which derive from the Directives are: equality, 

transparency and competitiveness. These are basic principles which have to be complied with 

in any contract. In the health sector the new legal framework has caused a revolution, as 

there is a high level of public procurement in the health sector administration. 

As in any other sector, deficiencies in the application of communitarian regulations in the 

Spanish legal system have been immediately identified. First of all, the Directives on the 

excluded sectors have not been implemented in time to our legal system. Secondly, the lack 

of determination in our public sector, from the organizational point of view, has resulted in 

the non-application of the law contracts, breaching the communitarian law. Thirdly, from a 

technical perspective, we should point out that there is excessive formalities in the 

enforcement of the regulations, a contradiction according to the communitarian principles. 

Finally, we should also mention the infringement of a rule which has lead the European Court 

of Justice to condemn Spain for putting into practice usages contrary to the freedom of 

movement of people, goods and services. These are some of the reasons which have lead 

the Spanish working party to make a study of the impact of the new legal framework on 

Public Procurement one of their main objectives. 

14 During the time we were doing our research, the European Commission has adopted a package of 

amendments to simplify and modernise the public procurement Directives. The Lisbon European Council 

acknowledged the importance of this legislative package for the competitiveness of European companies, 

effective allocation of public resources, economic growth and job creation, and recommended its adoption and 

implementation by 2002.

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2. The impact in the health services. Public procurement in the Andalusian regional 

government 

Introduction 

The system of purchase of goods and services by the Spanish health centres has undergone 

a series of changes over the last years as a result of the Community Integration process. The 

impact of European legislation on the system of purchase of goods and services materialises 

in Spain through the Act 13/95 on contracts of the Public Administrations, currently in force, 

and which derives mostly from Directive 93/36/EEC. 

During this phase of our research, our objective has been to demonstrate the impact of 

community policies on these services exploring the Spanish case in order to be able to 

establish comparative objectives among the countries participating in this project. 

We have started from the principle that in the public procurement of goods and services, 

there is an interaction between the demand of the public sector and the supply of the 

private sector. During the first stage of this project, we have identified the main legislative 

transpositions carried out within the Spanish legal system. 

The Spanish Act 13/95 regulates the process of purchase of goods and services by the 

Spanish Public Administrations. The main stages in this process are detailed in the graph 

that follows. This graph is the result of our field work in Spain and it is also the summary of 

the process, as described by the persons interviewed: 






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124 


Comparative analysis of real expenditure on goods and current services by the Andalusian 

health service (A.H.S.) in relation to calls for tender 

The following graph shows the real expenditure on goods and current services by the A.H.S 

in 1998 and the calls for tender in order to purchase them. 15 

As can be seen, the total value of tenders (525.07 millions of euros) represents 66.75% of 

the total expenditure (786.66 millions of euros. 

A description of the calls for tender by the Andalusian health service and their publication in 

the European Communities Official Journal 

The Spanish Public Procurement Act 13/1995 of May 18th establishes, in Book II, the 

publishing regulations in the European Community for the types of contracts according to the 

amounts involved and it lays down the following criteria: 

� Works Contracts : 

To be published in the OJEC if the amount is equal to or higher than 4,090,831 

euros. 

� Supplies Contracts: 

To be published in the OJEC if the amount is equal to or higher than 163,633 euros. 

� Management of Public Services Contracts : 

Publication in the OJEC is not compulsory. 

15 .- Goods and current services expenditure does not include the amount for concerted health care, for this 

reason it has not been included under type 62 "Health Care Services" of the analysis of tenders. The purpose of 

this is to establish a comparison between the amounts for real expenditure and calls for tender. 




� Consultancy and Assistance Contracts: 

To be published in the OJEC if the amount is equal to or higher than 163,633 euros. 

The following graph illustrates the calls for tender by the ANDALUSIAN HEALTH SERVICE and 

their publication in the OJEC as stated in the above mentioned regulation: 

Calls for tender and their publication in the OJEC. ANDALUSIAN HEALTH SERVICE-1998 

CALLS FOR TENDER % 

COMPULSORY PUBLICATION 482.30 89.57 

NON-COMPULSORY PUBLICATION 56.18 10.43 

TOTAL 538.47 100 

Data in millions of euros 

Source: Statistics and Information Service of the ANDALUSIAN HEALTH SERVICE 



125 

Note that 89.57% of the totality of calls for tender require to be published in the OJEC, 

compared with a 10.43% that do not require compulsory publication.

126 


Collection and analysis of the information obtained from the semi-structured interviews with 

economic administrative directors 

This information was collected in March 1999 in the different centres, in person and by a 

trained interviewer. Each interview was recorded and subsequently transcribed. 

The analysis of the information has been performed through a process of contents analysis, 

complemented by an automatic analysis performed by the computer programme NUDIST. 

Changes in the purchasing process: 

In general, the proceedings are very similar to the ones existing before this law. The main 

changes are shown in the following table: 

European publication is required. 

New criteria for the award of contracts. 

Different costs to establish the type of procedure. 




Positive aspects: Negative aspects: 

• Improvement of the 

organisation in a short 

period of time. 

• The objectivity of the 

awarding criteria 

increases. 

• Better publicity and 

more transparency. 

• The procedures to 

negotiate exclusivity 

contracts become 

quicker. 

• Increase in quality, rigor 

and protocolisation. 

• Increase in red tape, 

which affects quickness. It 

is compulsory to go 

through a long, hard and 

difficult process. 

• The law fails to adapt to 

the sector and to the 

specific needs of health 

bodies. 

• There is little clarity in 

some aspects, such as the 

framework agreement or 

the proceedings required 

for the negotiated 

process. 

• It becomes more difficult 

to detect needs. There are 

more information needs, 

and this implies an 

increase in services and 

personnel. 

• Extension of time limits to 

make the purchases. 

• Discomfort among 

professionals. 

“For example, one can say: 

“ how much am I going to 

spend on sutures in the 

year X? Or you can say: 

“well, I am going to spend 

money on a prosthesis and 

you think: we are going to 

buy fix prosthesis, but next 

year the decision is to buy 

rotative prosthesis, and 

what are you supposed to 

do with the contract 

signed for the fix ones?”. 

(ECONO1) 

“If you prepare the tender 

well, it normally works 

well. Sometimes, doctors 

have got used to a specific 

type of trade mark and if 

the tender is not well 

defined, there can be 

problems. There have been 

problems with needles and 

other lots”. (ECON02) 

“It has been a great effort, 

based on experience. 

When you get to the 

technical committees, in 

which the technical aspects 

are assessed, there are 

mistakes in the 

convocation which must 

taken into account for the 

following year” (ECON08) 

Reasons for the changes in the purchasing system 

Reasons for current changes in the purchase system are frequently attributed to the 

European Union's influence in the integration process of its Member States: 



127 

Changes and improvements can also be seen as a result of the enforcement of the Spanish 

Public Procurement Act which establishes the adaptation of services to the new situation:

128 


Another argument given by the people we interviewed is to ascribe the changes as the result 

of an evolutionary process towards the improvement of Public Administration, meaning more 

budget control and a reduction of administrative arbitrariness. 

Changes in tenders: Bi-annual tenders 

The increase of paper-work is one of the main consequences carried by the new contracting 

procedure, in particular when calling for a tender in order to purchase for the health sector. 

Pluriannual tenders are a way of avoiding and delaying the increase of "bureaucratic tasks". 

According to the people interviewed, pluriannual tenders have increased as a result of the 

new Spanish Public Procurement Act. This type of tenders have more complex procedures 

but also have more advantages. One is an increase of the contracting authorities' loyalty 

towards the supplier who will supply the merchandise for longer periods of time. In return 

there is an improvement of quality and better prices. 

However, the interviewees have also pointed out some restrictions and problems arising from 

this type of procedures: the impossibility of applying them to goods undergoing fast 

technological development and that require changes in their definition when purchasing 

them. 

Among the procurement services we contacted, there are some that do not apply this type of 

procedure to all the purchased goods and services. They are only applied for large contracts. 

Sometimes the people interviewed have declared that this type of procedures already existed 

and cannot be attributed to the new legislation. However, these cases have been 

exceptional. 

Contracts published in the Official Journal of the European Communities 

The publication in the Official Journal of the European Communities (OJEC) varies in the 

different health centres were we had staff interviewed. It varies between 11% and 80% of the 

total of procedures submitted to tender. 

In general, hospitals publish more if we compare them with the Primary Care Districts we 

have studied. The reason can be found in the differences in the volume of procurement. 

Among hospitals the Virgen del Rocio Hospital in Seville published more than any other 

hospital in 1998, in the OJEC. However, we have to take into account that it has the biggest 

assigned population, number of beds and budget. 

To publish in the OJEC implies a prolongation of the time limit for the awarding of tenders. 

Some interviewees have acknowledged that in some institutions the tenders are fractionated 

in order to avoid compulsory publication at European level and therefore shorten the time 

limits. 

Criteria for the award of tenders: Changes introduced by the new law 

The criteria for the award of tenders are different depending on the Andalusian health centre 

studied. It depends on the type of goods and services to be purchased whether more points 

are given to either price or technical quality. There is wide scope for case analysis. Generally, 

the first distinction is made between supplies and services. When considering supplies, 

prices are more important than in the case of services. In the latter the main considerations 

are mostly technical. 

These criteria are established according to the type of goods and services, based on the 

decisions made by the departments in charge of the procurement services, and the usual 

practices in the awarding of contracts. There seems to be a general criteria in each centre for 

the different groups of items or services contracted. 




In high-tech supplies and services priority is generally given to the technical report but for 

those goods which have an established quality and technology, money is the main 

consideration. 

Occasionally in some tenders we have found considerations being made to specific aspects 

that were not related to the technical report or price. 

In other cases the department doing the purchase can fix the price before calling the tender. 

In that way priority is given to the technical report because we start by fixing a "reference" 

price according to market considerations. 

In most of the cases studied the technical information is provided by the centre's specialised 

staff. However that is not always the case and it depends mainly on the type of centre. In 

the following quote we illustrate a case which corresponds to a situation where there was no 

separation between price and technical report when calling for a tender. 

The fact that you can't undercut prices in tenders in order to obtain the award of a hospital 

service, means that prices have to be as fixed as possible. This is done well before the 

preparation of a tender, then technical standards are taken into account . 

In some hospitals we have worked with the impact of the European Union will have price 

repercussions and therefore criteria will be established when purchasing goods and services 

for health centres. 

Adaptation to the new legislation 

Procurement services tend to adapt themselves to the time limits established by law in order 

to award tenders. That has been the most frequent opinion among the interviewees. 

In hospitals or primary care centres where we interviewed managers, the first problem they 

have mentioned were the formalities of the tender itself and the technical report which has 

to be drafted by the centre. 

The main inconveniences related to the processing of tenders are: the length of time, usually 

long, the establishing of objective awarding criteria, the comparative analysis and the 

definition of the technical characteristics. Also, it is necessary to obtain the consensus among 

professionals, which is also difficult sometimes. 

Once the formalities are fulfilled in their own centre, the external time limits are also 

mentioned as an obstacle to ensure compliance with legislation. They are mainly legal 

advice and publishing by the central services. 

Sometimes, particular problems appear with some companies when is time to sign a contract 

or deliver the goods. These problems also delay the fulfilment of the time limits. This is a 

result of the exclusivity that some companies have, resulting from the negotiated procedure: 

We have to take into account that the publication of a tender is a process for the planning 

and scheduling of the services. This aspect is regarded as an advantage for the procurement 

department's tasks. 

As regards improvements derived from "better purchases", publishing increases the offer 

from different brands and products. The increase in competition lowers prices and sometimes 

there is even an improvement in the technological quality of some items. Also, service 

managers are obliged to be better informed about the market. 

However, there are also cases in which the procurement departments we have studied 

consider the new directives as a path full of obstacles. Especially when they involve the 



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130 


publication process and the compliance with time limits, which do not grant any advantages. 

In our study these cases were very rare. 

Consequences for the market variations in the type of providers 

In general, the people we interviewed didn't remark on any substantial change in the type of 

providers that submit to tenders called by the Andalusian health services. 

In our study, we have noticed a larger presence of big companies and multinationals 

compared to small and medium-sized enterprises. This is due to the market's own dynamics 

and because of the latter's impossibility to tender. 

The arguments put forward in order to explain SMEs' difficulties for tendering are mainly due 

to debt but also because of not being able to prepare the required documentation for any 

tender. 

Among professionals there is a feeling of dismay because they had been used to working 

with the same suppliers from smaller companies for a long time. 

The change in the type of suppliers can also occur because of the improvements made by 

the departments in the purchase proceedings. They take advantage of competition among 

suppliers and try to avoid dependency as clients. 

We have found a case in which the changes occurred only in a specific type of contract and 

not in general. 

One of the main achievements of integration in the European Union could be a greater 

participation of foreign companies in tenders for health services. However, our data do not 

reflect such a situation. In most of the cases, the main tenderers are multinational companies 

with branches in Spain or they are simply the same companies as before the process of 

European integration. 

Subjective view of the impact of European legislation on public procurement departments 

For most of the people we have interviewed, their purchase systems haven't registered any 

impact as a result of the new European legislation. Some exceptions can be found in the 

following; the obligation to publish in the Official Journal of the European Communities, 

changes in the awarding criteria and in the procedures. 

In some of the procurement departments where we interviewed the staff, they have received 

phone calls from European companies interested in the tenders. No tenders by those 

companies were submitted after the calls. 

However, the impact can be perceived in the Spanish Public Procurement Act 13/95 which 

reflects European legislation. It can also be seen in the new formalities for calling a tender as 

established by law but not from the communitarian law. 

Some of the professionals interviewed, who work in public procurement in Andalusia, said 

that they felt they were under surveillance because the new law was brought into force to 

avoid corruption. Thus, it has caused some lack of confidence. 

For some of these professionals, in order to apply the law in the health services, its 

implementation should be more flexible and adapted to the situation and objectives of 

public services. 

In some cases, there have been complaints about the lack of information that services' 

managers have on the impact of the new European legislation on their departments. The 

following is an extract of an interview that illustrates this situation. 




3. Effects derived from the transposition of the European regulations to the Spanish legal 

framework. 

Intended effects 

The health sector's considerable amount of procurement emphasises the effects that the 

Communitarian rules will have in this area. Without including all possibilities, in the health 

sector there are important categories of contracts and it is worth mentioning the most 

important ones. We will provide what will be only a descriptive and qualitative analysis. 

Works contracts have a great deal of importance not only for building new health centres but 

because it is always necessary to reform and extend existing premises. However there is a 

great drawback in this type of contracts: insufficient formal budgets, as the investments 

budget is scarce if not non-existent. Apart from those works financed by the European 

Union's ERDF funds, this difficulty has been overcome with subsidies either from local 

Corporations, companies or instrumental entities that are in charge of the negotiation of 

contracts. These types of contracts do not have any repercussions in the peripheral 

management of the centres. This is because the negotiation of contracts is normally 

centralised due to the amounts involved. Over time a gradual externalisation of the 

execution controls has also been observed. Before, the administrative services had their own 

team of engineers and architects as well as project supervision departments. Nowadays these 

services are provided by professionals who do not belong to the organisation itself. So far, 

concerning the impact of the communitarian principles, there has been no effective opening 

of the market. The reasons can be found in the need to have branches in the area where the 

work is to be carried out or the need to purchase or transport heavy machinery and staff 

belonging to a firm, hampering the participation of foreign companies with very few 

exceptions. However, those exceptions are important as they have bided as temporary joint 

ventures usually with the participation of a Spanish construction company. 

The administrative award of public works has not yet developed greatly in the sector, but 

now the need to improve access and equipment in health centres is starting to make this 

type of contracts more commonly used, particularly in order to build and manage car parks 

and co-generation power stations in large hospitals. Concerning tenders, they are also 

applicable to works contracts. 

Another important category of contracts is the management of public services, strictly 

speaking concerted health care. This type of contract implies indirect management of public 

services. This is the case when the Administration, holder of the competency to provide the 

service, does not have enough resources to do it. In such cases it is necessary to hire 

services from private firms working in the same activity. Thus, in concerted health care the 

aim of contracts is always to provide health services, though we have to distinguish between 

complete concerted health care, when a private hospital or clinic is contracted to provide the 

totality of the services involved, and specific concerted services such as imaging diagnosis or 

particular services in order to treat certain pathologies. This could be the case when 

contracting services to operate on cataracts in a specific population group. In this category 

health transport is also included. Concerted health care is categorised as an administrative 

contract regulated by the Spanish Public Procurement Act and also, as established according 

to its specific set of rules, by the Spanish Health Care Act 14/1986 of April 25th , article 90. 

Despite economic and social importance, concerted health care contracts are irrelevant from 

the perspective of this study, as this type of contract already existed in the Spanish legal 

framework and is not subject to communitarian regulations. 

However, there is a fact worth mentioning related to private health centres or institutions. 

To study the running of such centres would be interesting as they are business activities 

linked to free entrepreneurial activities or movement of capital, as far as the investment of 



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communitarian funds is concerned. From that perspective alone concerted health care would 

be conditioned by the communitarian regulations. 

In health services the supplies contract can be categorised as the most important one due to 

the volume of activity that it produces. Among the purchase of goods electro-medical devices 

can be highlighted. Such supply contracts have traditionally had the same financial problems 

as the works contract, budget wise, as such purchases become an investment. New types of 

contracts have solved this problem. Now it is the hiring without purchase option which 

prevails, allowing not only the use of equipment but its fast renewal, an obligation due to 

scientific and technological improvements and at the same time avoiding depreciation of 

equipment that soon becomes obsolete. The introduction of new contract types such as 

leasings and hiring with purchase option offer new possibilities for these purchases. These 

sorts of goods are mainly supplied by European companies as well as American and 

Japanese companies with branches in Spain, therefore the application of the communitarian 

rules is not modified by the nationality of the supplier. These companies (communitarian 

and those included in the European Economic Area and the World Trade Organization) could 

benefit from the fact that they will be able to bid directly from their countries without the 

need to establish themselves in Spain saving costs. But from the perspective of health care 

services no change will be perceived in a short term. 

Another important supply for health care centres is medicines. Traditionally health care 

institutions purchased medicines for hospital dispensaries by direct contracting. This practice 

caused non-favourable judgement by the European Court of Justice concerning case C- 

328/1992 Commission versus Kingdom of Spain, Sentence of May 3rd 1994. The grounds on 

which the Luxembourg Court based its decision are derived from the fact that the directive 

does not exclude those products from its scope of application as well as being a 

infringement of the transparency and competition principles. Also the supremacy of 

Communitarian Law invalidates the ground argued by the defence based on the Spanish 

Social Security Act which establishes that medicines and pharmaceutical items destined to 

used in health centres will be directly purchased through an Agreement between the 

Administration and the pharmaceutical industry. Also, the Spanish Medicines Act categorises 

these products as mediatised therefore excluded from contract legislation. Regarding 

suppliers we can also apply our argument to the case of electro-medical equipment. Large 

laboratories keep a firm control on market forces which frequently makes free competition 

difficult in the supply of these products. In any case, in order to comply with the 

communitarian principles concerning the supply of medicines harmonisation techniques are 

also necessary as the nature of the product demands that the corresponding authorisations 

and administrative checking procedures be in tune with the fabrication and 

commercialisation. 

Everything we have said so far is also valid for the supply of all other health products; 

reagents, medicinal gases, surgical equipment, and so on, due to the fact the their technical 

features have already predetermined the market and therefore there is no variety in the type 

of supplier, though logically purchase by tender could lower the product's prices. 

In the case of ordinary supplies, generally due to their low cost, they are considered as 

minor items with no communitarian participation. It is the local companies who take charge 

of their supply. 

In the section concerning services, as well as consultancy and assistance contracts, in which 

the range of communitarian influence is modest, some important services required by health 

centres are: cleaning, catering, maintenance and security services. Such services are 

contracted through tendering and competition is fostered due to their high value. However, it 

remains that because of their inherent characteristics requiring the availability of many 




workers mainly Spanish companies and groups bid for the tenders. The compliance with the 

communitarian regulations has not attracted foreign companies. At another level we shall 

mention the computing services where participation of foreign companies is greater due to 

the sector's configuration. 

Other contracted services, of less economic importance, are publicity for health promotion 

campaigns, training services or legal services in which there is no communitarian 

participation. 

Insurance services are a recent addition to the Spanish health system. Communitarian 

regulations have an influence on the contracting of civil liability insurance policies due to 

their high costs which require advertisement at communitarian level. This sector, though 

supervised, requires a mandatory administration authorisation in order to operate the various 

insurance categories and has been influenced by the regulations established by the 

communitarian institutions. This influence has forced the Member States to adapt their 

internal regulations. In Spain such adaptation has been carried out according to the Private 

Insurance Code and Supervision Act 30/1995. The contract type envisaged by the Spanish 

State Contracts Act of 1995 revealed itself as inadequate. Which is why, after the reform, this 

service is considered as a private contract, though its awarding should comply with the 

contracting communitarian principles. 

To conclude this brief description, we will mention a series of contracts with patrimonial 

content and therefore excluded from the procurement legislation, but which have to be 

awarded complying with the communitarian principles. They are the awarding of contracts for 

the opening of cafes, press and lottery stands, cash lines and other business premises 

appropriate to health service buildings. In this contract category, rather unclear regarding its 

legal status, the communitarian regulations have not been applied and consequently there is 

no communitarian competition. 

UNintended effects 

The analysis of the influence that public procurement has in the health sector demands that 

we first look at some determinant regulations. First, the basic legislation on public 

procurement, according to the Spanish Constitution -article 149.1.18-, establishes it as an 

exclusive State competency. Being considered of a widespread nature, affecting the 

Administration proceedings in various sectors and closely related to the market regulations, 

the Spanish Regional Governments will only be competent with regard to its legislative 

development. Although the Spanish Constitutional Rights Court in its sentence of April 22nd 1993, rendered for case 513/1987 regarding a conflict of competencies, established that 

Regional Governments have broad competency in the sectors which affect the organisation of 

their administrative proceedings and in those areas of competency which are granted by 

statutory dispositions. For instance, some Spanish Regional Governments can regulate the 

extent of competency of the contracting authorities, the guarantee that bidders provide as 

financially and economically able, the securing and or exemption of guarantees in certain 

contracts, the reasons for ruling on a public service management contract, the leasing of real 

estate, payments in cash or other goods in a supplies contract, the summoning of Award 

Tables, etc. 

On the other hand, concerning the health sector, the Regional Governments have major 

competencies in health service management. Together, the various Regional Health Services 

form the Spanish National Health System. 

It is probably in the health sector where the debate on new management forms and the need 

to overcome the traditional model under the administrative law has had greatest importance. 

The National Health System Analysis and Evaluation Commission appointed by the Spanish 



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Parliament in 1990 advocated, in its summing up of the sector's problems, radical reforms 

which included, amongst others, the granting of greater autonomy to the health centres in 

order to transform them into public companies. 

To put in Spanish jurisprudent, Muñoz Machado's, own words "...the trend for abandoning 

Public Law guarantees and the infiltration of Private Law in every aspect of the public 

services goes against the reality our times. Whilst we abandon some of those sorts of 

guarantees the European Union, to which we belong as full members, is imposing the 

necessary maintenance of a series of guarantees, that of course belong to Public Law, for the 

functioning of certain establishments or in order to configure certain activities" (Muñoz 

Machado: 1995). 

Definitively, this is what is happening in spite of concepts or differentiated organisational 

models in topics such as public procurement in which the working tools have to suit the 

forecasts of Communitarian Law independently of the role of such rules as determining 

factors in a management model. As we have said, independently of the management model 

adopted, public procurement is fully submitted to Communitarian Law and the sometimes 

difficult position health managers find themselves in, who have to combine effectiveness, 

efficiency and legality in their task. 

The previous legal analysis allows us to come to the conclusion that the impact of European 

regulations in the purchase of goods and services is important because it has changed some 

patterns in administrative management bringing about some legislative modifications in the 

Spanish legal framework. These changes will be greater in the future. Planning for the 

purchase of goods and services has become an essential tool permitting a greater 

rationalisation of procurement. On the other hand such change, which has not been 

welcomed by an important portion of the management staff, has contributed somehow to the 

debate on new forms of organisation of the health services. 

4. Conclusions and recommendations 

The transposition of the European regulations to the Spanish legal framework on public 

procurement started in 1986 after the accession of the Kingdom of Spain to the European 

Economic Community. Since then, the extent of the influence of these transpositions has 

been gradual, although from a substantial perspective we can assert that communitarian law 

has been properly incorporated within the Spanish internal rules. However, such 

incorporation has suffered delays in certain cases and formally has meant the noncompliance 

of the Spanish State obligations as stated by the communitarian Treaties. Such 

was the case of the directives on supplies contracts in the utilities sector, as well as those 

that modify and adapt the directives on services, supplies and works, both adapted beyond 

the limit of the dateline. 

The communitarian directives have put forward a new concept in public procurement. Due to 

the diversity of legal frameworks in Member States, the administrative organisation or the 

denomination of contracts is not an issue for the European regulations. On the contrary, 

what is actually important is an effective opening of the public sector's market. Thus, any 

contract, fully or partly financed with public funds, is considered as a public contract and 

the contracting entities from the Public administration, or not, will be appointed as the 

awarding body. 

From this perspective, the impact of communitarian law in the purchase of goods and 

services in health care services has been as important as in the rest of the public sector. This 




is because procurement is a widespread subject that affects any activity involving public 

expenditure and investment. 

The impact of the communitarian regulations has been immediately perceived in its intended 

effects. The incorporation of regulations within the Spanish legal framework has meant, 

procurement wise, a reinforcement in the application of the communitarian principles of 

transparency and competition, as well as the application of the equality and nondiscrimination 

principles. This is evident if we look at the new regulations concerning the 

contracting proceedings, awarding proceedings, the fixing of time limits and datelines for 

publishing in the official journals, as well as the new regime for establishing the essential 

capacity and reliability qualifications of the contracted companies. 

From the contracted parties perspective, partly because of the market's configuration, there 

are no significant changes and because of this the supplier's features remain the same. 

Generally speaking, the contracting possibilities have substantially changed. Now we have 

new types of contracts and new possibilities in the purchase of goods and services that were 

not externalised from the administration. 

The unintended effects resultant from the application of the communitarian regulations have 

stressed the existent differences between the trend set up by the European Union and the 

need to provide health care management with alternative mechanisms. 

Concerning the purchase of goods and services in the health care sector, the debate on the 

wrongly called "privatising trend" has been heightened. We say wrongly called because in 

fact, the trend does not imply the transfer or sale of resources and services to the private 

sector. What is actually being questioned is a management model subject to Public Law. It is 

into this context which we can fit the so called "escape of Administrative Law" searching for 

alternatives that have to create instrumental entities subject to Private Law in their 

proceedings. 

When we deal with public service management public order in general and the inherent 

nature of things establishes a series of limiting factors. Public Administrations, as opposed 

to a private entity, can not without further questioning do anything that is not formally 

prohibited. In fact, in the public sector, any activity always requires a qualifying rule. Every 

proceeding carried out by the Administration is predetermined in rules according to the 

classical principle of legality, therefore there is no possible management model aside from 

the established rules and norms. 

If the communitarian legal framework establishes a particular administrative concept in the 

public sector, implying the existence of public law guarantees which are mandatory for the 

functioning of certain establishments or for the configuration of some proceedings, it is 

worth taking advantage of it. And it should be done with the right flexibility required for 

managing public services with more effectiveness and efficiency. 

The formal limitations that a regulation establishes can be compensated with more decision 

power. In our case, when Public Administrations have to contract services they have to 

comply with certain requirements and they are under constant supervision, not only political 

but legal, financial and economic. However, when the Administration contracts a service 

according to Public Law, it has a special regime not without advantages; it does not contract 

as a private entity among equals. The Administration is in a prevalent situation justified 

because it serves the general interest. 



135 

To sum up, the assessment we can give to this situation is positive, although the limitations 

alluded to should be taken into consideration.

136 



General 

Encouragement from the entities involved in the management of health care services should 

be sought in order to foster legislative and ruling initiatives. 

In Spain, the regulation proposals should be formulated by the competencies of the Regional 

Governments as established in the Spanish Constitution and the Regional Governments 

Statutes which grants them with competencies in the development of rules in contract law. 

Specific 

It is necessary to give managing entities mechanisms in the planning, co-ordination, and 

homologation of proceedings for greater effectiveness in procurement. 

In procurement it is absolutely necessary to previously define what we want to purchase and 

which services are needed. A very important mechanism is the preparation of a product and 

services catalogue. Catalogues define the technical features of the goods and services 

included in it. These would be subject to constant modifications as the health care activities 

are linked to scientific and technological progress. 

Regarding the contracting systems, the simplification of administrative proceedings can be 

achieved by creating centralised entities that would catalogue suppliers according to 

contracting capacity. Contract forms would need to be approved, not for types of works 

contracts, services or supplies but for specific contracts i.e. cleaning, supply of reagents, 

security, hiring of equipment, etc. As well as the approving, within the entities, of provisional 

and definitive security exemptions, the fostering of prototype contracts and tenders to decide 

on them, the creation of contracting boards, the preparation of contracting guides and the 

necessary moves to design management training courses. 

Although budgets are issued on an annual basis which sets the pace of public expenditure, 

it is important to fix a planning mechanism in order to establish the appropriate purchase 

time. 

Finally, a redistribution of competencies would be recommended in order to establish who 

purchases. Despite the fact that autonomy in taking decisions has proved to be an efficient 

mechanism in certain purchases more centralisation could save administrative costs and 

some services could benefit from the effects of scale economy. 



5. References 

ARIÑO ORTIZ, G. El concepto de contrato público en la CEE. Noticias/CEE 21, 1986. 

BAÑO LEÓN, J.M. La influencia del derecho comunitario en la interpretación de la Ley de 

Contratos de las Administraciones Públicas. RAP 151, 2000. 

BASSOLS COMA, M. Aproximación a la normativa comunitaria europea sobre contratación 

administrativa. Noticias/CEE, 21, 1986. 

BORRAJO INIESTA, I. Las Directivas sobre contratación pública como manifestación de la 

libertad comunitaria de circulación. Noticias /CEE 21, 1986. 

GARCÍA GÓMEZ DE MERCADO, F. Contratos administrativos y privados tras la Ley de 

Contratos de las Administraciones Públicas. REDA 95, 1997. 




GARCÍA RUBIO, F. Agrupaciones de interés económico y la influencia europea como sujeto de 

contratación administrativa en La armonización legislativa de la Unión Europea. Ed. 

Dykinson, 1999. 

GIMENU FELIÚ, J.M. Una valoración crítica sobre el procedimiento y contenido de las últimas 

reformas legales en contratación pública. RAP 144, 1997. 

GONZÁLEZ-BERENGUER URRUTIA, J.L. La incidencia de la legislación comunitaria en el 

régimen de contratación de obras. Noticias/CEE 21, 1986. 

GONZÁLEZ-VARAS IBÁÑEZ, S. La contratación de las Comunidades Europeas. RAP 142, 1997. 

JIMÉNEZ-BLANCO CARRILLO DE ALBORNOZ, A. El impacto de la normativa europea sobre 

contratación administrativa en la legislación de contratos del Estado. Noticias/CEE 21, 

1986. 

LÓPEZ BLANCO, C. La doctrina del Tribunal de Justicia sobre la contratación pública. 

Noticias/CEE 21, 1986. 

LÓPEZ FONT MÁRQUEZ, J.F. La apertura de los procedimientos nacionales de adjudicación 

de contratos públicos a las empresas de otros Estados miembros de la Unión Europea 

(Sentencia de 17 de noviembre de 1993 del Tribunal de Justicia de las Comunidades 

Europeas) RAP 133, 1994. 

MARTÍNEZ-CARDÓS RUIZ, J.L. La adaptación del Derecho español a las directivas 

comunitarias sobre contratación administrativa. Noticias/CEE 21, 1986. 

MESTRE DELGADO, J.F. La normativa comunitaria europea sobre contratación administrativa. 

Noticias/CEE 21, 1986. 

MONEDERO GIL, J.L. Criterios de adjudicación del contrato administrativo en el Derecho 

comunitario. Noticias/CEE 21, 1986. 

OLIVERA MASSÓ, P. La problemática sobre la delimitación del ámbito subjetivo de las 

normas internacionales sobre contratación pública. RAP 145, 1998. 

- VALERO LOZANO, N. El régimen de las actuaciones administrativas preparatorias de los 

contratos en la Ley 13/1995. RAP 142, 1997. 

VICENTE IGLESIAS, JOSÉ LUIS. Comentarios a propósito de la próxima reforma de la Ley 

13/1995 de 18 de mayo, de Contratos de las Administraciones Públicas. Actualidad 

Administrativa Núm. 31 de 1999. 

VVAA. La reforma del Sistema Sanitario. Análisis comparativo de siete países de la OCDE. 

ESTUDIOS DE POLÍTICA SANITARIA NÚM. 2 , 1998. 

VVAA. Mercados internos en evolución. Sistemas Sanitarios en Canadá, Islandia y Reino 

Unido. ESTUDIOS DE POLÍTICA SANITARIA NÚM. 6, 1998. 

VVAA. La reforma de los sistemas sanitarios. Una voluntad de cambio. ESTUDIOS DE 

POLÍTICA SANITARIA, NÚM. 8, 1998. 

6. An approximation to the public procurement of goods and services in other European 

Countries: The case of England and Sweden 

6.1 Public procurement of goods and services in the UK: NHS Supplies 

In the UK a body called NHS Supplies (NHSS) provides a service to most NHS Trusts 

(hospitals, community and mental health) for the procurement of goods and services. NHSS 

has the following capability: 



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• Customer services to Trusts: out posted teams which offer generic and specialist 

advice for procurement (this includes everything from foodstuffs, stationary to 

medical supplies and highly specialist equipment); 

• Contracts: the specification, negotiation and management of contracts; 

• Warehousing and logistics. 

There are a number of private companies in the same business which can compete for 

national contracts, especially in the generic business such as foods, stationary etc. Arguably, 

NHSS has built up considerable expertise in the medical supplies business, but not all out 

posted teams have this specialist knowledge available. Currently, there is debate about the 

future of the customer services part of NHSS and strengthening the specialist, clinical 

knowledge is one option. 

In terms of procurement of goods and services Trusts are free to choose themselves which of 

the following routes they choose: 

• Go through NHSS for the specification, negotiation and management of a contract; 

• Use NHSS customer services using their specialist knowledge to secure the best 

contract, and then manage it themselves; 

• Directly access, negotiate and manage the contract themselves. 

Decisions on the above options depend on what is considered best for the local organisation 

in terms of price, quality, accessibility etc. Thus, in practice there is considerable variation 

between organisations. 

An important advantage of using NHSS is the already mentioned expertise they have in the 

field, but also because they attempt to stay abreast of new developments in the field and 

appraise the costs and benefits for Trusts. Because NHSS works across many organisations 

they also build up incremental knowledge of what works in practice. They maintain a 

database of the range contracts held by NHS organisations. 

There is always the problem that consultants tend to believe the representatives of 

companies, especially when they have a medical/nursing background. NHSS offers ‘nonpartisan’ 

advice, and it is important that they develop the evidence-based aspects of their 

services in order to counterbalance the commercial sales talk of representatives. 

The financial benefit of NHSS is the potentially lower overheads in comparison to operating 

with a dedicated Trust-based supplies function. 

The procurement process 

There is no fundamental difference between the procurement of goods or services. When a 

need has been identified within an organisation the size of the contracts determines the 

process: 

• Below £25,000 the Trust can decide itself what and where to buy. This is mainly 

decided by the Executive Team (esp. Director of Operations and Finance Director) 

and put to the Audit and Performance Committee which is a sub-committee of the 

Trust Board. Mostly, decisions are made on the basis of comparing competitive 

quotations. At times smaller purchases are done as single tender actions. 

• Between £25,000 and £104,435 the Trust puts contracts out for tender. The length 

of the contract can vary, but the total sum needs to be within these limits. 

• Above £104,435 the contract has to be put out to tender and advertised in the 

European journal. This process takes a minimum of 77 days. If these are rolling 

contracts over a 4 year limit they also have to be advertised in the European 

Journal. 




For the contracts that have not been put in the European journal the rules in the Trust’s own 

Standing Financial Instructions apply. These lay down rules for the tendering process and 

management of contracts and the framework is developed by the Department of Health 

(there is local variation about the size of the £25,000 limit depending on the total size of the 

organisation’s budget). 

A number of routes are possible: 

• NHSS may have a series of ‘packages’ which can be bought. NHSS maintains a 

database of suppliers for a range of common services and can draw attention to 

these ‘packages’, e.g. the management of maintenance for information systems or 

ward supplies. NHSS manages the process of supplies throughout. 

• NHSS might offer advice for developing a service specification, manage the 

tendering process and be involved in contract negotiations e.g. competitive 

tendering for cleaning and portering services. Once the tender has been awarded to 

a specific company the Trust manages the contract directly or NHSS does it on 

behalf of the Trust. 

• The Trust organises a contract directly with a supplier. 

The main difference between goods and supplies lies in the fact that. In general, it is easier 

to specify the quality of goods than of services. However, there are notable exception such 

as highly specialist equipment such as MRI or ultrasound that are influenced by medical 

‘preference’. In terms of services, the issue of liability (health and safety) has to be 

considered. 

In general, procurement depends on foresight and sound planning, good negotiating skills, 

credibility (expertise) and building up relationships within the organisation (visibility). 

Impact of EU directives and regulations 

Setting the financial limits has been one of the main influences, and the process for Europewide 

tendering has to be followed to the letter. Thus, it is difficult to procure things quickly 

(77 days minimum) and long-term planning is essential. Safety issues concerning sterilisation 

have been influenced, esp. regarding autoclaves. Another example is the storage of liquid 

gases to comply with a 14 days supply requirement. This means the expansion of tank 

capacity. 

In the UK the Medical devices Agency issues up-to-date bulletins to NHSS and the NHS as a 

whole on EU regulations. In general, everyone appears to be well informed of the latest 

requirements. 

At present, the procurement issue is becoming politically important as the new government 

appears to want to move away from the ‘privatisation’ of services. The idea of developing 

central coordination across all public services for integrated procurement is gathering 

momentum. 

6.2 Public procurement of goods and services in Sweden 

In Sweden all the health care is decentralised to 21 regions. Because of this, all the buying of 

goods and services are decentralised to the regions. In Sweden we follow the directive 

93/36 so probably the procurement process is about the same in Sweden and Spain. 

The total spending in goods and services during 1998 by your health services in your region 

or country 



139 

For example, in Värmland during 1998 we spent about 500 millions in buying goods and 

about slightly more than one thousand millions in buying both goods and services.

140 


The percent of this amount that your service buys using competitive tenders 

All the buying of goods go though competitive tenders but it is about 700 millions of the 

one thousand millions that go through competitive tenders. 

The relation between the total number of competitive tenders and its publicity in the 

European Official Journal 

It is about 50 per cent that go through the European Official Journal. 

Main regulations related to public procurement 

Supplies 

Commision Directive of 17 December 1969 concerning the supply of products to the State, 

regional bodies and other legal persons in public law (70/32/EEC). 

Council Resolution of 21 December 1976 coordinating procedures for the award of public 

supply contracts (77/62/CEE). 

Council Directive of 22 July 1980 adapting and completing Directive 77/62/EEC on the 

coordination of procedures for the award of public supply contracts concerning certain 

awarding entities (80/767/EEC). 

Council Directive of 22 March 1988 amending Directive 77/62/EEC coordinating the 

procedures for the award of public supply contracts and derogating some provisions of 

Directive 80/767/EEC (88/295/EEC). 

Council Directive of 14 June 1993 on the coordination of procedures for the award of public 

supply contracts (93/36/EEC). 

Public Works 

Council Directive of 26 July 1971 concerning the abolition of restrictions on freedom to 

provide services in respect of public works contracts and on the award of public works 

contracts to contractors acting through agencies or branches (71/304/EEC). 

Council Directive of 26 July 1971 on the coordination of procedures for the award of public 

works contracts (71/305/EEC). 

Council Directive of 22 August 1978 amending Directive 72/305/EEC concerning the 

coordination of procedures for the award of public works contracts (78/669/EEC) 

Council Directive of 18 July 1989 amending Directive 71/305/EEC concerning the coordination 

of procedures for the award of public works contracts (89/440EEC). 

Council Directive of 14 June 1993 on the coordination of procedures for the award of public 

works contracts (93/37/EEC). 

Reviews 

Council Directive of 21 December 1989 on the coordination of the laws, regulations and 

administrative provisions relating to the application of review procedures to the award of 

public supply and public works contracts (89/665/EEC). 

Council Directive of 25 February 1992 coordinating the laws, regulations and administrative 

provisions relating to the application of Community rules on the procurement procedures 

of entities operating in the water, energy, transport and telecommunications sectors 

(92/13/EEC). 

Excluded sectors 

Council Directive of 17 September 1990 concerning the procurement procedures in the water, 

energy, transport and telecommunications sectors (90/532/EEC). 

Council Directive of 14 June 1993 coordinating the procurement procedures of entities 

operating in the water, energy, transport and telecommunications sectors (93/38/EEC). 




Services 

Council Directive of 18 June 1992 coordinating the procurement procedures of public service 

contracts (92/50/EEC). 

Services, supplies, works 

European Parliament and Council Directive of 13 October 1997 amending Directives 

92/50/EEC, 93/36/EEC and 93/37/EEC concerning the coordination of procedures for the 

award of public service contracts, public supply contracts and public works contracts 

respectively (97/52/EEC). 

Purchasing hospital services – the Swedish experience 

Soren Berg 

Abstract 

The procurement process in Stockholm County Council 

The presentation will consist of two parts: The first focused on political decisions, objectives, 

legal conditions and the present state of the process. The second focused on evolving 

challenges and dilemmas. The presentation will give an updated picture of issues like the 

following: 

Background and present state 

The scope of this procurement is a contract period of five years (2004-2008), with the option 

of a two-year extension, at a planned cost of ten billion Swedish kronor per year, which puts 

this procurement in a class by itself as the biggest of its kind in Sweden. 

A main objective is to increase the diversity among suppliers; to stimulate new solutions in 

the ways in which health care is conducted. 

The law on public procurement is not designed for such a complex object as acute health 

care. Nor has such procurement previously been undertaken anywhere within the EU. 

The procurement model is developing, but is not yet ready. 

Challenges and dilemmas 

The procurement raises many questions. Some of these have found their answer during the 

process; some still remain open: 



141 

• To what extent can and should itemised prising be used? 

• To what extent can and should objectives and incentives be tailored to fit different 

situations and objectives? 

• How can dynamics in large-scale responsibility – with focus on integrated care – be 

combined with openings for small size entrepreneurs?

142 


• How can the continuous flexibility and dynamics be strengthened under the 

condition of five-year contracts? 

• How can purchaser-power be combined with patient-power? 

• Which openings for parallel services, with non-public financing, should be given to 

contracted producers? 





Matthias Wismar 

Abstract 

Regulation EEC1408/71 – which serves to coordinate social protection systems in the 

European Union to allow the free mobility of workers and citizens – also provides the basis 

for facilitating rather than restricting the free movement of patients or, to use a different 

terminology, the consumer choice of cross-border healthcare goods and services. 

The project identified four dimensions to consumer choice: i) access to the widest possible 

range of services; ii) access with fewest possible restrictions (restrictions being authorisation 

procedures or mandated referral patterns); iii) the maximum choice of provider; and, iv) full 

reimbursement for any amount charged by the provider. (It may of course be desirable to 

restrict some of them in pursuit of other social objectives such as equity.) 

Potentially the impact of European legislation and ECJ decisions on cross-border consumer 

choice is high, although the outcome to date has been very limited. Four factors account for 

the limited numbers of patients actually taking advantage of cross-border choice: i) restrictive 

handling of the E112 procedure whereby care abroad has to be pre-authorised; ii) differences 

in the ‘healthcare baskets’ across Europe; iii) lack of cost reimbursement provisions in many 

countries; and, iv) the nature of medical goods themselves and their distribution. The 

political impact of the Kohll and Decker rulings, however, was substantial, since the ruling 

resulted in the much-debated method to enable cross-border care (in addition to E111 and 

E112), namely the ex-post patient reimbursement of unauthorised, but prescribed goods and 

services. 

Germany (the location for this case study) provides an illustration that there is potential for 

cross border consumer choice in prescribed medical goods. During the brief period when 

German legislation allowed free use of patient reimbursement instead of the usual 

application of the benefit-in-kind principle, there were reports from sickness funds that bills 

from abroad had been cashed in. Additionally, a strong claim in favour of the cost 

reimbursement principle for the purchase of prescribed medical goods and services was 

made by old age pensioners living abroad for long periods who did not wish to give up their 

German residency. 

As the Court ruling in the Decker and Kohll cases was restricted to 1) ambulatory care 

services which are 2) included in the benefits’ catalogue of 3) patient reimbursement 




systems, many Member States thought they would not apply to them. The recent Geraets- 

Smits/Paerbooms and Vanbraeckel judgements have, however, clarified that this is not the 

case, have established further rights for patients to acquire goods and services across 

borders, and provided a first hint towards a future standardisation of the benefits 

catalogues. 

Unrestricted access to services and providers outside the borders of the individual’s country 

of insurance, reimbursed by public payers, would pose serious questions for national policy. 

How could Member States deny choice inside their own country (for example, to restrict 

access to a limited number of contracted providers) if these limitations do not exist for cross 

border care? To what extent would such a new situation undermine national health policy 

measures, such as rationing/prioritisation, or (more generally) cost-containment? 

However, if the ECJ had decided against increased choice, i.e. in favour of a continuation of 

the status-quo, this would raise the question whether – within a SEM – it is justified that 

existing alternative methods of social protection institutionalise different methods to gain 

access to different benefits, partially different providers and potentially different levels of 

reimbursement. 




143 



Alain Coheur 

1. Introduction 

With increasing European integration taking place in many areas (e.g. freedom of movement 

for persons, goods, services and capital and also the advent of the single currency) and 

because of the various cases dealt with at the level of the Court of Justice, cross-border care 

is becoming an increasingly important question in the Member States. 

Thus the border areas should lend themselves particularly well to policy action in the field of 

health. In most instances, they constitute a geographical area with high worker mobility. 

They were the first areas to benefit from agreements and conventions concluded between 

neighbouring countries aimed at improving access to care, while the first pieces of social 

legislation at European level were drawn up for frontier workers residing, in most cases, in 

these territorial areas. However, these border areas have often been the result of a historical 

heritage which has taken no account of cultural and social affinities. 

At the present time, these areas offer new prospects and represent a unique area of 

experimentation for Europe. In fact, it is not only a matter of reflections on worker mobility 

but of pressure being exerted by each citizen in order to benefit from the care which is most 

appropriate to his or her state of health. This constant pressure is the result of a European 

process which has put the emphasis on freedom of movement for persons, goods and 

services as a fundamental value in the creation of a single area. It would therefore be

144 


paradoxical to encourage only the creation of a free trade area without accepting its indirect 

consequences and thus to try to reduce mobility when it is not possible to manage all 

aspects of it. This is particularly true in the field of health. 

However, not all border regions lend themselves to the development of the same kind of 

policy action project. Each region must, in fact, be evaluated in accordance with its 

geographical, economic and demographic determinants and infrastructure capacity (excess 

equipment or lack of equipment, medical oversupply, waiting lists etc.). Hence there are 

areas with a low patient flow and underdeveloped health facilities, and there are areas with 

a high flow linked to high worker mobility and highly developed infrastructures. 

At the present time, we are only just beginning to obtain information16 on the social and 

health characteristics of the Euregions and on the resident populations’ mobility potential. It 

has to be said that the initiatives which have been undertaken are the result of the wishes of 

grassroots actors, insurance funds, hospitals etc. And even though the legislatures seem to 

be showing passivity invoking the principle of territoriality, this has not always been the 

case. 

2. Dynamics and evolution of the European context 

To begin with, the legislatures’ interest was mainly shown through bilateral agreements. The 

oldest Conventions of any importance in the field of cross-border health care were signed 

between neighbouring countries such as Germany, the Netherlands, Belgium and France. A 

typical feature was that they concerned care providers. 

One of the first Conventions to be signed between neighbouring countries was the health 

Convention of 12 January 1881 between Belgium and France which was revised on 25 October 

191017 and which "authorised Belgian doctors of medicine, surgery and childbirth established 

in the Belgium districts bordering France to practice their art in the same way and to the 

same extent in any neighbouring French districts in which there is no doctor residing" and 

reciprocally. Germany and Belgium entered into the same type of Convention on 28 October 

1925. 

The Convention of 28 April 1947 concluded between the Netherlands and Belgium covering 

the practice of medicine in the border districts modified the Convention concluded on 7 

December 1868 between Belgium and the Netherlands "on the reciprocal authorisation 

granted to doctors and midwives to practice their art in the border regions of the two 

countries". 

This type of agreement was subsequently extended. Thus the origin of the Community 

principle (applicable legislation geared to the country concerned) has its roots in the 

simultaneous application of the Franco-Belgian Convention on social insurance of 23 August 

1930. Under these provisions, French frontier workers and disabled people residing in 

Belgium received Belgian benefits at the French rate: Belgian private insurance guaranteed 

them at least the Belgian benefits and rates which, where relevant, would have exceeded the 

French benefits. 

16 "Le Nord-Pas-de-Calais Littoral, milieu, hospitalisation, médico-social et perspectives." Report 

prepared for the Regional Nord-Pas-de-Calais Council. ORS Nord-Pas-de-Calais. O. Lacoste, L. 

Spinosi, S. Le Niniven. Fourth Quarter 2000. 

1 c Gezondheidsbericht van de Euregion Maas-Riin. Werkgroep Eureregionale 

Gezonheidsberichtgeving, R.J.M. Derkx, G.H.L. Franssen, J.H.Freund, Y. Pirenne. Fourth Quarter 

1999. 

17 This 1910 Convention was terminated only on 9 January 1998. 




On 29 August 1947, the Netherlands and Belgium signed a Convention "on the application of 

their reciprocal social security coverage legislation". Two agreements were later concluded in 

1957 and 1965 concerning social security coverage in respect of sickness expenses. To the 

extent that they related to benefits, these agreements ceased to apply on 1 January 1981 

because of the entry into force of the agreement of 24 December 1980 on the coverage of 

medical care. 

In addition, Article 51 of the 1958 Treaty of Rome granting the Council the power to adopt 

"such measures in the field of social security as may be necessary to provide freedom of 

movement for workers" and which were introduced by Regulation 1408/71 did not do away 

with the bilateral contractual arrangements. These have progressed by providing better 

coverage and easier access to care. 



145 

• The Grand Duchy of Luxembourg, in an effort to simplify the administrative 

procedures for reimbursement of its costs, has entered into agreements with 

medical establishments in the surrounding countries. Seven agreements have been 

signed with different German university hospitals, including two in Trier. These 

hospitals bill the Luxembourg health insurance funds directly for treatment provided 

to Luxembourg patients. 

• The Belgian-Luxembourg Convention concluded on 24 March 1994, replacing the 

one dated 16 December 1959. Any frontier worker and members of his family 

receiving benefits in kind on Belgian territory are entitled, where necessary, to an 

additional reimbursement under Luxembourg legislation. This additional 

reimbursement is payable by the competent Luxembourg institution. 

At European level the introduction of the coordination Regulations 1408/71 and 574/72 has in 

no way restricted the room for manoeuvre by Member States, especially through the entering 

into of bilateral agreements. However, there has been a gradual weakening of this instrument 

for coordinating social security schemes which, on the one hand, was drawn up for the 

purpose of guaranteeing rights to migrant workers and their dependants and which, on the 

other hand, was subsequently extended18 . On the one hand, it contains inherently restrictive 

elements whereas, on the other hand, European integration has resulted in changing the 

principle of freedom of movement for persons from an economic right to a personal right of 

European citizens. 

This weakening is all the more noticeable as Member States continue to claim a sovereign 

competence as regards organising health and social protection by invoking, on the one hand, 

Article 5 of the Treaty which defines the principle of subsidiarity and, on the other hand, 

Article 152 (5) of the Treaty which provides that "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 fact, Regulations 1408/71 and 574/72 do not 

rule out the principle of territoriality and their objective is not to ensure merely access to 

health care for citizens in other Member States. 

18 Article 51 of the Treaty of Rome entrusted the Council of Ministers of the European Economic 

Community with the task of adopting "such measures in the field of social security as may be 

necessary in order to provide freedom of movement for workers". The Council of Ministers first 

adopted: 

- Regulations (Nos. 3 and 4) covering social security for migrant workers; 

- Regulations (Nos. 36/63 and 73/63) covering social security for frontier workers; 

- Subsequently, the Regulations (1408/71 and 574/72) on the application of social security schemes to 

employed persons and their families [foreign nationals from one of the Member States, refugees and 

stateless people) moving within the Community

146 


We are therefore faced with the paradox that, while the content of the Regulation has not 

really changed since 1981, many changes19 have taken place in the various Member States in 

the field of social security as the result of national legislation and bilateral agreements and 

at the level of the European Union as a whole due to the case law of the Court of Justice (an 

aspect to which we shall not return). 

Following a relatively long period during which EU jurisdiction was based almost exclusively 

on Article 51 of the Treaty of Rome (Article 42 of the Amsterdam Treaty) which was 

strengthened, inter alia, in 1961 by Article 11 ("the right to benefit from all the measures 

enabling him to enjoy the best state of health that can be attained") of the European Social 

Charter (revised in 1996), it was not until the Maastricht Treaty in 1992 and the Amsterdam 

Treaty in 1997 that a new dynamic was introduced into the fields of social protection and 

health. 

The Community speaks of a contribution to the attaining of a high level of health protection 

(Article 3 (o)), ensuring a high level of health protection in the definition and implementation 

of all Community policies and activities (paragraph one of Article 152 (1)) and of improving 

public health, preventing human illness and obviating sources of danger to human health 

(paragraph two of 152 (1)). 

The Commission attaches growing importance to the development of health care systems20 and to the introduction of an information system21 which will enable the various health 

systems to be assessed. 

The European Union Charter of Fundamental Rights signed at Nice on 7 December 2000 

recognises the right to social security (Article 34) and health protection (Article 35). 

As far as social protection is concerned, the EU has also shown itself to be much more active 

since the early 1990s on the basis of the Council’s Recommendations22 and the Commission’s 

Communications23 . The social dynamic involved was reinforced by the adoption of a 

European strategy on employment at the Luxembourg European Council in 1997 and also at 

the Lisbon Council in 2000. 

Although the Community level has been assigned the competence to coordinate the various 

national systems with a view to ensuring freedom of movement for persons while preserving 

their social security rights beyond the borders of their affiliate home State, European 

integration has left each Member State’s competence in organising its own social protection 

system, define the conditions governing access to it and also entitlement to benefits intact, 

whilst leaving it to the discretion of Member States to specify the degree of freedom 

permitted to obtain care abroad or to negotiate the content in the context of any bilateral 

agreements. However, developments which have taken place since the 1990s are giving rise 

to new needs, new expectations, new possibilities and new hopes in the context of 

enlargement. 

19 

Opinion of the Economic and Social Committee No. 2000/C 367/05; OJ, 20.12.2000 

20 

Commission communication COM (1998) 250 final, 15 April 1998 

21 

Commission communication on the health strategy of the European Community and Proposal for a 

programme of Community action (2001-2006) (COM (2000) 285, 16 May 2000). 

22 

Recommendation 92/442/EEC of 27 July 1992, OJ 1992, L 245/49 concerning the convergence of 

social protection objectives 

23 

Communication COM (1997) 102 final of 12 March 1997 entitled "Modernising and improving social 

protection in the European Union" and communication COM (1999) 347 final, 14 July 1999 entitled "A 

concerted strategy for modernising social protection" 




3. Euregion dynamics in a restricted area of freedom 

In the light of the above, do the Euregions have any real autonomy in the field of health? 

Even if in principle the degree of freedom appears to be relatively small, it would 

nevertheless appear to be sufficient to permit initiatives to be taken and for experiments to 

be carried out which will promote freedom of movement for persons and will facilitate access 

to cross-border care. 

The border regions account for 15% of the Community's territory and 10% of its population. 

These regions are extremely varied in terms of population density and economic 

development. They also have to face a number of legal and institutional obstacles which do 

not always have to do with the jurisdiction of the regions, in particular in the field of health 

and health insurance, as we have shown. 

In 1992, the European Commission launched a major Community initiative known as 

INTERREG. 

Community Initiatives are specific instruments of the Union's structural policy which the 

Commission proposes to the Member States to support activities which contribute to solving 

problems which have a special impact at European level. 

The general principle underlying the Initiatives24 was and continues to be that national 

borders should not be an obstacle to balanced development or to integration of the 

European territory. 

We can highlight three elements characterising and constituting the added value of the 

Interreg Initiative: 



147 

• support for the development of and complementarity in cross-border and 

interregional cooperation; 

• their method of partnership and implementation of the "bottom-up" approach; 

• a grassroots visibility which it offers citizens. 

Another original feature is the distinctive method of financing. Budgets are not allocated to 

the individual Member States but by border, and this has the effect of creating and 

strengthening cross-border partnerships at the level of regional authorities. 

Although the priority areas25 for Community action are defined in advance by the 

Commission, each Euregion has a great deal of leeway as regards applying these guidelines 

within a specific field of measures suited to its own regional situation. For example, the 

Meuse-Rhine Euregion26 has adopted eight priorities which include "improving cooperation 

and cross-border accessibility in health care". 

24 

Interreg I-II-III 

25 

The priority areas defined in the communication to the Member States (COM (2000) 1101 include: 

- sharing human resources and equipment relating to research and development, technology, 

education, culture, communication and health for the purpose of improving productivity and 

contributing to the creation of sustainable jobs; 

- increasing human and institutional potential relating to trans-national cooperation for the purpose of 

contributing to economic development and social cohesion; 

26 

Euregion priorities are in preparation in the PIC 200-2006 of the Meuse-Rhine Euregion, September 

2000

148 


In the light of the regional priorities thus defined, the local partners (public and private 

institutions, associations etc.) have the same autonomy in preparing joint cross-border 

projects27 . 

The most significant results and progress achieved as regards cross-border accessibility to 

health care have been under the Interreg programme. The most relevant question relates to 

the assessment of the deliberate mobility of patients when the prior authorisation procedure 

is lifted. This assessment should make it possible to evaluate the scale of care flows even if 

it initially gives little information on the cost of such liberalisation or on the behaviour of the 

providers. 

On the basis of the results involved, we shall be able to identify the motives for this mobility 

and determine whether the Euregions can, within a geographical area, constitute a suitable 

response to the needs and expectations of citizens. Thus, is a patient seeking local care as a 

matter of priority? Are the language barriers an obstacle? Are medical services available and 

if so for what types of care and with what technologies? Do external factors such as waiting 

lists encourage people to resort to care abroad? And so on. 

Apart from the European and national legal and institutional frameworks, these 

complementarity projects have given rise to: 

• an easing in the administrative procedures for the authorisation of care abroad; 

• partnerships between care establishments; 

• bilateral agreements between neighbouring social security schemes; 

• exchanges of knowledge and know-how. 

This kind of cross-order accessibility implicitly ensures de facto mutual recognition of medical 

and hospital practices in the Member States concerned. 

4. Cross-border experiments28 Many healthcare projects have arisen within the framework of the Euregions, these projects 

have allowed the way in which European citizens can obtain better access to health services 

to be analysed29 . So, generally speaking, we can note two types of approach, one in relation 

to contractual practices and the other to citizens’ cross-border mobility linked to an 

administrative simplification. 

4.1 Contractual practices 

The agreement may relate either to a request for collaboration or a reciprocity convention 

between individual service providers or hospital institutions and/or the insuring bodies in 

order to supplement a range of care services which is insufficient on one side of the border 

and/or plentiful on the other side or to reduce problems in accessibility for certain patients, 

mainly connected to the distances to be travelled. 

The development of these partnerships is built on the notion of complementarity and on the 

search for medical cooperation. In practice this always requires a derogation to the principle 

27 Coheur Alain, Final report of the cross-border project in the Meuse-Rhine Euregion "for the purpose 

of guaranteeing greater access to health care in the cross-border region". 

28 There are many experiments in progress in the border areas for instance the Gronau, Rhein Waal, 

Ems Dollart, SaarLorLuxRhein, Bodensee and Inn Salzach Euregions. The cases mentioned here are 

not exhaustive but we do not currently have any assessments or results obtained. 

29 There are many experiments in progress in the border areas for instance the Gronau, Rhein Waal, 

Ems Dollart, SaarLorLuxRhein, Bodensee and Inn Salzach Euregions. The cases mentioned here are 

not exhaustive but we do not currently have any assessments or results obtained. 




of the territoriality of the services which is based on the limits of the care infrastructure in 

these regions. 

Up until now, within the framework of these conventions, the impact of the rulings issued by 

the Court of Justice has been negligible or even non-existent given the particularly welldefined 

framework, the target population and the negotiated nature of the terms and 

conditions of payment for the services. 

A number of elements are taken into account before it is possible to enter into a convention: 

• The drawing up of an exhaustive inventory of the capacities existing in each of the 

border regions, 

• The analysis of administrative procedures and levels of reimbursement for the 

services, 

• The defining of criteria for approval, quality and costs in order to obtain an 

equivalence in the requirements in terms of public health in each of the countries. 

The main actors in these processes may act in a differentiated manner according to the 

specific context of the border regions in question, in this way we have been able to identify 

4 modes of inter-hospital conventions negotiated between: 

1. Hospitals only, 

2. Hospitals, the national authorities who are competent on matters of health 

insurance and the regional insurers, 

3. Hospitals and regional insurers, 

4. Hospitals, public administrations (national or local) and insurers. 



149 

• Conventions between hospitals, essentially on hi-tech matters, for instance: 

o protocol of collaboration entered into for paediatric cardiac surgery and renal 

dialysis between the Acadamisch Ziekenhuis Maastricht (NL) and 

o 

l’Universitätklinikum der RWTH in Aachen. 

Collaboration entered into in the field of radiotherapy in the Schleswig region 

(D) and Südjütland (DK) where the Danish inhabitants have the opportunity to 

be cared for at the hospital in Flensburg whilst continuing to be monitored by 

the Danish oncology department at the hospital in Sonderborg. 

• Conventions between hospitals, the national authorities who are competent on 

matters of health insurance and the regional insurers: there is the example of the 

cross-border cooperation between the hospitals in Tourcoing (F) and Mouscron (B). 

So French nationals suffering from renal insufficiency are cared for by the CH 

(Hospital Complex) dialysis department at Mouscron. Belgian patients suffering from 

immune deficiency syndrome are cared for by the infectious diseases department at 

the Tourcoing CH. The assessment of the number of beneficiaries shows that on the 

French side 20 patients have been monitored since the signing of the convention in 

1994 and for Belgian patients benefiting from care at the CH in Tourcoing, since the 

beginning of the convention (1994) 17 people have been monitored. 

• Conventions between hospitals and insurers: for example, since 1 March 1978 30 , 

Dutch people insured under the Zeeland-Flanders and West Brabant health 

30 This Convention was modified and extended in 1998. The number of person benefiting annually 

from this regulation is around 2,300, which corresponds to approximately 4% of the persons insured 

by OZ in this region. Oral communication sources, 15 January 1999, Mr A.F.M. Bootsma, Medical 

Manager of OZ)

150 


insurance fund (OZ) have been able to receive medical care at the expense of the 

Dutch social security system at two Belgian hospitals: the University Hospital of 

Ghent and the Saint-Jean Hospital in Bruges. 

Thus, when a patient's state of health requires immediate treatment, on the basis of 

the treating physician's opinion (scheduling of treatment) and after obtaining 

(administrative) approval from the competent health insurance fund (which issues 

an E112 for identification of invoicing details), the patient is sent to one of the 

above two Belgian hospitals. In other cases, the normal procedure (E 112) for 

requesting health care abroad is followed. The patient pays the portion of the cost 

of clinical care not reimbursed by the Dutch social security scheme. The health 

insurance fund reimburses the cost of any hospital treatment. 

• Conventions between hospitals, public administrations and insurers 

o Public health administrations: there is the example of the agreement 

signed between the transfusion centres in Liege (B) and Maastricht (NL) 

allowing the blood products with a short storage life to be delivered in 

connection with emergency care at the Hermalle-sous-Argenteau hospital. 

This hospital is located 20 minutes from Maastricht and had to obtain its 

supplies from the transfusion centre of the Liege University hospital 

located more than 40 minutes away. Following a detailed examination of 

the GMP31 conditions and the standards laid down by Netherlands 

legislation and in accordance with the quality requirements relating to 

blood products under Belgian legislation, a memorandum of agreement 

was signed which had received the approval of the Belgian Ministry of 

Public Health. The assessment made between May 2000 and March 2001 

shows that a total number of 130 packs of blood were delivered 

representing 46 trips between the transfusion centre and the hospital in 

Hermalle. 

o Municipal administration: emergency transport agreement (in force since 1st July 2000) signed between the municipality of Riemst (Riemst, Kanne, 

Vroenhoven, Lafelt) (B) and the Belgian insurance bodies in order to allow 

Belgian nationals involved in accidents on the territory of Riemst and 

urgently transported to the AZ in Maastricht (NL) to benefit from 

reimbursement at the Belgian tariff, the difference with Dutch tariffs being 

paid for by the Municipality of Riemst. 

4.2 Experiences with cross-border mobility : 

These experiences are based on an overall approach to the situation in the border region, 

the steps taken allow the following: 

• The supply of and demand for care can be used as a basis with the aim off 

providing better efficiency in the use of the resources so as to improve the state of 

health of the populations involved and to take account of the needs of people 

covered by insurance who reside in border regions. 

• The creation of an institutional dynamic thanks to the direct involvement and 

agreement of the authorities. 

• Thanks to cooperation with the public authorities, to encourage greater flexibility in 

the procedures for access to care and mechanisms for authorisation and, if 

necessary, to bring about an adaptation of the national legislative framework in the 

countries in question. 

31 GMP = Good Manufacturing Practice 




The regulatory reference is still, however, the European regulation (1408/71) given that it 

guarantees pricing security but contrary to inter-hospital conventions, the rulings of the Court 

of Justice, in particular Kohll and Decker, 32 have encouraged the setting up of projects using 

the definition of a functional framework which does not require any prior authorisation from 

the health insurance fund as a reference, thus giving rise to an administrative simplification 

of the request for authorisation. 

The authorisation to use an E 112 form depends not only on the legal framework but also on 

the discretionary power of the consultant or the doctor from the insurance fund. So, the 

more centralised the authorisation decision is (e.g. France, Denmark) the more the control 

exercised over the conditions for eligibility is strictly respected 33 and vice versa, the more 

decentralised the process of authorisation is (Belgium, Netherlands, Luxembourg) the more 

the appropriateness of care provided abroad is taken into consideration. 

So therefore it is logical that the most advanced cross-border projects with regard to mobility 

have developed in Euregions where insurance bodies and the national environment both 

work in favour of a cross-border dynamic. This does not necessarily mean that citizens have 

total freedom in their choice of medical services. In most cases, projects relate to medical 

specialties available in hospitals, up to now general practitioners and dentists have not been 

involved, deeming that the populations’ needs are met by the services currently on offer. 

Given that this is an overall approach where national elements may interfere with the 

content of the projects developed, such as the over or under capacity of the infrastructures, 

whether or not there are any waiting lists, etc. there may be two situations: 

• a restrictive policy on access to cross-border care: the public authorities are looking 

to make investments and to use the domestic medical infrastructure, which results 

in a reduction in the use of E112 forms; 

• a liberal policy: cross-border care is no longer considered as a burden but as a 

contribution to the objectives of health policy resulting in far greater use of E 112 

forms. 

These elements do, effectively, assign the management bodies a function as the main 

contact for the needs of individuals but also for the political authorities in the search for 

innovative and appropriate solutions in border regions. 

The results of the experiments described below shed light on the potential in border areas in 

terms of innovation and accessibility to health services. 

4.2.1. Hainaut (B) and Nord Pas de Calais (FR) regions: the aim of the Transcard project is to 

facilitate access to the care provided in particular hospital establishments34 , whether this is 

outpatient care or care provided in hospital for Belgian or French employees and to check 

the interoperability of health cards from each of the two countries (Vitale for France and SIS 

for Belgium). This project disregards certain provisions made under regulations 1408/71 and 

574/72 given that it does not require any prior authorisation from the health insurance fund 

doctor in the country of affiliation. The experiment offers both Belgian and French people 

living in the border region the opportunity to use their cards, SIS or Vitale respectively, in 

precise cases requiring the E111 or E112 forms. The SIS and Vitale cards replace these forms 

32 

The Smits and Paerebooms, Vanbraekel rulings being too recent for their impact to be measured. 

33 

Luca A Crivelli, Cross border care between Swiss cantons: a testing lab for the single European 

market, in 

34 

For the Belgian part, the Fagnes Health Centre in Chimay, for the French part, the Pays d’Avesnes 

Hospital Complex, Felleries Liessies Departmental Hospital, Fourmies Hospital Complex, Brisset 

Hospital Complex in Hirson, Nouvion Hospital in Thiérache, Vervins Hospital Complex, Thiérache 

Private Hospital in Wignehies. 



151

152 


with regard to the identification of “cross border” patients and the monitoring of their 

insurability. The information contained on the cards is used by the parties involved (the 

hospital establishments and insuring bodies) in order to be able to invoice for the care and 

obtain the reimbursement of the monies owing35 . 

From the first exploitable data36 it emerges that, during the period from 17 May 2000 to 30 

April 2001: 

• 22 people insured in Belgium received care in France 

• 250 people insured in France received care in Belgium 

Distribution by age: A majority, 66 %, of these insured people are between 20 and 60 years 

of age, which is the age range of the active population. The remaining one third is 

essentially made up of people aged over 60 (27%) 

AGE WORKFORCE PERCENTAGE 

0-10 8 3% 

11-20 13 5% 

21-30 23 8% 

31 41 54 20% 

41-50 62 23% 

51-60 38 14% 

61-70 32 11.5% 

71 and over 42 15.5% 

TOTAL 272 100% 

Distribution by sex: 61% women as against 39% men 

Distribution according to place of residence: we can see a flow of patients whose place of 

residence is located within a radius of 20 km from the hospital attended for people insured 

in Belgium and France. 

Distribution according to the nature of the care: For people insured in France who were 

treated in Belgium this is mainly outpatient care; nevertheless we can see the emergence of 

a flow of hospitalisation (8 patients recorded at 31/12/2000). On the other hand the cases 

listed in France correspond to stays in hospital. 

35 In practice, for instance, the Fagnes Health Centre reads the French insured person’s Vitale card 

using the “Transcards Vital” software application. If the insured person is part of the experimentation 

region, the card contains the Transcards zone, which allows a special E112TF form to be printed out. 

This is then automatically filled out with the information from the Vitale card, the hospital personnel 

complete the form by entering the insured person’s address and send the E112TF with the request for 

payment to the Belgian mutual insurance system which assigns an identification number to the French 

affiliated member. 

36 Final report Transcards project November 2000 until May 2001, 17/07/2001. 




Types of services recorded 

The year of experimentation has allowed us to record the following movements of patients: 

CARE French patients 

Receiving care in Belgium 

OUTPATIENT CARE 173 patients / 273 examinations 

Scanner = 28% 

Other medical imaging = 14% 

Neurology = 18% 

Nuclear medicine = 12% 

ONE DAY CLINIC 12 patients / 59 fixed cost 

Intra-vascular perfusion = 24 

Chemotherapy = 29 

Surgery = 5 

Scanner = 1 

INPATIENT CARE 8 patients 18 patients 

Belgian patients 

receiving care in France 

Functional 

= 13 

rehabilitation 

TOTAL 193 patients 

Haemodialysis = 2 

Other = 3 

18 patients 



153 

So we can conclude that, a posteriori, the project has allowed the following 

complementarities to be fulfilled: 

• Patients residing in France travelling to Belgium for nuclear medicine and medical 

imaging services plus neurology consultations. So these are mainly outpatient 

services. 

• Patients residing in Belgium travelling to France for haemodialysis and functional 

physiotherapy, so these are mainly inpatient services. 

This can be explained by the fact that the care establishments may be some 

considerable distance away, whereas they are available by simply crossing the 

border. 

Financial flows for Belgian patients 

Belgian patients cared for in France (period from 15 May 2000 to 30 April 2001) 

Cost paid by Health 

Insurance 

Share to be paid by 

the patients 

Total 

Outpatient care 107.70€ 46.33€ 154.03€ 

One day clinic 1,281.74€ 0€ 1,281.74€ 

Inpatient care 114,133.62€ 3,319.30€ 117,452.92€ 

TOTAL 115,523.06€ 3,365.63€ 118,888.69€

154 


Financial flows for French patients 

French patients cared for in Belgium (period from 15th May 2000 to 31st December 2001. This 

data is incomplete due to normal invoicing times). 

Cost paid by Health 

Insurance 

Share to be paid by 

the patients 

Total 

Outpatient care 25,257.25€ 2,969.19€ 28,226.44€ 

One day clinic 23,259.50€ 1,551.22€ 24,810.72€ 

Inpatient care 15,411.34€ 1,115. 64€ 16,526.98€ 

TOTAL 63,928.09€ 5,636.05€ 69,564.14€ 

Although we can see an imbalance in the flow of Belgian patients heading for France (a small 

flow), on the other hand the imbalance is inverted with regard to the financial flow, which 

can be explained by the nature of the care provided and the length of stays in hospital. This 

shows a complementarity in the range of care available. 

We can see a considerable difference in the sums remaining to be paid by the patients: in 

Belgium, the share to be paid by the patient is 8.82% of the total to be paid by the Health 

Insurance Policy whereas this is only 2.91% in France. These values have been calculated for 

all forms of care as a whole. 

Using the same indicator and making a distinction between the types of care (outpatient 

care/one day clinic/hospitalisation), we can see that in both France and Belgium the shares to 

be paid by the patients are the highest for outpatient care and are the lowest for One Day 

Clinics. 

Still according to the type of care, the share to be paid by the patient is between 0% (one 

day clinic) and 43% (outpatient care) whereas in Belgium it is between 6.6% (one day clinic) 

and 11.7 % (outpatient care). 

This data is supplied for information only, it has not been possible to carry out a comparison 

between prices for identical services. 

In addition to the medical aspects, this experiment shows that it is possible to use a social 

identity card from one country to another and it also shows the interoperability of the 

systems in the medium term. For the social security bodies, this system of transmitting data 

solves the problem of the heavy administrative load required for the management of forms 

for access to care and financial regulation. 

This project is in addition to another experiment with the reading of the NETLINK card 

between France (Strasbourg) and Germany (Bad Wurtenberg) for dialysis patients. 

4.2.2. Liege (B) region, Limbourg (B), Limbourg (NL), Kreis Aachen (D) Meuse-Rhine 

Euregion: the aim of the IZOM project which brings all of the insurer bodies together is to 

facilitate access to care for all populations residing in this geographical area for general care 

provided by specialist doctors, on both the diagnostic and the therapeutic levels, the 

prescribing of medicines within the framework of this treatment and the relevant hospital 

care. This unique experimental project is implemented within the framework of international 

agreements (EEC Regulations CEE 1408/71 and 574/72), as a result the legal provisions on 

health insurance, the tariffs and the procedures in each country are applicable. In practice, 




the insurer authorises the cross-border care with the aid of a specific form, IZOM EMR E112+ 

without prior agreement from the consultant. This project is based on the results of a 

previous experiment carried out in the region under the name of Zorg op Maat. 

4.2.2.1 Results of the Zorg op Maat project. This is a Dutch ZOM project monitored by the 

NZI37 in the Meuse-Rhine Euregion. This latter, on the basis of a form, E 112+, allowed Dutch 

patients to receive outpatient care from specialists in Belgium or in Germany. The project ran 

from April 1997 to December 1998. 

On the scope of the mobility: the regional insurer (CZ) assessed the number of insured 

persons who benefited from the project in relation to the total population of the CZ in the 

region (4% in Zealand Flanders cf. note above) at less than 1% on an annual basis and 

estimated the number of potential beneficiaries at 3%. 

On the type of medical specialties (n=989): in the league of medical specialties, the results 

show that ophthalmology comes in first, followed by gynaecology and orthopaedics. 

Medical specialties on the basis of the E 112+ form (period from 1 January 98 to 1 December 

98) CZ. 

Belgium Germany Total 

1 Ophthalmology 50 119 169 (17%) 

2 Gynaecology 1 120 121 (12%) 

3 Orthopaedics 8 101 109 (11%) 

4 Internal medicine 2 100 102 (10%) 

5 Dermatology 40 53 93 (9%) 

6 Scan 5 75 80 (8%) 

Etc. 

These figures have been compared with the national data for waiting lists. They do, in fact, 

show that ophthalmology is in first place and orthopaedics in second place for the 

specialties on waiting lists, gynaecology only comes in 6th and dermatology in 10th . On a 

regional level, there are no waiting lists for gynaecology and for dermatology, only one 

hospital (AZ Maastricht) has this specialty available, hence the congestion effect. 

On the main reason for recourse to cross-border care (n=280) first comes the existence of a 

waiting list (88.7%), then comes a detailed examination of the state of health (77.8%). In 

third place (71.7%) is a different system of medical care. This latter point can, for instance, 

be explained for orthopaedics by a more organic system of care, so in Germany 

physiotherapy care is part of the treatment as a whole, for oncology Germany offers a 

number of therapeutic alternatives and not only hospital establishments, for ophthalmology 

Germany is quicker to use the laser treatment technique. The insured person’s knowledge of 

the treatment plays a positive and considerable role in recourse to cross-border care 

On geographical accessibility: the further away the beneficiary lives from the service provider, 

the more he tends to have recourse to these services. So, in the Zuid Oost Limburg part, 

proximity is mentioned in 73% of cases. The inhabitants of Maastricht tend to travel within 

Belgium and the inhabitants of Vaals, Kerhade, Heerlen choose to go to Germany. In the 



155 

37 Grensoverschrijdende zorgproject Zorg op Maat report. Zienkenfondsraad, Minister van 

Volksgezondheid, Welzijn in Sport, 25 March 1999

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Midden Oost Limburg region geographical proximity is only involved in 9% of cases. 

According to the type of population, in particular for German cross-border pensioners 

residing in the Netherlands, there are other factors involved, such as a system of payment 

which is appropriate to their own circumstances (43%), having already benefited from care 

abroad (32%), the language used also reinforces these two latter factors (23% of cases) 

For other groups such as the elderly and the disabled, only having to travel a short distance 

to obtain care is an important qualitative element. 

On the consumer profile: more than half of beneficiaries had received care abroad on one 

occasion and more than a third had received care at least five times. There are three groups 

of people which emerge from this. Pensioners who used to work across national borders and 

who continue to travel due to the fact that they trust the service provider, a group based on 

the existence of waiting lists and a third, looser group of people who travel because care on 

offer abroad can offer more value or for reasons related to discontent or in order to obtain a 

second medical opinion. 

5. Euregional divergences, convergences and perspectives. 

In spite of the trends, developments and results sketched out above, the practical and legal 

hindrances to cross-border circulation will still remain considerable for the time being. The 

convergence of healthcare systems can only be viewed as a long-term objective within the 

European Union. The points of divergence are based upon the following: 

• the historical and legal development of European social models, 

• the organisation and financing of social security and health insurance, 

• the role played by the public authorities, the social partners and private 

organisations in the decision-making process and the implementation of health 

systems. For complementary systems, the differences are even greater. 

The room for manoeuvre within the Euregions is very small, since we have to plan, build and 

collaborate on the basis of a whole patchwork of differences. 

Nevertheless, we can note that independently of their differences, all of the systems are 

faced with analogous problems and challenges which will require a greater degree of 

convergence. This potential convergence will be influenced by a number of factors. 

The consequences of the rulings made by the Court of Justice, even though the Euregional 

impact remains low within the framework of contractual agreements, have played a not 

inconsiderable role in cross-border mobility projects. In addition to this, following highly 

marked developments on a national level, certain Member States are thus being forced to 

think ahead. Waiting lists in the Netherlands, which are creating a new dynamic in particular 

in Germany and in Belgium, are a good example of this. 

The uniqueness of the Euregions shows that there are various possibilities for continuing 

with the development of the practical results obtained up to the present. The unique 

geographical location of the Euregions means that we can experiment here on a small scale 

with projects for complementarity or full mobility, where this does not yet appear to be 

possible on a European scale. The Euregions are in fact a field for experimentation in the 

development of new cross-border initiatives on European territory. 

One interesting development which can be seen is the trend towards a growing diversity in 

cross-border circulation. When the European regulations on the coordination of social 

security were established, the legislature had only made provision for a very limited number 

of categories of insured persons within the framework of cross-border circulation, insured 




persons who, at the time, also had to be employees. Since then, the diversity of the types 

and categories of insured persons and patients who can obtain aid abroad with or without 

the prior authorisation of their insuring bodies has become extremely large. However, it is 

not a question of a growth in cross-border circulation in all of the existing categories. The 

studies carried out in the Euregions show that, in many cases, patients receive 

complementary care abroad which is either not available at all or else scarcely available in 

their own countries. 

Cross-border circulation is becoming more and more a matter of guaranteeing that insured 

persons who live in the Euregion can receive care which is “nearby over the border”. In many 

cases, the care which the insured people require is available just over the border in the 

neighbouring country, in the bordering part of the Euregion, whereas, in their own country, 

these insured persons would have to travel further in order to obtain the same care. For 

services which are also covered by the social security system in the insured person’s own 

country, the obtaining of aid abroad, when this is either not available or not sufficiently 

available in his own country, does not generally pose a problem. 

It is important to underline the fact that the composition of the population plays an 

important role in the establishing of the dynamic. Amongst the inhabitants of the various 

Euregions, we find many insured persons who are originally from another country. For 

instance, in the Meuse-Rhine Euregion many people of Dutch origin live in the Belgian 

Limbourg area near the border, insured persons of German origin live in the part of the 

province of Sud-Limbourg close to Germany and people of German origin also live in the 

German-speaking part of the province of Liege, in Belgium. These insured persons have 

greatly encouraged and stimulated the particular dynamic of the Euregion, especially recently. 

As the image obtained in this way is extraordinarily complex and as the results are specific 

to each Euregion as such, they cannot be generalised to cover all of the Euregions, and even 

less so to cover the systems in general. 

On the basis of the above, the future prospects for cross-border health care in the Euregions 

could entail: 



157 

• a relaxation in cross-border care arrangements, with accessibility for all insured 

persons, and with the highest common denominator as regards the provisions laid 

down in the arrangements (for two or three countries, depending on the Euregion 

involved) for social security cover in respect of health care; 

• the emergence of cross-border traffic for local care, where necessary supplementing 

that which can be provided to insured persons in their own country; 

• an extension of cross-border care to cover patients and insured persons from other 

Euregions, in the context of bilateral and multilateral (experimental) arrangements. 

At the outset this will only be available to the residents of a single Euregion and 

mainly for high-technology care. 

Finally, the last point to be underlined is the need to ensure that the populations are better 

informed and to get to know the socio-demographic characteristics and the potential of the 

range of healthcare services available in border regions better. There have been a number of 

specific examples. Since October 1997, insurers in the Scheldemond Euregion have opened 

up information booths. The aim of these is to provide citizens - workers and heads of 

companies - with information about the specific problems of border regions, in particular on 

the financial and administrative aspects. In addition to this, specific training for personnel 

from the insurers is organised so that they can get to know the health insurance system in 

the neighbouring country better.

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The year 2000 saw the creation of a Franco-Belgian regional Health (OFBS) watchdog in the 

Hainaut (B) and Nord Pas-de-Calais (F) geographical area. In 2001 this latter has been 

extended to cover the Luxembourg (B) and Champagne – Ardennes (FR) area. 

7. Conclusions. 

On the basis of an analysis of the various projects, we have been able to show that there is 

a not inconsiderable potential demand for cross-border care in the Euregion areas and 

therefore a high level of intentional mobility. This demand corresponds to a real need among 

the populations involved but is conditioned by a large number of parameters deriving from 

the characteristics of such populations and from the health infrastructure specific to each 

region. Taken separately, these factors do not have any impact, and this conveys an image 

of a highly complex cross-regional mobility in relation to health care, although it also ensures 

that each Euregion is unique. 

These Euregions are therefore becoming partners in the search for appropriate solutions in 

the light of populations' needs and in accordance with existing health care capacity. We can 

therefore reject the argument which is regularly put forward regarding the risk of 

destabilisation of the organisation of health services due to uncontrollable movements of 

citizens, especially because, on the one hand, such intentional mobility continues to be 

supervised by the partners from the legal and institutional point of view and, on the other 

hand, the geographical and attraction area is limited. This kind of mobility should be 

accompanied by a wider process providing the inhabitants of these regions with information. 

The Euregion projects should receive greater support from the European authorities. A 

complete listing of all cross-border initiatives should be drawn up, a survey of Euregion 

infrastructure should be carried out, and a profile of the populations involved should be 

drawn up. This process of capitalising on information would allow a specific programme of 

action to be drawn up so as to allow the development of cross-border health projects. 

As for the revision of Regulation 1408/71, it could benefit from the work and the practical 

results obtained by the carrying out of the experiments and offer new perspectives in the 

health field because it is no longer a matter of providing a regulatory framework for the 

mobility of workers but also for the mobility of citizens. 



The SEM and health care – policy conclusions from the EHMA project 

Reinhard Busse 

1. Context and overall significance 

In political terms, there appears to be a contradiction between the purpose of the Single 

European Market (SEM) and the manner in which statements in article 152 of the Treaty 

Establishing the European Community are widely interpreted (“… excluding any 

harmonisation of the laws and regulations of the Member States. … 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.”). 

This study investigated the impact of SEM Regulations and Directives as well as respective 

European Court of Justice (ECJ) rulings – taken together as “interventions” – on the health 

services of the Member States. It demonstrates that the relationship between health services 

as a major sector of Member States’ economies and the SEM are intertwined in such a 

complex manner that it is virtually impossible to separate them. The argument, therefore, 

that subsidiarity applies to health services is not fully sustainable within the context of the 

SEM. 

Thus, the SEM may rightfully be seen as a challenge for health services, adding a further 

complexity to the principal driving forces such as changing healthcare needs, increasing 

patient expectations, the development of e-health, a regionalization of political decision 

making in a context of economic globalization. This is particularly true because the SEM 

inevitably regards the patient as an individual consumer rather than as a citizen with 

collective rights and responsibilities. 

2. Markets and the European social model 

At a European level, the SEM requires health services to adapt to market rules, while at 

national level, governments seek to adapt market rules to ensure the effective delivery of 

health services within a social model. 

Differing views on the future structure of health services in Europe underlie much of the 

debate on health in Europe. These differences are based on two principal, divergent models 

– the European social model and market forces. 

SEM Regulations and Directives, while stressing the market, have not been exclusively aimed 

at achieving economic objectives – indeed some SEM interventions have a social purpose in 

terms of consumer and health protection (such as the Directive on medical devices 

93/42/EEC). Some directives are, arguably, even geared to regulating or limiting market forces 

(for example the Directive on pharmaceutical price control and regulation 89/105/EEC). 

Nevertheless, there is a need to recognise that market forces and the European social model 

have differing objectives. 

There is, however, no option for simply ‘exempting health from the Single European Market’. 

There may however be significant cases where regulation of the market is required in order 

to achieve health objectives. Paradoxically, this requires a new coherence and prominence for 

EU health policy – not just to draw a sustainable rather than accidental line between Member 

State policy and EU-wide policy, but also to make the aspirations of both these actors more 

coherent. 

3. Intended and unintended effects 

SEM interventions have both intended effects (principally to create a single market with free 

movement of goods, services, people and capital) as well as unintended effects. 

Intended effects include providing the basis for a range of European activities in healthcare, 

e.g. a common public procurement system for goods and services, Europe-wide mobility of 

doctors and nurses, a common system for regulating medical devices, common licensing and 

market access procedure for pharmaceuticals as well as a European system to provide health 



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160 


services for tourists, and provisions to ensure healthcare coverage for persons working in 

other EU Member States. 

Unintended effects on the purchasing, supply and delivery of health services often result 

from the fact that these have not been sufficiently taken into account when the Regulations 

and Directives were drafted. For example, SEM interventions have sometimes led to 

increased health service bureaucracy. Small and medium-sized enterprises were also effected 

negatively by such requirements. SEM interventions may also lead to patient/citizen 

movements from one country to another in order to obtain treatment, thus undermining 

attempts at priority setting within the publicly-funded systems of member-states. Movement 

of doctors and other professionals may create shortages in poorer - especially accession - 

countries. 

The different political or organisational settings of health services, as well as countries’ 

geographical settings within the EU, may lead to differing effects of SEM interventions within 

Member States. Policy-makers (and judges) should be aware such of differences. 

4. Impact on health services 

While the actual impact of some SEM Regulations, Directives and ECJ rulings on health 

services may currently be marginal, the inherent conflicts behind many of the directives and 

ECJ rulings may have a significant impact and may cause unexpected systems turbulence. 

For example, should the cases which are currently pending at the ECJ be decided in favour of 

free choice of healthcare goods and services, then the patient-provider relationship would be 

more firmly embedded in the range of European activities in healthcare – with free choice of 

provider dominating other objectives. Should such free choice be permitted across national 

borders, it might also have to be mandated within countries – with potentially major 

consequences for healthcare systems. 

The thrust of such policy is to emphasise individual rights as opposed to the collective 

priorities (and collective rights) of public healthcare systems. While it is generally the betteroff 

who can currently take advantage of such individual rights, the extension of free choice to 

healthcare within Member States would make the benefits more widely available. On the 

other hand, collective priorities may be undermined by mobility which prevents effective 

national planning. Basic characteristics of Beveridge (NHS) systems in particular may be 

threatened. 

5. Implications for health policy-making 

Even if the impact of many SEM interventions is small in terms of numbers of patients or 

professionals affected by these interventions, the systems turbulence caused by these 

interventions, particularly those resulting from ECJ decisions, may be greater than the 

numbers involved. SEM directives and ECJ rulings have the potential – in a “worst case” 

scenario – to undermine Beveridge systems if ‘managed competition’ in compliance with 

other aspects of European law leads to the spread of sickness funds in the context of the 

insurance model. Equally, there could be considerable turbulence in Bismarckian systems if 

the rules were to be changed away from a “social” health insurance model. 

To address such problems, arising from the unintended consequences of European Union 

regulation on health services, it is therefore time to raise the profile of health policy at the 

European Union level – but in a manner consistent with the aspirations of Member States. 




Based on the future scenarios conducted as part of the study, neither total integration of 

health services at a European level nor the exclusion of health services from the SEM are 

probable. The third option, “muddling through”, does not provide easy solutions, but doing 

nothing is not a sensible option. 

An honest and explicit debate on the advantages and disadvantages of “muddling through” 

must take place. This first requires an acceptance of the intertwining between the SEM and 

health services. Such an acceptance would enable the development of a proactive role for 

health policy-making – as opposed to the current decision-making which is all too often 

reactive, especially to ECJ rulings. While different objectives and interests will no doubt 

continue to be the subject of compromise, an overt healthcare strategy to manage the 

relationship between the SEM and healthcare should be developed. 



Acknowledgement: This presentation is based upon the BIOMED project “Impact of European 

Union Internal Market Regulations on the Health Services of Member States” in which the 

author participated jointly with Philip C. Berman, Pauline Ong, Calum Paton, Clas Rehnberg, 

Barbro Renck, Nuria Romo, Fernando Silio, Mona Sundh and Matthias Wismar. 

A summary of the conclusions has been published under the title “The European Union and 

Health Services – The Impact of the Single European Market on Member States” by the 

European Health Management Association. The full report is available as a book published 

by IOS Press (edited by Reinhard Busse, Matthias Wismar and Philip Berman). 

Summary Report of Forum III 

Philip Berman 

1. Introduction 

Forum III was hosted by the European Commission, DG Health and Consumer Protection, and 

organised in association with the European Health Management Association (EHMA). Mr 

Michael Hübel of DG Health, who chaired Forum III, was responsible for the design of the 

meeting, together with Philip Berman and Paul Belcher of EHMA. The purpose of Forum III 

was to explore the impact that the Single European Market (SEM) is likely to have on the 

ways that health services function. The forum explored three principal aspects of the SEM 

as it may affect health services: 

• The development of the labour market for doctors and nurses 

• Public procurement of goods and services 

• The free movement of patients. 

The forum also considered the recommendations of a major EU-funded study on the impact 

of SEM regulations on health services, recently published by the European Health 

Management Association. 



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Three major questions dominated both the papers and the discussions among the forum 

participants: 

• What are the policy implications of the SEM both for national and regional health 

services, and how should legislators – at European and national levels – respond to 

these issues? 

• Will the impact of the SEM change the way in which European hospitals are 

managed, and how should managers respond to these developments? 

• Will the impact of the SEM lead to better services for patients? 

2. Labour market for doctors and nurses 

There was widespread acceptance that the free movement of health professionals will be of 

considerable benefit to countries with specialist shortages while, at the same time reducing 

the problems of countries with an oversupply of doctors and nurses. Evidence was shown of 

the extent to which the UK relied on EU doctors and nurses, as well as the (temporary) 

oversupply of German doctors that had helped to ameliorate the UK shortage. 

It was emphasised, however, that in the context of a European market in specialist areas 

where there are shortages (such as anaesthetists or paediatric intensive care nurses) 

countries seeking such specialists from other European Member States may have to pay the 

“market rate” (i.e. the top rate) for those specialists. This will make it easier for the wealthy 

European countries to recruit specialists, and will make it much more difficult for poorer 

countries, paying lower salaries, to retain their specialists. 

It seemed probable that, particularly for nurses, the development of a European market 

might drive up salary scales within hospitals, since employees may not be willing to accept 

that a co-worker from another country, performing the same functions, is paid at a higher 

rate. 

Concerns were also expressed that such movements of professionals might have an adverse 

effect on medical and nursing education in poorer countries. What incentive, it was argued, 

would there be for poorer countries to invest in medical and nursing education if their 

doctors and nurses then emigrated to other EU Member States? Some poorer countries 

might even, it was suggested, be tempted to abandon medical and nursing education to the 

private sector which, in turn, could lead to the growth of the private sector in healthcare. 

The forum concluded that, although workforce planning is rarely successful, nevertheless 

there is a need, at a minimum, for the provision of better information on the numbers of 

doctors and nurses moving between EU Member States, as well as better information for 

their motivation in moving. It was suggested that the European Commission might have a 

role in providing such information or in sponsoring such research. It was even suggested 

that medical schools might need to begin to exchange information, and even to coordinate, 

their recruitment policies. 

3. Public Procurement of goods and services 

Evidence was presented that the public procurement process has been to the advantage of 

health services, providing greater objectivity and transparency in the procurement process, 

and improved planning and organisation of services. The Stockholm experiment, in which 

the provision of hospital services for much of Stockholm may be put out to public tender, 

was alluded to as potentially the largest public procurement process within the European 




Union. The question as to whether these opportunities for entrepreneurship would be good 

for the citizen was discussed but not resolved. 

It was also clear that the EU’s public procurement processes had problems as well as 

benefits – increased bureaucracy and personnel numbers, and a slower purchasing process. 

There was evidence that healthcare organisations were using techniques, such as splitting 

the size of contracts, to avoid the EU’s complex public procurement process, and that there 

had been a decrease in the number of Small to Medium Enterprises (SMEs) competing for 

tenders because of the complexities involved. Disturbingly, it was demonstrated that – at 

least in Andalusia – the EU’s public procurement process had had little or no effect on the 

system – the same companies were winning contracts as had won them in previous years. 

4. Free movement of patients 

The effect of the Kohll/Decker and Peerbooms cases were much discussed in this forum, and 

it was felt that it was necessary to distinguish between the effects on the “home country” 

(i.e. where patients live) and the effect on the “host country” (i.e. where patients receive 

treatment) 

The scope for resolving waiting list/waiting time problems was a clear benefit for the “home 

country”, which would be able to transfer patients elsewhere for more rapid treatment. 

However, it seems likely that the effect of the Peerbooms case may be to require Member 

States to redefine their healthcare baskets if patients are to have the right to go elsewhere 

for internationally accepted procedures which are not available in their own country. The 

benchmarking of hospital procedure costs will almost inevitably follow. 

If patients are to move more freely across Europe, this will inevitably lead to demands for 

comparisons of quality standards. Patients will want to be reassured that the hospital that 

they wish to attend has similar standards, if not better, to their local hospital. While it is 

unlikely that the European Commission will wish to become engaged in the accreditation 

process, it may well wish to accredit accrediting agencies in the Member States in order to 

ensure consistency in quality standard-setting across Europe. 

It was acknowledged that the principal benefits will be to patients at border areas, but that 

there is considerably greater potential benefit than has so far been realised. Concerns were 

expressed that this freedom to choose is more likely to be used by the well educated and 

mobile, but not by those with greatest need – the poor and those with little education. 

As far as the “host country” is concerned, overcapacities (such as in Germany) could be put 

to good use by countries with undercapacity (such as Norway). On the other hand, the free 

movement of patients might exacerbate waiting times if patients seek treatment in countries 

with pre-existing waiting lists. It is also possible that some systems may seek to recruit 

patients in an aggressive manner, which could have negative effects on the home country. 

As far as the Applicant States are concerned, the free movement of patients to and from 

those countries is likely to trigger a debate on the financial differences between Central & 

Eastern European and Western European healthcare, which may lead to some turbulence 

among professionals. Where there is acknowledged expertise and lower costs, there may be 

an influx of patients from Western Europe. Again, there is significant potential in border 

areas, which could to be activated through EU regional cooperation initiatives such as 

Euregio. 



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5. The significance of the SEM for health systems 

It is important that the tension between the objectives of the Single European Market and 

those of the European social model should be recognised and managed proactively. At the 

European level, the SEM requires health services to adapt to market rules, but at national 

level, governments seek to adapt market rules to ensure effective delivery of services within 

the social model. The SEM, if it were not held in check, might threaten the widely held 

European values of solidarity and universality. 

If the values of the European social model are to be protected, greater prominence will have 

to be given to health issues vis-à-vis market priorities both at national and especially at the 

EU level. 

Policy-makers and judges should be made aware that the different political, organisational or 

geographical settings of the health services of Member States will be affected in different 

ways by SEM interventions. European Court of Justice (ECJ) rulings may, for example, have 

different effects in Bismarckian countries than in Beveridge systems, just as the impact may 

be different where countries have long land borders from more isolated countries. 

6. Enhancing opportunities and diminishing threats: Some recommendations 

The Commission, the Member States and healthcare providers all have roles to play in 

enhancing the opportunities provided by the SEM and diminishing SEM threats: 

• At the European level, health experts and policymakers should be involved in key 

discussions that impinge on health. Thus, when there are – for example – 

negotiations on competition regulations, it must be recognised that these 

negotiations will have a significant impact on health. It is not acceptable that 

decisions are taken without, at the minimum, an effective “vetting” function by 

health experts and policymakers during a process which should be open and 

transparent. 

• Article 152 seems inadequate to deal with the reality that the Community must have 

the legal basis to deal with the “intertwined” consequences of the SEM for health 

systems specifically from the health perspective, and the inherent contradiction 

between the SEM and the European social model is just one of these consequences. 

The time has now come to revise Article 152 to recognise these realities. 

• It must be recognised that the likelihood is that Member States and the 

Commission are most likely to adopt a “muddling through” approach, rather than 

taking a radical approach to resolving these contradictions. Member States, 

though, should replace their current reactive behaviour with a proactive approach, 

seeking to use ECJ judgments to benefit European citizens, while preserving the 

financial basis of health services. Citizens should be informed of their (equal) 

rights; technical innovation should be encouraged; more cross-border activities 

should be developed; best practices should be fostered; and quality should be 

guaranteed across Europe through a process of accreditation. 

• It should be recognised that health is a minor actor in the macro-economic play 

called “globalisation”, and that the globalisation process is the extension of the 

Single European Market on a global scale, affecting our health services, particularly 

in relation to health professionals, pharmaceuticals and the increasing prevalence of 

market forces. 

• Managers and policy-makers must recognise that health systems are no longer 

bound entirely by national boundaries. They need to look across borders for both 






165 

opportunities and threats. It is important that the voice of the providers, who will 

be particularly affected by these developments, should be clearly heard. 

• The European Community should explore the potential impact of workforce 

movements and, at a minimum, should ensure that there is reliable and comparable 

data on the extent of the movements of doctors and nurses. 

• Research will continue to be required at a European level to understand the 

implication of all these issues. 


http://www.ehfg.org/website01/abstracts.htm

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Forum IV: Building a healthy Common 

Agricultural Policy (CAP) 

Shifting CAP's objectives to the provision of healthy, sustainable food 

production and safeguarding the health and vitality of rural 

communities and landscapes 

Aileen Robertson 

Agriculture policy, health and nutrition 

This article argues that public health workers need to pay increasing attention to agriculture 

policies. Agriculture can provide employment, food security, healthy diets and a healthy 

environment, but it will only do so when its current practices are challenged. 

The major nutritional problems related to the food supply in Western Europe are not caused 

by a lack of protein (our diets are rich in meat and milk products) nor a lack of energy (we 

consume high levels of fats and sugars) but primarily by an inadequate consumption of 

vegetables and fruit.[†] 

Appropriate policies – for example to encourage greater investment in horticultural 

production – can help to resolve this imbalance, and simultaneously improve prevailing 

environmental and social conditions. Vegetables and fruit can be made more accessible to 

the local population, improving food security and nutrition, enhancing the local economy and 

strengthening social cohesion in rural areas. In this way, food policies can be geared towards 

socioeconomic and environmental goals as well as improving public health. 

Health authorities, especially, can promote intersectoral collaboration to address the 

determinants of public health. We look at the links between agriculture and health, especially 

nutrition, and describe some opportunities for changing agriculture policy. 

Nutrition, food and agriculture 

Recent experience in Europe (such as dioxin contamination in Belgium, BSE in Britain, and a 

decline in wildlife across Europe) has shown how food contamination and environmental 

pollution are directly linked to agricultural production methods. These links can be given 

financial costs: for example, an assessment in the UK suggested that the environmental and 

health costs of agriculture were as high as $6bn annually.[1] 

This assessment excluded any links between nutrition and agriculture, for which 

documentation is less well established. More research is needed in this area, but there are 

several reasons why the nutrient quality and diversity of our diets are linked to agriculture 

policy: 



Forum IV: Building a healthy Common Agricultural Policy (CAP) 

• The biodiversity of our diet has declined dramatically. One estimate suggests that 

just 15 crops supply 90% of the world´s human food and livestock feed.[2] 

Supermarkets may appear to have a great variety of foods, but a wide range of 

brand names does not mean a diversity of nutrients and other valuable 

biochemicals. 

• The selection of species for commercial crops has favoured productivity (high yields, 

fast growth, response to fertilisers etc) over nutrient diversity and nutrient density. 

• Stocks of wild foods (fish, wild edible plants, wild game) with high nutrient density 

and an abundance of protective phytochemicals and polyunsaturated oils are 

threatened.[3] 

• Policies which lead to the mass destruction of vegetables and fruit in the EU reduce 

access to these foods, in turn reducing the nutritional content of the European diet. 

Besides antioxidants (carotenoids, vitamin C & E, selenium), vegetables and fruits contain 

dietary fibre and other phytonutrients, such as quercetin, which are biologically active 

compounds in human metabolism. There is now clear evidence of the health benefits of 

eating more vegetables and fruits. Estimates suggest that 30-40% of certain cancers (colorectal, 

gastric and lung) are preventable by increasing daily intakes of vegetables, fruit and 

fibre.[4] A low intake of vegetables and fruit is also associated with micronutrient 

deficiencies, hypertension, anaemia, premature delivery, low birth-weight, obesity, diabetes, 

and cardiovascular diseases.[5] 

As a result of these observations, the World Health Organization recommends the daily 

consumption of more than 5 portions (> 400g) of vegetables and fruits per day.[6] This does 

not include potatoes but does include eating an average of 30 grams of legumes every day. 

The supply of vegetables and fruits varies considerably throughout the European region. The 

greatest supply is in Greece where there is over 1000 grams of vegetables and fruit available 

per capita per day.[7] Greece has the lowest rate of premature mortality from cardiovascular 

disease.[8] 

In contrast most other EU countries do not have enough vegetables and fruit to ensure 

nutrition security for the population. Accession countries are in an even worse state. It has 

been calculated that levelling up the intake to the highest consuming groups could result in 

tens of thousands of lives saved each year in the EU.[9] 

What should the objectives of food production be? 

A reformed agriculture policy should incorporate the following elements: 



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• Following the Rio Summit and Agenda 21, there is an overriding objective to 

encourage sustainable forms of agriculture. This includes producing foods that 

mirror the population’s needs, as set out in dietary guidelines for EU member 

states. All dietary guidelines stress the need to increase intakes of vegetables and 

fruit and to decrease saturated fats, which come mainly from meat and milk 

products. In addition, to meet wider public health needs, agriculture policy should 

stimulate social cohesion and enhance socio-economic status for rural populations. 

• Publicly financed subsidies for agriculture should aim to achieve the above goals. 

For example funding should go to support promotion of increased consumption of 

vegetables and fruit, instead of promoting the consumption of meat products and 

full-fat milk. In contrast , intervention price support for cereals (the bulk of which 

are used for animal feed) has encouraged farmers to convert land from vegetable 

and fruit production to cereal production.[‡]

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• Resources for research and development into sustainable agriculture and health 

impact assessments should be provided. At present, most agricultural research 

resources are devoted to the needs of conventional methods of production 

(including biotechnology), and most resources for impact assessment are devoted 

to a narrow range of environmental concerns. 

Opportunities: 1. Health Impact Assessments 

Health cannot be protected, sustained or promoted by the action of the health care sector 

alone. There is a need to assess and change the impact of other sectors on the health of the 

population, and to do this through the development of intersectoral health policies. 

This need has given rise to a call for the development of a systematic approach, 

methodology and procedures for Health Impact Assessment (HIA).[10] The significance of 

human health and its determinants has been emphasized as an aspect of Environmental 

Impact Assessment (EIA), particularly in the USA, Canada, Australia and New Zealand as well 

as in the World Bank.[11] 

Research into the health impact of agriculture policy is urgently needed. Under the 

Amsterdam Treaty, the European Union is committed to ensuring that ’…a high level of 

health protection shall be ensured in the definition and implementation of all Community 

policies…’ (Article 152). The single largest policy operating in the EU, responsible for around 

half the overall budget, is the Common Agricultural Policy (CAP). As has been discussed in 

several documents, many of the measures under the CAP act to reduce the potential for high 

consumption of fruit and vegetables, and promote the consumption of meat and dairy 

products, sugars and fats.[12] 

Opportunities: 2. Enlargement 

As we have suggested, the EU's system of compensatory payments to farmers distorts 

agricultural markets and, in our view, encourages poor diets. If the EU's intention is to apply 

these payments to the countries of Eastern Europe currently applying to join the EU, then the 

implications for social cohesion and public health in these countries are serious, with the 

following likely distortions: 

1. Land prices will rise, which will make it harder for young farmers going into 

agriculture. 

2. Production of crops and livestock will intensify, with concomitant burdens placed 

on the environment. 

3. Absentee ownership is common in accession countries, and much of the income 

from EU subsidies would be invested outside agriculture. Thus, payments will be of 

little benefit to those working on the land, resulting in an agricultural policy that 

transfers wealth to a substantial number of non-farming landowners. 

4. Agricultural productivity in 2000 in the accession states was only 11% of the EU 

level.[13] Increasing productivity will mean that less labour will be required, creating 

high levels of unemployment. In Poland the agriculture policy calls for the 

percentage of the working population engaged in agriculture to be cut from 28% in 

1998 to just 5-7 % before joining the EU.[14] 

5. Food production policies during the 1970s and 1980s led to the consumption of 

high levels of fats and meat products but low levels of fruits and vegetables. An 

extension of the present EU agricultural policy would perpetuate these eating 

patterns and discourage healthier diets. 




In many accession countries, the price of foods has increased more rapidly than income 

levels, and in some countries between 30% and 60% of household income has to be spent 

on food, compared with less than 20% in the EU.[15] In response to this household food 

insecurity, supplementary food production and small-scale farming has increased, and 

appears to be more efficient than larger-scale farming methods.[16] A rapid change due to 

high levels of capital investment may jeopardise the food security being developed in the 

region. 

Opportunities: 3. the General Public 

In 2000 the total support for agriculture in the EU was some Euro 40.2 billion [17] (nearly 

50% of the total EU budget) creating a tax burden on EU citizens of some Euro 130 per 

capita. The protective measures also raise the price of food compared with world market 

prices, adding another Euro 120-150 per capita cost to the consumer.[18] The average family 

is thus paying some Euro 1000 annually as a result of EU agricultural policies. 

Consumer expectations will be an important consideration in the CAP discussions. In order to 

assess public perceptions, two Eurobarometer opinion polls were carried out among farmers 

and the general public in 2000. The surveys were carried out by telephone interview on 

16,000 members of the general public and 3,500 farmers and revealed a widespread interest 

in agricultural issues and a wish for more information.[19] 

Whilst 92% of the general public think that agriculture is important, only 50% had heard 

about the CAP. Both farmers and the general public were asked to rate the importance of a 

list of 12 policy objectives, including food safety, environmental protection, the improvement 

of rural life, the protection of farm incomes and the competitiveness of European agriculture 

on international markets. (Questions on nutrition and diet were not asked.) A clear majority 

of people thought that all the objectives were important (ratings varied between 76% and 

97%) but the levels of satisfaction with how they were being met ranged between 16% and 

57%. 

The protection of farm incomes and small farms was seen to be badly served, by both 

farmers and the general public. Food safety and environmental protection were considered to 

be the top priorities but the survey revealed an acute need for information about agriculture 

policy. With respect to enlargement, only half of the respondents in both groups had heard 

something about it and only 10% of the general public felt well-informed on the subject. 

Indirectly, consumers are already protesting against agriculture policy because they buy less 

meat. Since the BSE crisis demand for beef dropped by around 27% on average and in 

Germany by 50-80%. This is damaging for agriculture policy, but, from a nutritional health 

perspective, this trend may prove to be healthy if the dietary changes include the 

consumption of more fruit, vegetables, wholegrain cereals or fish. 

Opportunities: 4. The First Food & Nutrition Action Plan for the WHO European Region 

In September 2000 the 51 member countries of the European Region of the World Health 

Organization unanimously endorsed a resolution to implement the region’s first Food & 

Nutrition Action Plan.[20] This document makes the case for combining nutrition, food safety 

and sustainable food production concerns into an overarching, intersectoral policy, and offers 

support to member state governments to develop, implement and evaluate such policies. 

Progress with implementation, both by WHO and member states, will be reported to the 

Regional Committee in September 2002. In addition, a more comprehensive evaluation of the 



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impact of this first Action Plan will be reviewed during the first Ministerial Conference on 

Food & Nutrition in 2005. 

This political commitment gives public health experts an extraordinary and important 

opportunity to lobby both at national and European level for an agriculture policy that 

explicitly promotes health. 

Conclusion 

Unsustainable agricultural systems have grown out of the narrow focus on productivity that 

has monopolized agriculture policy. Their economic costs are already becoming apparent but 

their human health costs – including their nutritional impact – have not received sufficient 

attention. 

A number of opportunities for changing agricultural policy are becoming available, and public 

health experts are urged to ensure that their views are fully expressed in this process. 

Notes 

† This has been the finding of several WHO reports over the last decade: Diet, 

nutrition and the prevention of chronic disease (WHO Technical Report Series 797, Geneva, 

1990); Preparation and use of food-based dietary guidelines (WHO internal document 

WHO/NUT/96.6, Geneva, 1996); Countrywide Integrated Noncommunicable Diseases 

Intervention (CINDI) dietary guidelines (WHO Regional Office for Europe, Copenhagen, 2000). 

‡ Between 1960 and 2000, the countries of Mediterranean European saw a reduction 

in the land used for fruit and vegetable production by nearly a quarter (2.1million hectares) 

and an increase in land devoted to cereal production by a similar amount (1.5 million 

hectares). 

References 

1. Agriculture and the Environment: An impact statement prepared by the 

Environment Agency, Consultation draft, UK Government Environment Agency, 

Bristol, October 2000. 

2. D Pimentel et al, 1974, cited in RD Sainz, ‘Livestock-Environment Initiative, Fossil 

Fuel Component: Framework for Calculating Fossil Fuel Use in Livestock Systems’, 

Livestock, Environment and Development program (LEAD), FAO, Rome 2000 

[http://www.fao.org/WAIRDOCS/LEAD/X6100E/Intro.htm]. 

3. For game, see MA Crawford, Fatty acid ratios in free-living and domesticated 

animals, Lancet, 22 June 1968, p1329-1333; for plants, see A Trichopoulou et al, 

Nutritional composition and flavonoid content of edible wild greens and gren pies: 

a potential rich source of antioxidant nutrients in the Mediterranean diet, Food 

Chemistry, 70, 2000, p319-323. 

4. World Cancer Research Fund, and American Institute for Cancer Research, Food, 

Nutrition and the Prevention of Cancer: a global perspective, WCRF/AICR, 

Washington, 1997. 

5. World Health Organization Diet, nutrition and the prevention of chronic diseases, 

Technical Report Series 797, WHO, Geneva, 1990. 






171 

6. World Health Organization Diet, nutrition and the prevention of chronic diseases, 

Technical Report Series 797, WHO, Geneva, 1990. 

7. Food and Agriculture Organization Statistical Database: Food Balance Sheets, FAO, 

Rome [www.fao.org] annual. 

8. World Health Organization, Health for All Database [www.who.dk] annual. 

9. Joffe & Robertson, The potential contribution of increased vegetable and fruit 

consumption to health gain in the European Union, Public Health Nutrition (in 

press). 

10. J Lehto and A Ritsatakis Health Impact Assessment as a tool for intersectoral health 

policy, a discussion paper for a conference: Health Impact Assessment: From Theory 

to Practice, Gothenburg 28-31 October 1999. 

11. See, for example, WHO and CEMP, Environmental and Health Impact Assessment of 

Development Projects. A handbook for practitioners, Elsevier, London, 1992; British 

Medical Association, Health & environmental impact assessment. An integrated 

approach, Earthscan, London, 1998; The World Bank, Environmental Department , 

Health Aspects of Environmental Assessment. Environmental Assessment 

Sourcebook Update, July 1997. 

12. Agra Europe, page 7, March 2000. 

13. Agra Europe, page 12, May 1998. 

14. M Bobak, D Blane and M Marmot Social determinants of health: Their relevance in 

the European context draft paper for the Verona Initiative, 1998 

[www.who.dk/Verona/Publications/Bobak1.htm]. 

15. G Hughes, working papers 2/7 and 2/10, in Agricultural Implications of CCEE 

Accession to the EU, FAIR1 CT95-029, Wye College, University of London, 1998. E 

16. European Commission [http://europa.eu.int/comm/agriculture/survey/index_en.htm].T 

17. The First Action Plan for Food and Nutrition Policy: WHO European Region 2000- 

2005, WHO Regional Office for Europe, Copenhagen, 2001 

[www.who.dk/Document/E72199.pdf]. 

This contribution is a revised version of an article by Tim Lobstein and Aileen Robertson 

which originally appeared in Eurohealth Vol. 7, No. 2, Summer 2001 



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Local level: Using urban agriculture and local sustainable food 

production to safeguard food security, reduce health inequalities and 

preserve cohesion in rural communities 

Jeannette Longfield 

Abstract 

For many, sustainable food production and consumption automatically incorporates all the 

elements listed in the title of this presentation, and more besides. Given the growing 

evidence, and groundswell of public support for sustainable food systems, the question 

remains, why do we not yet have this? Unless we have a clear view of the obstacles, as well 

as the opportunities, our efforts will fail. How, for example, can local, small-scale 

experiments in sustainable food systems help to tackle: 

• Global organisations with major financial interests in keeping the current, 

unsustainable system in place. 

- these include not only major sectors of the agriculture (including 

agrichemical supplies) and food production, processing and distribution 

(including advertising) industries, but also transport and associated 

businesses 

• Governmental inertia, intellectual dishonesty, cowardice or corruption. 

- even sympathetic governments tend to move only slowly towards reform 

- many profess powerlessness in the face of the “inevitable” results of 

increasing global food trade 

- others refuse to acknowledge the financial vested interests outlined 

above, couching reform efforts in terms of “partnerships” 

- some suspect (though find it hard to prove) collusion between some 

governments and parts of the agri-food business to prevent reform 

• Consumer ignorance and sense of helplessness. 

- because of the lack of social cohesion exacerbated by the current food 

system, many consumers are unaware of the damaging consequences of 

their buying habits 

- those consumers who become aware often feel powerless in the face of a 

complex, global food system and therefore fail to make the transition from 

passive consumer to active citizen 

Taking the last point first, sustainable food projects can: 

• demonstrate what can be done. Urban food projects are particularly important in 

Europe since that is where most people live. Seeing improvements in the food 

system, however modest, empowers people. 

• help raise awareness. While information and education is often assumed to be a 

necessary precondition for action, “action speaks louder than words”. 

• show government that change is possible and popular. Practical projects can also 

help generate more tangible evidence that sustainable food systems have health 

and environmental advantages. 

• provide a direct economic challenge to the dominance of unsustainable food 

systems by offering people the opportunity to Buy Something Else – an alternative 

BSE! 




However, sustainable food projects alone are not “the answer”. Their very advantage for 

citizens i.e. that they are local and human-scale, makes them too small, individually, to affect 

government and business. To increase their influence food projects need to: 

• form groups or federations of similar projects from local to global level 

• form links between these federations and other, like-minded networks 




173 

National level: Austrian farmers call for a radical change in CAP to 

provide healthy food 

Elisabeth Baumhoefer 

Society and the environment need a new agricultural policy 

The Coordination Paysanne Européen (European Farmers Coordination, CPE) is convinced 

that the EU´s Common Agricultural Policy (CAP), within the Agenda 2006 programme, needs 

to be redesigned. Stories of nitrates and pesticides in ground water, antibiotic residues in 

meat, dioxins and salmonella in poultry, the risks of genetic engineering, and not least BSE 

and MFD , far too often make sad headlines in the media and have given a bad image to 

agriculture. All these problems and crises are a consequence of industrial farming and under 

this now all farmers have to suffer. Small and medium sized farms still constitute the 

majority of farming enterprises and they are far more environmentally friendly than industrial 

agriculture. In the actual situation small farms run the risk of being sacrificed in the interests 

of multinational companies and global trade. 

Society´s real needs 

The CPE wants an agriculture that focuses the real needs of society like production of high 

quality and healthy foods, protection of the environment and biodiversity, regional 

markets,... The so called European model of Agriculture is full of contradictions. How can it 

be environmentally friendly and pollute the ground water or produce healthy food and have 

the antibiotics and dioxin scandals at the same time? 

It is high at the time that the CAP will be changed to a „farmers„ agriculture which respects 

the environment. Also the subsidies shouldn’t be linked to the number of hectars and 

animals. It should be linked to the labour and working places. Also subsidies should be 

limited and linked to an ecological minimum standard. We think, that the society will accept 

this better than the actual programme. In the long run food prices should cover production 

costs. The prices should take into account the consequential cost of environment, transport 

and so on. 

Food Souvereignity 

Under Food Souvereignity we understand the right of every region and nation to produce its 

own food and it is the fundamental basis for Food Security. This unites the farmers in the 

North and the South. The orientation of the CAP towards the world market instead of 

focusing on internal needs has negative consequences beyond Europe. Export dumping not

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only undermines food production and, in turn, the existence of farmers in many regions of 

the world, but it threatens food security and the environment. 

The CPE and the Austrian Mountain Farmers Association are convinced that to ensure the 

nutritional value of our food and to preserve the ecological balance worldwide, this can only 

be possible with a non-industrial and responsible agriculture. 

EU level: Interpreting the multifunctional role of agriculture and rural 

development across Europe 

Elisabeth Guttenstein 

In discussions with Génon Jensen of EPHA last summer she suggested to me that the 

environmental movement in agriculture can today reap the fruits of its success. European 

Leaders such as Schröder and Blair now speak about the need to reform the CAP along the 

same lines we have been promoting over the last ten years. It clearly is a success. 

However, I replied, our new challenge is even greater. We now have to achieve 

environmental standards and the provision of environmental services through a policy which 

is still based on the objectives of productivity and security of supplies. 

The concept of ‘multifunctionality’ in agriculture has not been around for very long. The 

different aspects of multifunctionality have been around for much longer, of course, the 

environment, food security and safety, consumers, landscapes and rural economies. 

However, in Europe we champion the concept of multifunctionality because we recognise the 

need to bring these different issues into a coherent framework. Articles 2 and 6 of the 

Treaty of Amsterdam are arguably an expression of this. These two articles stipulate the 

need for all community policies, including the CAP, to integrate sustainable development and 

environmental protection. I will not list all the different functions we want integrated in the 

CAP to make it more sustainable. The recent crises in the agricultural sector have once again 

provided us with clear evidence of the depth of public concern about the future of agriculture 

and rural areas. I will instead analyse the example of environmental integration in the 

process of CAP reform, and whether CAP reform is contributing to environmental protection. 

WWF is the first to agree that the management of natural resources is at the heart of the 

daily work of farmers. Nonetheless, evidence shows that when environmental constraints 

pose a challenge to productivity, achieving environmental protection through agriculture 

creates tensions. The tensions can be competing demands on natural resources such as 

water; on finances available to deliver agricultural and environmental services; or 

contradictory incentives provided for the two sectors. 

These are just the most common conflicts that occur between the environment and 

agriculture. If we then add the need to respond to consumer demands, to maintain fragile 

rural economies, not to mention a sustainable impact on the economies of developing 

countries; multifunctional agriculture seems doomed to failure from the outset. 

Policy may not be able to resolve all those conflicts alone. Today we recognise the 

increasing role played by the market, global trade and the consumer. The question I would 

like to address is the following: which policy model for a future CAP is most likely to deliver 

on multifunctional objectives? 




Many people think of the WWF as being a ‘visionary’ organisation, campaigning for radical 

overhauls and global solutions. Far be it from me to dispel this image. Later in my speech I 

will tell you about our requirements from a future CAP. But we also believe that much can 

be done within the current framework to improve the sustainability of agriculture. 

The first step in achieving environmental integration is to define the objectives. These are 

well known: to manage natural resources (water, soil, forests…) habitats and biodiversity 

sustainably. Most of these objectives are addressed through specific EU legislation, such as 

the Water Framework Directive, the Nitrates Directive, or the Habitats and Wild Birds 

Directives. Under the CAP we have a better funded agri-environment scheme since the 

Agenda 2000 reforms, which aims to support those environmental services which are best 

provided through farming. 

However, having specific instruments to achieve environmental objectives is not the same as 

integrating environmental protection in the CAP. Very little has been done to integrate the 

environment into the core of the CAP, into the basic incentives and obligations of the market 

regimes, which after all still account for 90% of the total CAP budget. Without integration 

into the very structure of the CAP, environmental objectives will not be achievable, let alone 

achieved. 

It is clear what could be done to improve environmental integration in the CAP. Let me give 

you the example of the olive oil sector. Olive oil is possibly the most antiquated regime in 

the CAP. The environmental problems it is driving have been widely documented, including 

by the Commission itself. In fact, we know that olive farming is one of the major causes of 

one of the biggest environmental problems affecting the EU today: widespread soil erosion 

and desertification, in terms both of land and people, in Spain, Italy, Greece and Portugal. 

Over the last three years the regime has been twice through Commission and Council for 

reform. Twice the proposals of the Commission and the final decision of the Council have 

fallen short of even attempting to steer the sector towards better environmental, and social, 

integration. Yet the means are clear: change the current production-based subsidy into a 

standard flat-rate payment per hectare; stop new plantations from being eligible for funds, to 

halt their current expansion; establish local codes of good agricultural practice and make 

farmers’ receipt of payments dependent on them respecting these standards. Similar 

changes have been successfully implemented in other sectors and would provide immediate 

benefits in reducing the degradation of natural resources caused by intensive olive farming. 

It would also improve the viability of marginal or low-input farms. 

Last December the Commission proposed to delay reform again for another two years, and 

our Ministers, at their Council meeting last June, played heed to the political pressures of the 

producer countries, and to those production and supply interests they still believe to be 

over-riding all others. 

The MacSharry reforms launched in 1992 represented a new departure for the CAP, and were 

overall beneficial in strengthening the environmental dimension of agriculture. Since then 

there has been little concrete willingness to pursue that move. Although there is a lot of 

rhetoric about how to make the CAP greener, we seem to have reached a stalemate. 

WWF considers this regrettable particularly with respect to enlargement. WWF also believes, 

however, that enlargement provides the best opportunity the CAP may have ever had to be 

reformed in favour of greater sustainability. 

We can only extrapolate the specific effects exporting the CAP would have on the Candidate 

Countries. Nonetheless, we can learn lessons from the CAP’s impact on the Member States. 

We must also recognise the economic forces of the global market. Beyond the effects the 



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CAP might have on the natural environment of the Candidate Countries, the reason why we 

believe enlargement could lead to CAP reform is, of course, financial. 

We now know that the current model of the CAP has frozen production patterns in many 

regions of Europe, pushing for specialisation to the detriment of mixed farming systems and 

local distinctiveness. Those farmers that could have adapted through economies of scale. 

They have either increased the size of their farms or intensified their production to maximise 

yields. Those who could not have left farming. Compensation payments, with no agreement 

as yet to phase them out, maintain the strong link to the farming patterns the CAP has 

traditionally supported. 

None of this bodes well for enlargement. According to Commission calculations if full direct 

payments were paid today to Candidate Countries this would represent roughly Euro 7-8 

billion per year. This would already exceed the ceilings laid down for the CAP in Berlin in 

1999. But enlargement is of course a political rather than an economic choice, and I have no 

doubt that when enlargement will happen, our politicians will find the means to pay for it. 

What we need to ask is should they pay to extend a CAP we are already unhappy with in the 

current Member States? 

Let me speak briefly to you about a project which clearly demonstrates the model of farming 

and CAP support that WWF would wish to see as a basis for a reformed CAP in the 

Candidate Countries. 

At the end of the 1990’s WWF launched the Väinameri project in Estonia. Our aim was to 

manage valuable coastal eco-systems by ensuring economic viability for farmers living in 

these traditionally sparsely populated areas, so that they would not abandon them. Both 

goals, as you will know, are central to the rural development policy of the Union. The 

approach we adopted was to enhance the financial opportunities of farmers through 

developing recognition for their ‘natural grazing meat’ as added value to consumers. We 

also were able to identify financial support for the provision of the grazing patterns and 

mowing services required to manage the semi-natural meadows of this coastal area. The 

financial security this gave farmers had the knock-on effect of creating further economic 

opportunities, developed from the recognition of the natural values of the area: small-scale 

green tourism developed, the local cultural heritage was revived and new crafts developed 

from using local materials. Väinameri’s coast is now under active management, and the 

environmental and economic future of the region is secured. 

What lessons can we draw from this? Not all farming areas would benefit from this type of 

approach, nor would it be relevant to many of the more favourable farming regions. 

However, this indicates to us that maybe, in the medium to longer term, we really do need 

to reconsider what the CAP must support and what instead can be left to the market. There 

is no longer any doubt that over time, as market liberalisation is pursued, it will become 

increasingly difficult to support either market stability or farming incomes. The CAP must, 

therefore, reconsider its basic objectives. 

WWF believes that both the 1992 and the 1999 reforms of the CAP were insufficiently 

focussed on delivering environmental protection through agriculture. 

On the one hand, because they attempted to manage the environmental impact of farming 

and provide positive environmental services under the same means, and therefore were 

insufficiently focussed or resourced for either; 

On the other hand, market developments and the economic choices within the CAP have 

continued to push farmers and governments to choose between productivity and the 

environment. This generally still results in the environment losing out; 




Finally, the reforms did too little to define and remunerate those environmental services 

which may not be a simple by-product of farming, and that are not automatically provided 

for by the market. 

From WWF’s perspective a future reform of the CAP needs to take these issues into 

consideration and address them. In particular, WWF calls on the Member States and the 

European Commission to: 

Pursue the reforms of the market regimes. Respecting the environment must become an 

integral criteria of all commodity payments; 

Agri-environment measures must be better focussed and strengthened. This will require 

further funding but also ensuring that those regions and sectors where the environmental 

problems are the greatest are included; 

In the longer-term, however, it may be necessary to reconsider altogether the objectives of 

CAP payments, to redirect them towards supporting those services which are not provided 

for by the market; 

Before this can be done, the objectives we are aiming for need to replace those of 

productivity and supply management. For this we will need an honest assessment of what 

farming can provide, and what it cannot; 

I have spoken to you about multifunctionality from the perspective of the environment. The 

lessons I have drawn are, however, applicable within other spheres. I hope we will be able 

to discuss them further throughout the day. 

The EU farmers’ views on the development of the CAP 

Anton Reinl 

Ladies and Gentlemen, Chairman, 

Thank you very much for the invitation to present you today the position of European 

farmers and their cooperatives on “Obstacles to changing the CAP and the farming industry’s 

vision”. However, I did not have any influence on the topic of the Forum. I would have 

preferred to discuss “Building a healthy European food policy” (instead the narrow CAP) 

together with representatives of medicines, consumers, food industry and retailers who are 

missing today. 

Therefore, I choose the title “The EU farmers’ views on the development of the CAP”. I will 

try to show you some incoherent aspects in the European policy and would enjoy to hear 

your opinion on that issue. 

BSE, dioxin crisis, food and mouth disease, classical swine fever etc. demonstrate – 

according to the general public opinion – that “there is something wrong in agriculture”. 

Although these incidents really only involved a few European countries, the impression in the 

mass media was that despite the strict regulation of the agricultural sector, these above 

mentioned incidents occur regularly all over Europe. 



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While the public often criticises politicians for their inept handling of such situations, the 

recent political solution to scandals and crisis seems to be to tighten up existing legislation 

(new regulations) - rather than focusing on the practical control of existing rules. A recent 

example is the ban on the use of meat and bone meal in animal feed for pigs and poultry as 

a result of the lack of control and illegal use in cattle feed. 

As you may know, the Common Agricultural Policy, created already in 1958, has changed 

through its reforms in 1992 and 1999 (Agenda 2000). Progressively, support prices have been 

reduced, increased direct aid to farmers have been introduced, which are becoming more 

decoupled from production and where environmental considerations are coming more and 

more to the forefront. 

Taken together, these reforms amount to a major change in direction for our agricultural 

policy. The new focus is now on the multifunctional nature of agriculture rather than on its 

food producing role. 

The second large reform, Agenda 2000, decided by the European Council in Berlin, is being 

implemented over the period 2000 to 2006. Now, only one year after Agenda 2000 was 

introduced there are moves in some quarters to press for yet a further wide-ranging reform 

of the CAP before well before 2006. 

COPA and COGECA are keen to engage in a debate about the direction agricultural policy 

should take once the current CAP reform has been implemented. However, they believe that 

a further reform before 2006 is not only unwarranted but also unwise. When deciding upon 

Agenda 2000 the European Council requested the Commission to submit a series of reports 

over the period 2002 and 2003. 

The only possible justification for changing the CAP prior to 2006 would therefore be if 

budgetary expenditure in the agricultural sector was at risk of exceeding the ceiling set by 

the European Council in Berlin and/or there was a serious deterioration in the overall market 

situation. 

This is clearly not the case since the agricultural budgetary situation and the market outlook 

are sound. COPA and COGECA consider that the European Union must maintain a strong 

position in the forthcoming WTO round and farmers and their co-operatives need stability 

and a coherent policy. 

There is an attempt in some circles to use the above mentioned crisis to press for further 

reform of the CAP prior to 2006. Some, for example, are pressing for yet more reform of the 

CAP along the lines of the 1992 and Agenda 2000 reforms. This means increased 

liberalisation, greater price competitiveness and more rapid productivity growth. 

In contrast some others are calling for a move in a totally opposite direction –blocking the 

trend towards larger farms and encouraging more extensive farming which will inevitably 

reduce productivity and the competitiveness of European farming. 

These opposing views are also increasingly reflected in EU policy: on the one hand trade 

policy is pushing towards lower prices, forcing farmers to cut costs while internal policy is 

resulting in increasingly restrictive regulations on agriculture which lead to higher and higher 

costs. 

In economic terms, this development means that European society has imposed conflicting 

demands on food production at the agricultural level: 

While the European society demands 

- more productivity at lower prices to meet the WTO trade concerns 

It also demands 




- stricter environmental, animal welfare and food safety standards, thus often higher 

costs leading to a loss of international competitiveness. 

Examples: 

- Antibiotics (ban of 4 antibiotics as additives in feeding stuffs 1999; imports not 

covered) 

- ban of meat and bone meal for internal production, imported products can be 

produced with meat and bone meal 

- animal welfare (higher standards for European producers, imported products are not 

covered; e.g. Ban of battery cages for laying hens) 

Whatever farmers try to do they are squeezed and their attempts to meet society’s 

expectations are thwarted. This conflict must be resolved but the path of the past CAP 

reforms has clearly not brought the solution. It is evident therefore that another quick CAP 

reform along the same lines is not the solution. To our opinion, the current contradictions 

have to be solved beforehand. 

Consistent objectives must be pursued in the policy approach to the current WTO 

negotiations! 

EU farmers wish to respond to the expectations of society to develop the quality of products 

and production methods but trade and other policies, as well as market conditions, must 

make this possible. 

The agri-food sector should never be treated in the same way as other economic sectors, and 

equal account must be taken of the very special and important role of non-trade concerns in 

the case of agriculture. 

Agriculture differs from other economic sectors in several critical ways: 



179 

• farmers work directly with the environment: their production is dependent upon the 

climate, soil, water and sunlight. 

• food is a vital necessity – all governments must be able to guarantee their 

population secure and stable supplies of safe food. This is too important to be left 

solely to market forces: agricultural commodities are subject to significant 

fluctuations in supplies and prices due to climate, economic fluctuations and 

international strategic considerations. In an increasingly global market these 

fluctuations are becoming more rather than less acute. An effective agricultural 

policy is therefore essential; 

• farmers (and their co-operatives) supply services to society which provide a public 

good over and above the production of commodities. They contribute towards the 

economic viability and employment in rural regions and the maintenance and 

enhancement of the countryside. Agriculture also has the capacity to make a 

significant contribution towards reducing pollution – through the production of biodegradable 

industrial raw materials and bio-fuel. 

It is therefore essential that the European Union follows a trade policy in the current WTO 

negotiations which takes account of the wider role of agriculture compared with other sectors 

and ensures society’s expectations of agriculture are met. This concern is not restricted to 

the European Union. Fewer and fewer societies, throughout both the developed and 

developing world, are willing to move towards freer trade without taking into account its 

impact on other issues of equal or greater concern. This was illustrated very vividly in Seattle 

and is now presenting WTO members with their most important challenge. The forthcoming 

negotiations must achieve a balance between trade and non-trade concerns and enable

180 


agriculture to fulfil its multi-functional role. If not the credibility of the WTO will be seriously 

eroded. 

The rules concerning market access must ensure that the concerns of European consumers 

are met and that there is fair competition between EU and imported products. 

Let me draw your attention also to one aspect which is seen quite controversial by the 

public. The agricultural budget: The Common Agricultural Policy has been the first really 

harmonised common policy at European level and is still mainly financed by the European 

budget. Imagine a Brussels financed pension or public health system! The current European 

agricultural budget would be a very small part of this total budget. Concerning the famous 

50 percent discussion: If you count all 15 national budgets and the European budget 

together the expenditure for agriculture is less than 2 percent of all expenditures! 

Europe has to have the means of its ambitions. And its ambitions eventually have to be 

translated in policies. 

Farmers (and co-operatives) are determined to meet EU regulations concerning food safety, 

quality and environmental protection, sustainable production methods and animal welfare 

but it must be ensured that this is compensated either via the market or through the budget 

so that they do not lose markets to competitors. In this respect 3 items for the further 

development of the CAP are important: 

1. food safety and animal welfare rules applied to domestic production must also be 

applied to imports; 

2. it must be possible to apply the precautionary principle in the case of legitimate 

concerns about food and environmental safety when scientific assessment is 

inconclusive or incomplete. Therefore, the precautionary principle should be clarified 

at the next WTO round; 

3. Farmers' (and co-operatives') positive contribution to the environment, rural 

development as well as the maintenance, of a countryside and landscape must be 

recognised as a public good which can be remunerated under WTO – green box. 

European level: European supermarkets set standards for their 

suppliers in response to growing consumer demand for 

environmentally sustainable and pesticide free products 

Nigel Garbutt 





Summary Report of Forum IV 

Mike Rayner 

In reporting back on Parallel Forum IV: ‘Building a healthy Common Agriculture Policy’ I will 

firstly summarise the most important issues discussed at the Forum, secondly I will mention 

some controversies that arose and finally summarise the four recommendations that were 

agreed. 

Issues 

Firstly the Forum discussed, in some detail, what the health objectives of the Common 

Agriculture Policy (CAP) should be. 

The issue of ‘food safety’ has generally been the focus of thinking about incorporating health 

objectives into European food and agriculture policy and the Forum agreed that one 

objective of the CAP must be to ensure that food is free from microbiological and chemical 

contamination. 

However it was noted that diet-related chronic disease - particularly cardiovascular disease 

and cancer - are a larger cause of mortality and morbidity than acute food-borne diseases. 

The Forum therefore considered that those setting health objectives for the CAP needed to 

consider how the CAP could help to reduce the burden of chronic diet-related diseases as 

well as acute food-borne diseases. 

The Forum noted that the European Commission had recently funded the Eurodiet Project to 

develop dietary goals for European populations which if achieved would help to reduce the 

burden of diet-related diseases. The Eurodiet Project had taken two years and involved 

over 200 experts from all over Europe. The report of the project had just been published 38 . 

Eurodiet sets out 17 population dietary goals which if achieved would significantly improve 

the health of the European population. A priority goal is for an increase in consumption of 

fruit and vegetables. 

The Forum noted that the CAP has other effects upon health other than upon food 

consumption – through its effects on the environment, employment, etc. These effects are 

complex but nevertheless need to be considered when setting health objectives. 

The Forum noted that, under the CAP, tobacco farmers are paid subsidies for growing 

tobacco. The subsidised tobacco is for export and therefore its consumption does not affect 

the health of Europeans, but its consumption is highly damaging to the health of people 

living in the countries to which it is exported. The Forum noted that the European 

Commission had agreed to the phasing out of subsidies for tobacco farmers. 

The second issue discussed by the Forum was the relationship between health and other 

objectives – particularly environmental objectives. The Forum noted that it is increasingly 

recognised that what is good for human health is generally good for the environment. The 

First Food and Nutrition Action Plan for the World Health Organisation European Region – 

agreed at the WHO Regional Assembly in September 2000 – proposes that there should be 

three strands or pillars to food and nutrition policy: food safety, nutrition and sustainable 

production. 

38 

Eurodiet Project (2001) Eurodiet Reports and Proceedings. Eds A G Kafatos and C A Codrington. 

Public Health Nutrition 4.2(1) 325-336. 



181

182 


The third issue discussed by the Forum was how health objectives could be incorporated into 

the CAP. The Forum noted that CAP reform is already being considered in order to achieve 

other objectives in relation to the liberalisation of international trade and to enlargement of 

the European Union. Broadly speaking there are three policy options currently under 

consideration: 

• little or no change to the existing system of agricultural subsidies (there is virtually 

no support for this option in view of the enlargement process); 

• a ‘two-tier’ system where the subsidy system remains largely unaltered and 

subsidies remain high in current members of the EU, but are lower in accession 

countries; and 

• a reduction of subsidies across the whole of the EU with a re-direction of subsidies 

- away from subsiding production to subsidising rural development and 

environmental protection. 

Controversies 

There were four main issues which where not resolved at the Forum. 

Firstly in speaking of health objectives, whose health objectives are we talking about? Do 

we mean the objectives that consumers would want if asked? Consumers seem to be more 

concerned about food safely – not only in relation to chemical and microbiological 

contamination of food but also in relation to genetic modification of foods – than about dietrelated 

chronic disease. Or do we mean public health objectives – with a greater focus on 

reducing the burden of diet-related chronic disease than of food-borne diseases? 

Secondly to what extent do health objectives conflict with other objectives such as economic 

or environmental objectives? In the case of the olive oil regime there appears to be a 

conflict between health and environmental objectives. Most nutritionists would agree that 

an increase in consumption of olive oil in Northern European countries would be beneficial 

to the health of people living in those countries. However environmentalists suggest that 

increasing the production of olive oil in some Southern European countries is already having 

adverse environmental effects in those countries. Would the health benefits of consuming 

more olive oil in Northern European countries outweigh the environmental costs in Southern 

European countries? It was agreed that this would seem unlikely and that conflicts between 

health and other objectives are often more apparent than real. 

Thirdly if we want to build health objectives into the CAP should the focus be on supply or 

demand? Reducing the burden of diet-related chronic disease would mean changing the 

food consumed by Europeans and this would inevitably change the food supplied. Some at 

the Forum thought that the CAP should aim to shape the supply of foods, others thought 

that it was consumer preferences that should shape that supply. 

Fourthly should the CAP seek to influence the price of foods and if so what should that price 

reflect? It was generally agreed that farmers should receive a fair return for their labour but 

should the costs of consumption in relation to the health and the environment be 

internalised to reflect the true cost (e.g. to health and other services funded through 

taxation) and if so how? 


The Forum agreed that an increase in fruit and vegetable consumption would be desirable in 

most European countries. The Forum considered that the CAP should help to promote the 

consumption of fruit and vegetables but did not agree on how, precisely, this should be 

achieved. 




It was agreed that the relationship between the CAP and health needed further and more 

systematic investigation though ‘Health Impact Assessment’ and that the issue was of such 

importance to warrant the formation of an Inter-service Working Group on the CAP and 

health within the European Commission. 

The Forum agreed that the European Commission needed to be clearer about its policy 

objectives in relation to food and nutrition and that this would be helped by the publication 

of its proposed Action Plan on Nutrition Policy. 

In summary the Forum’s recommendations were: 

1. Everyone should affirm that a multifunctional agriculture should incorporate health 

objectives. 

2. The Commission should publish its Action Plan on Nutrition Policy by the Spring of 

2002. 

3. There should be an Inter-service Working Group on the CAP and health. 

4. The CAP should promote the consumption of fruit and vegetables. 



183 



184 


Forum V: The informed patient / 

citizen: a new partner in the political 

health arena 

What are the information needs of citizens? Results from research & 

academia 

Angela Coulter 

Abstract 

Patients in all European countries have a great thirst for health information. They want to 

understand how to prevent illness and how to cope with diseases and disabilities. Access to 

appropriate information can empower patients to express their treatment preferences and 

help professionals to improve the appropriateness of clinical decisions. Information to 

support patients’ involvement in prevention, treatment choice and self-care should therefore 

be a central part of any quality improvement strategy. 

The paper will discuss the evidence on patients’ information needs and look at ways in 

which these can be met. Issues raised by widening access to the internet and to commercial 

sources of information will be outlined together with the implications for national and 

international health policy. 


The Right to Health and Patients’Rights: Population-based 

assessment 

Anne Brunner & Manfred Wildner 

Patients’ rights from the citizens’ view: areas for improvement* 

*See also: 

• Brunner A, Wildner M, Fischer R, Ludwig M, Meyer N, Crispin A, et al. 

Patientenrechte in vier deutschsprachigen europäischen Regionen. Z f 

Gesundheitswiss 2000;8:273-286. 



Forum V: The informed patient / citizen: a new partner 

in the political health arena 



185 

• Wildner M, Kerim-Sade C, Fischer R, Meyer N, Brunner-Wildner A. Regionale und 

geschlechtsspezifische Unterschiede in der Erfüllung von Patientenrechten: 

Ergebnisse einer repräsentativen Bevölkerungsumfrage in München, Dresden, Wien 

und Bern. Soz Präventivmed 2001;46: 248-258. 

Abstract 

Patients’ rights as part of a human rights framework are of considerable importance for 

future medical and public health practice. So far little empirical evidence has been provided 

on the status of patients’ rights and especially not from the citizens’ perspective. The 

European Office of the World Health Organization formulated the Amsterdam Declaration in 

1994, demanding thereby the realization of the principles of a humane health care. These 

principles relate to the protection of dignity of personhood, to self-determination, the right of 

information and the right of quality, continuity and equality in health care. Goal of our study 

was a population-based assessment of the perceived fulfilment of these rights. 

Computer-assisted telephone interviews were conducted during the months February and 

March 2000 in four German speaking European cities (Munich, Dresden, Vienna and Berne). 

The questionnaire was derived from the framework of the WHO-sponsored Amsterdam 

consultation. 125 persons randomly drawn were interviewed in each city (total 500 

interviews). A paragraph of the Declaration on the Promotion of Patients’ Rights was 

regarded as fulfilled if there was at least 80% agreement. 

High grades of fulfilment were found for respect, self-determination, humanity of treatment, 

free choice of care providers, confidentiality and issues of consent. Some problematic areas 

of fulfilment of patients’ rights were found consistently across all four regions: patients‘ 

information rights, inpatient/outpatient transfers and humane terminal care. Deficiencies were 

most pronounced for the provision of community and domiciliary services after hospital 

treatment and for the right concerning humane terminal care and dying in dignity. Moreover, 

regional differences were found between Munich, Dresden and Vienna on one side and Berne 

on the other side, with degrees of fulfilment being higher in Berne. These regional 

differences are more pronounced than gender-specific differences. 

Although in general fulfilment of patients’ rights was high, problem areas could be identified. 

This provides an evidence base for further research, targeted action and monitoring of 

patients’ rights within complex and technologically advanced health care. We conclude that a 

health rights framework contributes to a patient-centred assessment of health care systems. 

Key Points 

• Patients’ rights are of increasing importance for medical care in the “era of the 

patient”. The legitimate representation of the patients’ view is a controversial issue 

between stakeholders in health care. Population surveys on the patients’ 

perspective hence were conducted in four cities in Germany, Austria and 

Switzerland. 

• This empirical evidence suggests high degrees of fulfilment in areas like dignity, 

respect and equal access in these regions. 

• Low degrees of fulfilment were found for information rights, continuation of care at 

the inpatient/outpatient interface and humane terminal care. 

• Further research may target different regions or specific diseases, health care 

settings or population subgroups 

Patients' rights have advanced to a topic of high priority in health politics. The discussion on 

patient's rights is being led in many countries and at the European level. It has been claimed 

that the "era of the patient" has begun. Founding principles of contemporary health care

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ethics are beneficience, nonmaleficience, distributive justice and patient autonomy. Patient 

autonomy is also an essential principle of patient advocacy with its meanings of free action, 

effective deliberation, authenticity and moral reflection. Free action focuses on health rights 

such as the right to decide on one’s treatment options, effective deliberation on the 

rationality of the decision making process in view of information levels and cognitive ability. 

Authenticity requires consistency of a choice with personal preferences and life plans while 

moral reflection makes reference to consistency with beliefs and values. 

Patients' rights as health rights can be linked to the human rights legislation. Health rights 

can also be found in the new rights charter of the European Union 

(http://www.europarl.eu.int/charter/). Protection of human dignity, and health protection and 

health promotion have been discussed recently with an explicit reference to rights. This 

approach reflects a comprehensive understanding of health promotion as expressed for 

instance by the Ottawa Charta. There are voices in favor and against elaborating patients' 

rights further. 

The legitimate representation of patients' interests has been claimed by several groups: 

consumer organizations, patients' self-help groups, self-made patients' representations, 

sickness funds, political organizations and medical professional organizations. Not 

surprisingly these different organizations are motivated by different interests: citizens' 

empowerment, consumer rights, market transparency and fair market competition, costcutting 

by informing consumers or lobbying professional interests. Correspondingly a 

confusing number of labels can be found: consumer, customer, user, client, citizen, insured, 

patient. 

The traditional label "patient" reflects a special situation of the sick individual: An 

extraordinary situation which is characterized by illness, functional impairment or disability 

and increased vulnerability. Impairment ranges from a limited rationality due to pain and 

anxiety over somatic and cognitive functional deficits to a complete loss of consciousness. 

The patient-doctor relationship in this context is characterized by a special need of the sick 

individual to be protected and is best describe as a trust relationship. 

The European Office of the World Health Organization (WHO) has issued in 1996 a 

Declaration on the Promotion of Patients’ Rights in Europe as a common European 

framework for action following the Amsterdam Consultation on Patients’ Rights. This 

document contains specific sections concerning human rights and values in health care, 

information, consent, confidentiality and privacy, care and treatment and their application. 

Patients’ Rights and citizens’ views were endorsed by the Ljubljana Charter on Reforming 

Health Care of 1996. 

It is evident that patients’ rights will play an increasingly important role in medical practice 

in the 21st century. Causes are manifold. The need for the development of patients’ rights 

emanates from a new role informed patients want to play, from scientific, ethical and moral 

concern and the human rights movement in health care, including experience with 

(mis)managed care. 

Much conceptual and legal work has been done in the context of patients’ rights and their 

advocacy. However, in the at times competitive efforts towards a legitimate patients' 

representation the view of the key agents, i.e. the past, present or future patients, hardly 

ever has been assessed in empirically. Empirical evidence however is essential for the 

rationale setting of health targets to guide health policy. As this is an obvious deficit in the 

current discussion over patients' rights, our study aimed at a systematic, populationrepresentative 

assessment of the perceived fulfilment of patients' rights from a patient 

perspective as detailed by the Amsterdam Declaration on the Promotion of Patients’ Rights 

in Europe. 





Methods 

A survey questionnaire was constructed using standard questions on demographics (age, sex, 

occupation, marital status, insurance status, hospital stays, German as mother tongue), 

health status (SF-12), a previously developed and validated Human Rights questionnaire (HR- 

Questionnaire) and questions derived from the WHO document Declaration on the Promotion 

of Patients’ Rights (PR-Questionnaire). 30 of the 49 articles were reformulated as statements 

for the interview, so that respondents could express their agreement with their content. The 

wording was kept as close as possible to the original wording of the document. For example, 

article 5.6 of the document was reformulated as „I can choose and change my own physician 

or other health care provider and health care establishment“. 

The questionnaire was worded in German. In order to maximize comparability of study 

regions and to avoid language bias four German speaking cities were selected: Munich in 

former West Germany, Dresden in former East Germany, Vienna in Austria and Bern in 

Switzerland. A simple random sample of telephone numbers were drawn from available 

telephone directories on CD-ROM. Interviewed household members were selected with the 

nearest birthday method to enhance representativity. Only persons between 25 and 78 years 

of age were included. A total of 502 interviews were conducted from February 15th to March 

8th, 2000. The response rate was between 43% (Dresden) and 60% (Vienna), which is a 

normal response for telephone interviews. 

Statistical analysis was descriptive and based on the proportion of respondents who agreed 

with the statement out of all interviewed persons. A distinction was made between „I don’t 

know“ and „no answer given“. About half of all rights had a fulfilment below 80% in German 

study regions. Hence special focus is given to fulfilment below about 80%. This threshold of 

80% fulfilment was set to define potential for improvement. It must be noted that low 

fulfilment consists of both low agreement and high uncertainty („don’t know“). Results were 

analysed after direct standardization for the New European Standard Population. The regional 

differentiation was kept and results were reported separately for men and women. No 

statistical hypotheses were tested. 

Results 

In Munich (West Germany), areas with relative potential for improvement were found for 

access to health care and prevention, information about health services, information about 

one’s own health status, the right not to be informed and the right to have someone else 

informed about one’s health condition (men only), information about health care providers 

and rules and routines on hospital admission, written summary on hospital discharge, 

continuity of care and especially coordination of care after discharge out of the hospital, 

humane terminal care, ability to seek legal redress and access to information on patients’ 

rights. 

In Dresden (East Germany), areas with relative potential for improvement were found for 

access to health care and prevention, information about health services (men only), 

information about own health status, the right not to be informed, the right to have 

someone else informed (men only), information about health care providers and rules and 

routines on hospital admission, written summary on hospital discharge, the right of access 

to one’s own medical files (men only), continuity of care (men only) and especially 

coordination of care after discharge out of the hospital, humane terminal care, ability to seek 

legal redress and access to information on patients’ rights. In general, patterns of perceived 

patients’ rights were similar to those seen in former West Germany. 

In Vienna (Austria), areas with relative potential for improvement were found for information 

about health services, the right not to be informed, the right to have someone else 



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informed, information about health care providers and rules and routines on hospital 

admission, written summary on hospital discharge, access to medical files (men only), 

coordination of care after discharge out of the hospital, humane terminal care, ability to 

seek legal redress (women only) and access to information on patients’ rights (men only). 

Although the pattern was in many aspects similar to German patterns, better fulfilment was 

observed for access to health care, continuity of care and ability to seek legal redress. 

In Bern (Switzerland), perceived fulfilment was generally superior compared to the other 

German speaking regions. Areas with relative potential for improvement were found for the 

right not to be informed (women only), information about health care providers and rules 

and routines on hospital admission, written summary on hospital discharge, coordination of 

services after discharge and humane terminal care (women only) and ability to seek legal 

redress (women only). There was a general high agreement between sexes. 

Discussion 

Occasionally, empirical studies have been done on patients’ rights before, which were 

however either restricted to special topics like information rights, were limited to special 

professional groups, or both. The importance of patients’ rights for future medical practice 

underline the need for a systematic evaluation of the status of patients’ rights in the 

population. As the aim of our study was the assessment of a representative population 

perspective, the citizen’s perspective in their role as former or current patients was chosen. 

As the survey was based on judgement and subjective experience, only those persons who 

ever have had a hospital stay were included for the hospital questions. Because citizens role 

as tax payers or insurance payers is different from their role as sick individuals, this focus on 

the citizen as a patient is essential and was made clear in the wording of the questions to 

the interviewees. The selected representativity for households ensures a basic information 

base for urban populations. Focussing on special patient groups defined by illness (e.g. 

AIDS), setting of medical care (e.g. long-term care), demographic (e.g. old age), social 

characteristics (e.g. migrants) or other regions (e.g. with high penetration by managed care 

plans) would have been a valuable extension of this study. Subset analysis of the study data 

base is limited by power considerations. 

The comparability of the study populations appears satisfactorily from the demographic 

variables, and was enhanced by the calculation of age-standardized results, stratified by sex. 

For a graphical representation, it was chosen to visualize a theoretical patients rights „space“ 

with indentations corresponding to human rights problem areas. The 80% alert line serves as 

a visual anchor for the comparison between countries and represents lack of fulfilment 

perceived by one out of five interviewed persons, although any judgement on what degree of 

fulfilment is regarded as satisfactory in principle is arbitrary. 

This approach identifies in all four regions generally perceived deficits or uncertainty in the 

areas patient information, continuity of care on transition between the inpatient and the 

outpatient sector, and humane terminal care. More specific are deficits regarding access to 

health care and prevention (Munich and Dresden), information about own health status 

(Munich and Dresden), right of access to medical files (Dresden and Vienna men) and ability 

to seek legal redress (both German study regions). The latter deficit corresponds to the lack 

of a patient ombudsman system or patient advocacy, that the other study regions have 

implemented. The deficits recorded in Vienna and Bern are reported by women only and may 

be spurious. Uncertainty regarding access to one’s own medical files may be a late sequel of 

the former East German political system in Dresden. Again this consequence may be spurious 

in Vienna as it is only found for one sex. Similarly, deficits regarding access to health care 

and prevention were only reported by Bernese women and may hence be due to chance. 

Alternatively, this may reflect concern stemming from several managed care experiments 





being currently in place in Switzerland. However, the proportion of the Bernese population 

insured in managed care plans is about 4% only. 

Differences between the responses of men and women were generally small and were more 

pronounced in Dresden than in the other study regions. Again one could speculate that this 

latter finding is due to social adjustment processes taking place currently in former East 

Germany, with high rates of unemployment and resulting dissatisfaction among men. 

Moreover, the perceived health status was considerably lower in Dresden compared with the 

other study regions, more persons were currently receiving medical care and less patients 

could afford private health insurance. 

The areas patient information, continuity of care on transition between the inpatient and the 

outpatient sector, and humane terminal care require further research and potentially 

corrective action. Any perceived lack of fulfilment of patients’ rights has a considerable 

proportion of respondents stating „I don’t know“, reflecting a general uncertainty regarding 

these rights in all study regions. If the analysis of such surveys excludes these statements of 

uncertainty, then higher degrees of fulfilment of patients rights will be calculated, which 

however must not be reported or interpreted without information on the proportion of 

uncertain responses ( „I don’t know“). 

On the positive side respect, self-determination, humanity of treatment and connectedness 

to family and friends while in the hospital, free choice among health care providers and 

confidentiality of data and issues regarding consent to treatment, study participation and 

participation in teaching ranked high in all four study regions. These are certainly valuable 

achievements of the systems under investigation. 

Generally, the study design does not allow to differentiate between existing differences in 

deficits between study regions from differences in the subjective perception between regions. 

For example, perceived dissatisfaction with the information about the own health status in 

Munich may reflect the unmet demand for information of an urban, well educated population 

rather than a true deficit relative to Dresden. It is possible that education on patients’ rights 

sensitises a population on existing deficits and may lower perceived fulfilment of these 

rights. An answer to this hypothesis, however, requires a different study design, e.g. 

longitudinal analysis concurrent to informational intervention. 

Other perspectives, e.g. the perspective of caregivers, legal experts, patients or patient 

organizations have the potential to add to the understanding of this area. We found a 

number of patients rights in the Amsterdam Consultation Charter which were not suitable for 

assessment by a population-based survey. For example, article 3.6 states that cases of 

dissent between health care providers and legal representatives regarding necessary medical 

interventions should be referred to a legal court or some form of arbitration. Evaluation of 

the fulfilment of this right requires the knowledge and experience of legal experts and 

professional bodies. 

There is no doubt that in all four study regions modern and effective health care systems 

were in place, which are maintained with allocation of considerable financial resources, and 

with professionals working with high ethos within these systems. The essence of our study is 

the identification of problematic areas within these complex, technology-intensive and human 

resource-intensive care giving systems with the aim to further improve the quality of health 

care systems. Basis of our analysis were the articles of the Amsterdam Consultation on the 

promotion of patients’ rights. The pattern of deficits is in part consistent across study 

regions (information rights, transition between inpatient and outpatient sector and humane 

terminal care), in part it is regionally specific. There is no doubt that further research is 

required to evaluate further patients’ rights strengths and weaknesses, e.g. among vulnerable 

subgroups defined by illness, health care setting, demographic or socioeconomic 



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characteristics. Nevertheless, fields for action are mapped by the presented empirical 

evidence from a patients’ view and may contribute to the formulation of health targets, to 

the formulation of human rights-based strategies to reach them and to the impartial 

monitoring of progress. It has the potential to strengthen both the scientific basis, the 

democratic legitimization and the acceptance of calls for action. 

Acknowledgement 

The presented study was supported by a grant of the MSD Merck Sharp & Dohme European 

program on Health Targets 1999. We would like to thank Dr. Michaela Moritz from the 

Austrian Federal Institute for Healthcare (ÖBIG), Professor Thomas Abel from the Department 

of Social and Preventive Medicine of the University of Bern and Professor Georg Ress, Judge 

in respect of Germany at the European Court of Human Rights at Strasbourg for their 

support. 



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Albert Jovell 

Abstract 

Goals: 

To highlight the main findings of quantitative and qualitative research carried out in Spain on 

information needs in health care 

Method: 

1. Review of health care surveys carried out at country level since 1989 based on 

population random samples 

2. Focus groups structured across different patients and citizens characteristics carried 

out in July 2001 

Main findings: 

Health surveys: 

� Lack of public opinion studies in Spain

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� Data were not found dealing with issues such as patient's rights and responsibilities, 

consumer empowerment, policies and participation by the public in health policy 

decision-making, medical errors, shared decision making, and doctor-patient relationship 

� The most important source of information was the patient-physician relationship 

� Population expressed a wish to obtain clear and understandable information on 

diseases, prognosis, and treatment 

� Population expressed concerns on the impact of genetic and biotech research 

Qualitative study: 

� Participants expressed lack of appropriate information in health care 

� Internet appeared as a source of information although there were concerns on the 

quality of the health information in the net 

� Internet did not replace the patient-physician relationship 

� There were multiple sources of information for patients, which resulted in different levels 

of expectancies in the population. Doctors were valued as the best source of information 

� Participants valued positively to get information on sources of quality of health care 

� Smart cards might be helpful as sources of information in health care 



Theresa Petrangolini 

1. Traditional and new citizenship 

Recently (Politeia, Conference on “Citizen Participation in Europe”, November 2000) Giovanni 

Moro, the general secretary of Cittadinanzattiva, has presented a very useful definition of 

new citizenship that I want to report in this conference. It may be a synthetically way to 

present the aim of my speech: citizen participation in health policies. 

Our starting point has to be the traditional idea of citizenship. It can be defined as follows.: 

Citizenship is the belonging to a national identity, witch is realised through a set of 

rights and duties that rule the relationship between the state and individuals or 

social groups. 

Two elements of this definition: 

• Voting is the highest expression of citizenship. The background idea is that citizens 

don’t’ have sufficient time, information, capacity and self-identification with the 

general interest to participate actively in public life. Consequently, they have to 

choose, through voting, persons that are competent, free of time, and really linked 

to general interest. 

• There’s a primacy role of state and public institutions. In the “Standard View” on 

public participation, citizens can ask, but it is the state that has to answer; citizens 

can express loyalty, voice or exit, but always in respect of the state; citizens can 





criticize, but the power to really manage things and solve problems is in the hands 

of public institutions only. 

This traditional idea of citizenship is hardly questioned because of: 

• The double process of globalisation and localisation, that imply a weakening of the 

national state; 

• The migrations (it is difficult to say precisely “who is in” and “who is out”); 

• The crisis of effectiveness of public institutions in the implementation of norms and 

in the protection of rights; 

• The lack of consensus of representative institutions (the so- called anti-politics and 

the mistrust in the ability of political leadership to represent people); 

• The crisis of traditional welfare systems, since there are new needs without rights 

and old rights without funds. 

Otherwise it is emerging a new feature of citizenship and civic participation: This new kind of 

citizenship can be defined as follows: 

Citizenship is the exercise of powers and responsibility of citizens in the arena of 

public policies, in the context of governance. 

A comparison of this two concept of citizenship may be useful 

TRADITIONAL CITIZENSHIP NEW CITIZENSHIP 

Rights and duties powers and responsibilities 

In civil society-state relation in public policies 

In the government context in the governance context 

Electoral participation civic participation 

Firstly, while rights and duties characterize traditional citizenship, powers and responsibilities 

characterize new citizenship. Second, the new citizenship is exercised in the field of public 

policies (i.e. the everyday life politics). This is a relevant difference: in the traditional 

approach we are citizens when we relate with the state; in the new approach we are citizens 

when we face the public problems that affect our life (i.e. health programs). Thirdly, 

traditional citizenship is part of the context of government, i.e.: the context in which the 

responsibility for the management of public life is assigned, in an exclusive way, to 

executives and administration directly linked to elected bodies. The new citizenship, on the 

contrary, works in the context of governance (Commission on Global Governance, Prodi, 

2000). This is an approach that sets off the cooperative role of public, private and social 

collective \ comunitarian actors of public policies, in logic of interdependence, in an 

interactive modality of policy-making and overcoming the traditional distribution of roles. In 

other words, governance in a way to manage public affairs shared out between a number of 

public, private, and social actors that exercise their own powers and responsibilities in 

policymaking and that interact with each other in forms based on co-operation or conflict. 

2. Active citizens in public policies 



195 

The main expression of this new way to be citizens is what we can define as active 

citizenship:

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Active citizenship is the capacity of citizens to self-organize in a multiplicity of 

forms, to mobilise resources, and to exercise powers for the protection of rights, to 

achieve the end of caring for and developing common goods. 

About this phenomenon there is a sort of “Standard View”, with a reductive vision of civic 

participation: 

• It has no institutional or political definition; 

• The scheme is “demand of citizen – answer of the state”; 

• The activity is only pushing, protest, claim, without any constructive aim or 

capacity; 

• It is a problem making and not a problem solving activity; 

• It implies no own power of citizens, but dependence on the others’ power (of 

market, of the state); 

• Il appears as a “temporary post” in front of the financial crisis of welfare systems. 

The wide diffusion of active citizens organisations is a trend that contradicts this vision. 

Looking at the common operational modality of the various experiences of civic participation, 

it is evident that they exercise many powers, a kind of new powers, very different of 

traditional ones. 

• the power to produce information and interpretations of concrete situations that 

affect people (i.e., new needs not considered as rare illness or immigrants health’s 

condition, quality of services in formations); 

• the power to change the field of perception and the conscience of actors involved 

in public policies by using symbols; 

• the power to promoting the consistency of institutions with their mission (e.g. an 

hospital must serve users and not workers, the health service must create a net of 

in formations services); 

• the power to change material conditions (door to be opened, architectural barriers 

to be destroyed, services to be built, etc.) 

• the power to promote partnerships and collaborations between the stakeholders 

and to combine their different interests (alliance promote with general practitioners 

to improve the outpatients services). 

As for the result, in a very partial and incomplete way, we could say that the action of 

organized citizens has reached objectives such as: 

• New laws 

• Mobilitation of human, technical resources, 

• Changes in the behaviour of social and collective actors, 

• Modifications of mass culture and common sense, 

• Modifications in political agendas, styles and languages, 

• Modification in market rules and functioning, 

• Etc. 

Until now, in its daily life democracy has prevailingly considered citizens as beneficiaries of 

programs and public interventions, and consequently often as a problem. The time has come 

to affirm that they are actually a resource for democracy. 

3. The European citizenship 

In the European environment there are many official documents regarding citizen’s rights, 

citizens/consumers/patients participation and involvement in public policies. They are 





finalized to reduce the lack of confidence of citizens in EU institutions and to make citizens 

closer to the European Union. There is still an underestimation of the role and the meaning 

of citizen’s initiatives and organizations, but something has been done in the direction of 

understanding this new phenomenon. 

The main documents in this direction are: 

• Maastricht and Amsterdam treaties (EU) 

• Ljubljana Charter on health care (WHO) 

• Charter of fundamental rights (EU) 

• Recommendation adopted by the Council of Europe on the development of 

structures for citizen and patient participation in the decision –making process 

affecting health care. 

This last document is important because recognize the fundamental right of citizens to 

determine the goals and targets of the health care sector and the role of civic and self-help 

organisations in representing users interests. 

… patient empowerment and citizen participation can be achieved only if basic 

patient’s rights are implemented and …, in this turn, patient participation is a tool 

for the full implementation of these rights in daily practice (Rec 2000/5) 

4. The experience of Cittadinanzattiva/Tribunale per i diritti del malato 

identity and mission 

“Cittadinanzattiva” is a civic Movement that was established in 1978 and whose 

members - individuals, groups and networks - share a commitment to ensure that 

the general public affirm and play an active role in governing society. 

The Movement identity is comprised of two closely linked aspects. The first involves 

promoting civic participation. The second aspect is a commitment to protecting rights, that is 

the main objective of participation exercised through civic powers. 

Therefore, the Movement works to enrich the democratic system with a new protagonist - the 

active citizen - who can thereby take on government responsibilities at local, regional, 

national and international level - along with the actors that have been established 

throughout the history of democracy. 

the organization 

From a legal viewpoint, the Movement is a non profit-making organization of social interest, 

and acknowledged as a consumer organization, with representation in the National Council of 

Consumers and Users. 

The Movement is democracy-based, comprising Territorial Assemblies of Active Citizenship 

linked to regional Congresses. An Assembly of Active Citizenship requires the membership of 

at least 50 citizens for establishment. There are currently over 180 Assemblies throughout 

Italy with 53.000 members. 

Any individual or association interested in supporting the Movement’s mission is welcome to 

join. Membership is free, occurs on a voluntary basis and is affected through the Territorial 

Assemblies. The Movement is mainly organized and run through voluntary work, although the 

National Headquarters and various regional centres employ qualified people to carry out 

programs and activities. 



197

198 


The Movement has always adopted three procedures for collecting funds - public funding (at 

local, regional, national, and community level), private funding (partnerships with private 

enterprises for specific programmes) and donations and contributions from the general 

public. 

networks 

The Movement since its foundation has always adopted networks to ensure that individuals 

or organizations join forces. The Movement could be best described as a “network of 

networks”. 

The main networks operating at the national level are as follows: 

• The Tribunal for the Rights of the Patients; 

• The Chronically Ill Associations Coalition; 

• The Citizens’ Advocates; 

• Justice for Rights Coordination; 

• The School for Active Citizenship; 

• A network of employees applying good practices in public services and public 

administration. 

Except the network there are other important fields of commitment. One of these is the 

programme on Corporate Citizenship that aims to support and distribute information 

regarding the renewal of social responsibility in private Italian and European enterprises. In 

June 2000, a “Manifesto of Corporate Citizenship” was prepared and distributed by a group 

of the Movement’s partners, while a project to research and design ways of labelling 

corporate citizenship in the four south-European countries and Great Britain - sponsored by 

the European Commission - is currently underway. 

tribunal for the rights of the patients 

The Tribunal for the Rights of the Patients is an initiative that began in 1980 to protect the 

health and welfare rights of citizens and to help achieve a more humane and functional 

health service. The Tribunal is comprised of ordinary citizens, workers from the sector and 

professionals who provide their services on a voluntary basis. It involves local units 

throughout Italy and over 10,000 citizens working in hospitals and territorial services, a 

central structure to co-ordinate the network activities. The ongoing programmes and 

campaigns implemented by the Tribunal for Patients’ Rights include the following: 

• The “Safe Hospital Campaign”; 

• A programme for good practices in the health sector, for which the “Andrea Alesini 

Award” is given; 

• An experimental project to reduce waiting lists; 

• A programme on safety and quality in medical practices; 

• A project on the “surgical path and citizens’ rights”; 

• A campaign on pain therapy; 

• A campaign to sponsor generic drugs; 

• An oncology campaign following the so-called “Di Bella” case; 

• A campaign for compensation for damages through the transfusions of infected 

blood; 

• Experimental implementation of a network for “PIT” services at the local level. 

The Tribunal for Patients’ Rights is linked to the Chronically Ill Associations Coalition, which 

has around one hundred member Federations and Associations for patients suffering chronic 

diseases. The Coalition aims to intensify action implemented by each individual Organization 

through a common policy for all chronically ill patients and thereby receives greater attention 





and care from the National Health Service, especially with regards to free prescriptions for 

pathological patients and access to pharmaceuticals. In 2000, the Coalition began publishing 

an annual report on the policy regarding chronically sick people in Italy. 

The Tribunal for the Patients’ Rights is linked to “PIT Salute”. This service was created in 

1996 to offer all members of the general public information, advice and mediation in the 

protection of their rights in the welfare and health fields for both public and private 

structures. This service that is carrying out at national level and on 35 local provinces also 

receives and manages reports on how the health sector works and the quality of services 

offered. “PIT Salute” acts on any request regarding both public and private medical and 

health sectors and more specifically with regards to the following: 

• Hospitals and assistance in the home; 

• Assistance for elderly and chronically ill patients; 

• Diagnoses; 

• Provision and use of pharmaceuticals; 

• Bureaucratic issues such as reservations and waiting lists; 

• Free prescriptions and disabilities; 

• Relations with health workers; 

• Efficiency and effectiveness of structures; 

• Emergencies. 

“PIT Salute” prepares an annual report on “Citizens and Health Services” based on the 

reports and cases they deal with, which is presented on the National Day for the Rights of 

the Patients (the 21st such occasion to be held in 2001). 

operational procedures for rights protection 

Cittadinanzattiva - as mentioned above - aims to ensure that citizens assume a leading - 

constructive rather than destructive - role in public policies. At operational level, this is 

affected via a commitment to ensure that rights set forth in the law are effectively 

implemented. It is exceedingly difficult to guarantee such rights and the Government bodies 

responsible often do not guarantee them at all when left alone to do so. On the contrary, it 

often occurs that the bodies responsible for protecting rights actually violate them - the Law 

being a prime example of this. 

Every project, programme or campaign implemented by the Movement and the Tribunal uses 

one or more of the following tools and strategies for rights protection: 



199 

• Charter of Rights, such as the Charters for the Rights of the Patients; 

• Structures designed to listen, provide assistance and advice, such as “PIT” services; 

• Monitoring aspects such as safety in hospitals or service quality levels; 

• Mobilizing and making the general public aware (by distributing leaflets, collecting 

signatures, initiating petitions, etc.); 

• Symbolic and demonstrative actions (such as those against wildcat strikes in the 

transport sector, etc.); 

• Roundtables or other forms of negotiation (such as the Conferences on services 

offered by Local Health Service Units (ASL) or workshops on security in hospitals); 

• Protocols of Intent and agreements with other parties (such as health service 

units); 

• Alliances and partnerships (for example with family doctors and hospital doctors on 

the management of risks of malpractice); 

• Implementation of the protection tools set forth in the law (Ombudsmen, 

committees for the appropriate use of blood, etc.); 

• Legal action (civil action in criminal proceedings; inhibitory measures; etc.);

200 


• conflict management (Conciliatory commissions, Alternative Dispute Resolution, 

etc.); 

• Collecting and encouraging best practices (awards, catalogues, etc.); 

• Planning new services (for example house services); 

• Civic use of the Internet (for example for pressure campaigns); 

• Training (such as experimental programmes for the reform of civic education); 

• Lobbying (for the passing of laws, changes to the financial law and so forth). 

some results 

The Movement got important outcomes at the time, including the following: 

• Reform of the health sector (Section 14 on Citizens’ Rights); 

• Reform of local self-governing bodies (introduction of the Ombudsman and citizens 

participation procedures in City and Province Council statutes); 

• Reform of public services (rules on participation from citizens in the Ciampi-Cassese 

Directive regarding Service Charters). 

More recently and regarding health sector: 

• A policy of good practice for professionals and operators. 

• Built risk management units in twenty pilot-hospitals. 

• Reinforced its nation-wide network of civic safety monitors. 

• Bought and put at citizens’ disposal equipment for checking the level of 

electromagnetic pollution. 

• The new law on pain therapy. 

• The introduction of generic drugs in the national health system. 

• The zero costing of new drugs for certain categories of chronically ill patients. 

• The increase of investments in radiotherapy and in mental health services. 

• The suing for damages in several important criminal proceedings (most of them 

regarding malpractice and environmental issues), 

• Improvement of policies on transplants and on mental illness 

Regarding the promotion of civic space in Italy, Cittadinanzattiva has contributed to the 

reform of paragraph no. 118 of the Constitution, which now states that the State, the Regions 

and the local administrations have to enable citizens to freely and independently carry out 

activities of general interest. 

the European dimension 

The Movement has been working at the European level for a number of years, including 

cooperation with the European Commission for programmes concerning the protection of 

consumers, access to justice, training and information for citizens. It has participated - and 

still participates - in the public forums on institutional reform in the European Union. 

The Movement is a member of the “European Forum of Civil Society” - a coalition of 

organizations that act to expand and strengthen democracy and citizenship in Europe. 

The Movement laid the foundations for the creation of a “Centre of Documentation and 

Initiative on the Rights of Consumers in Southern Europe” in 2000, which currently involves 

30 organizations from Greece, Italy, Portugal and Spain. 





5: Closing remarks 

• How to reduce the gap between the underestimate vision of civic participation by 

institutions and the growth and the effectiveness of active citizenship; 

• May civic participation helps the health care system to overcome his actual crisis 

(funds, organisation, new needs, general public consensus, new knowledge); 

• How to introduce civic participation on decision-making process without confining 

this practice to resolving problems and simply choosing between solutions, which 

have already been drawn up? 

• It is necessary to create favourable conditions, both in the legal and fiscal system, 

for the founding and operating of the civic organisations and civic programs. It Is 

also necessary to create favourable legal conditions to support financing of these 

kind of programs by the industry while avoiding conflict of interests; 

• In every European country policy makers are seeking to strike a better balance 

between state intervention and the intervention of other partners (fund holders and 

care providers); this change (liberalisation and privatisation of public services) 

requires a new definition of patient rights, explaining the meaning of solidarity, 

equity and efficiency in health system. In this scenario the participation of 

consumers can be considered a means of harmonising out market mechanisms. 

• Civil society and patients associations have high expectation of participatory 

process. At the same time, the health system lives a lack of consensus (confidence, 

compliance, transparency, gap of information). Participation (open doors) may be a 

way to reduce this distance and rebuilt a relationship between services and citizens. 

• Empowerment of citizens is a goal by a modern health organisation. At the same 

time, citizen well informed and conscious of their opportunity can introduce new 

inputs (new technologies, new drugs, change in models of professionals, different 

planning of services, etc.). Is the health system (hospitals, doctors, providers, fund 

holder, authorities, etc.) disposed to accept this challenge? 




Rodney Elgie 

Europe, in geographical terms, is made up of 51 countries and approximately 870 million 

citizens. It comprises some of the richest and some of the poorest nations on Earth. Despite 

this diversity, all governments across Europe wrestle with the insoluable problem of squaring 

the circle of need versus cost. We are experiencing rapid changes in the manner in which 

health care is delivered and this will continue unabated due to the advances in medical 

science. Need can never be fully satisfied in the health field. Currently, we have needs and 

wishes. If all needs are satisfied, what were formerly wishes become needs, and what were 

just thoughts, become wishes, and so on. EU citizens are intelligent enough to appreciate 

that some form of rationing is inevitable. What is lacking is a sufficient feeling of 

involvement or partnership between state and citizen, coupled with confidence that 

government has a viable long-term plan. 



201

202 


The problem for patients is that governments tend to think short term as the average 

administration lasts for around four years. This produces two consequences. Firstly, there is 

an automatic preference to treat acute conditions rather than chronic illnesses. The return 

and impact is almost immediate thereby producing political capital for the party in power. 

Secondly, governments tend to look backwards after two years in office to examine what 

election pledges have been fulfilled, which are half way to fulfilment and which ones require 

a radical review before the next election to keep faith with the electorate. Any long-term 

health programme might only enjoy success when the implementing government is no longer 

in power, presenting the former opposition, as the party now in office, with the opportunity 

to claim credit at the expense of its opponents. For these reasons it is vital for the 

patient/citizen to become involved as an equal partner in the political health arena. 

Patients with a chronic medical condition will often become an expert in their particular 

illness. Whilst this expertise is extremely narrow in comparison to health professionals, it is 

nonetheless valid. The knowledge will not only include treatment options, be they 

pharmacological, psychological or complimentary, but also first hand experience of what it is 

like to live with the illness, to experience the side effects of medication and to combine 

family and work life with the condition. It has been estimated that there are around 30,000 

illnesses/diseases known to the medical world. It is inconceivable that a GP can possess a 

detailed knowledge of more than 10% of such conditions. Hence, the patient is a valid 

partner when discussions centre on his or her specific condition. After all, that condition is 

the same across Europe. The symptoms are the same and so should be the available 

treatments. 

In the UK in 1998, the government of the day sought to introduce an initiative known as 

PRODIGY. The concept was excellent and potentially of tremendous benefit to patients. It 

revolved around GPs prescribing rationally. The initiative would compensate for a doctor's 

lack of expertise in certain disease areas and also guard against contra-indications. 

Regrettably, the whole concept appears to have been cost driven. Almost without exception, 

the medicines recommended as first line treatments under PRODIGY for any given condition 

were the cheapest available. But the notion of cost containment was fundamentally flawed. 

For example, in the case of depression, the text published by the Department of Health 

acknowledged that between 400 and 600 patients committed suicide annually whilst taking 

the old antidepressants recommended by PRODIGY. It is well known that such medications 

are highly toxic! So when governments talk about the quality, safety and efficacy of 

medicines their views should at least be scrutinised and validated by the informed patient. 

Experience shows that clinical effectiveness and cost effectiveness frequently represent a 

contradiction in terms. 

Health is, perhaps, the most important single factor for all citizens. There is a very real 

prospect that we shall all become a patient at least once in our lifetime. It has been 

interesting to note the development of pan European patient groups over the past decade. 

As the concept of the European Union has gathered strength with the enlargement process, 

so has the notion of patients joining together across national boundaries to press for better 

healthcare and equality of access to newer medicines. There is a realisation of strength in 

numbers and how "divide and rule" tactics can be overcome by this approach. In my own 

field of mental health, Gamian-Europe has brought together over 50 national patient 

organisations in 27 European countries covering the whole spectrum of psychiatry. The 

principle has been followed by those affected with a neurological condition who, earlier this 

year, created the European Federation of Neurological Associations. We have now come 

together with health professionals to form The European Brain Council. Slowly but surely, 

patient groups are abandoning their old territorial concerns and the preference for working in 

isolation. There is a growing realisation that we can all learn from one another and, all too 

often, we share the same problems, such as non-diagnosis, mis-diagnosis, failure to seek 





treatment and stigmatisation, to name but a few. We now have the concept of a European 

Patients Platform becoming a reality in 2002 with the support of DG SANCO. This will 

certainly hail the advent of patients taking a key role in many decisions affecting health. 

With the introduction of the Internet, better developed patient organisations and the more 

extensive use and availability of patient leaflets, the "informed" patient is becoming an 

increasingly educated and sophisticated being when it comes to debating health issues. 

Coupled to this is the fact that no government generates income of its own; its income is 

only derived from the fiscal measures it implements. Accordingly, it is only equitable that 

citizens, as taxpayers, should automatically become a partner in one of the largest spending 

areas of government. Patients/citizens are able to provide a valuable insight into the 

provision of health care, not only in terms of its efficient delivery and offering value for 

money, but also in setting standards and priorities. After all, what multi billion Euro industry 

does not spend a proportion of its revenue on market research? Citizens and patient groups 

represent a rich seam of knowledge, skill, resources, experience and expertise that could 

prove of immense benefit to national and supranational governments. 

It is difficult for patients to accept that within the EU there are the four basic freedoms and 

very soon there will be a shared currency for the majority of Member States, yet at the start 

of the 21st century we are still no nearer to creating a freedom for health. Perhaps a chink of 

light is beginning to shine through as a result of the recent judgement by the European Court 

of Justice. But should the judiciary, rather than the European Parliament and the European 

Commission, be leading the way? Some may well answer in the affirmative and advance the 

view that the judiciary is more in touch with the views of European citizens than elected 

politicians. Perhaps too great an emphasis is placed by the EU Institutions on the cost of 

medicines and the alarmist views promulgated by some at the prospect of Europe 

introducing a form of Direct to Consumer Advertising (DTCA). 

It seem highly unlikely that Europe will adopt wholesale the system in use in the USA for 

DTCA but what is wrong with patients being included in the debate before any decisions are 

reached? Evidence within the EU tends to suggest that pharmaceutical products account for 

less than 10% of the total cost/disease burden for the majority of conditions. Again, using 

the UK as an example, it is estimated that cost of medicines used to treat mental illnesses in 

1999 amounted to £460 million. Yet the total cost of these illnesses to the Exchequer was 

estimated to be in the region of £20 billion. In other words, over 95 % of the cost was 

attributable to welfare and social security payments, days off work, unemployment, 

attendance at hospital for attempted suicide, successful suicides, drug and alcohol abuse, 

crime and housing problems. Excluded from the calculation is the social and economic cost 

on carers and other family members. If better and more appropriate medicines are used, 

perhaps the "indirect" cost of mental health in the UK and elsewhere would be 

correspondingly less. In other words, it is unsafe to advance an argument using limited or 

selected facts. 

The point can be further underlined by the examining the terms of reference for the High 

Level Group on Health, the G 10. One such term required the Group to examine drugs that 

either saved lives or cured people. Without the citizen's involvement in this decision making 

process, a whole and most important area in the field of medicines was overlooked - drugs 

that do not save lives or cure people but do vastly improve the quality of their lives. This is 

especially true in the fields of psychiatry and neurology for a host of illnesses such as 

Bipolar Disorder and Parkinson's Disease. It is generally accepted that there are two areas of 

particular concern within Europe. Firstly, the ever increasing incidence of mental illness, 

particularly stress and depression. Secondly, the ageing population and the financial 

implication this will have on health budgets, particularly as the number of traditional unpaid 

carers within the family is dwindling rapidly. These are problems that will affect us all, either 



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directly or indirectly. Again, it is only right that citizens should be involved in seeking 

solutions and assisting in determining which proposals will be implemented. In this way they 

will more readily assume ownership and, perhaps more importantly, responsibility for seeing 

that those decisions are carried through to completion. 

The educated patient can add an extra dimension to the political heath arena as may be 

viewed in the UK through such bodies as the National Institute for Clinical Excellence, the 

Commission for Health Improvement, the National Clinical Assessment Authority and the 

Clinical Standards Advisory Group. On the European scene, it is hoped that the creation of 

the Commission's proposed EU Health Forum coupled with the introduction of a European 

Patients Platform will see the concept of "patient partnership" at a political level reach new 

heights that could only have been dreamed of less than two decades ago. The manner in 

which medical care is delivered through the primary care system will change radically in the 

next twenty to thirty years. Patients will be required to accept a greater degree of 

responsibility for the management of their illness in partnership with the healthcare 

professional. Involving citizens in the health decision making process at this time is simply 

the start of that process. We are living in rapidly changing and challenging times. The health 

care challenge will be met, to a significant extent, by doing more with less. This involves, 

inter alia, reducing the currently high wastage levels. Reduced wastage can be achieved 

through improved compliance rates, through more knowledgeable patients who can assist 

the doctor in reaching an accurate diagnosis and through educated citizens appreciating the 

value of not smoking, exercise and a healthy diet. But this win/win situation will only come 

about if citizens feel engaged in the decision making processes and a genuine and equal 

partner with the EU Institutions. To adopt a policy of exclusion would be foolish in the 

extreme and unsustainable in the long run. The current initiatives of DG SANCO are 

welcomed and to be applauded. 


David Lansky 

American health system researchers have examined quality of care issues since the mid- 

1970s and found a widespread and persistent pattern of overuse, underuse and misuse of 

health care services. More recently, high rates of medical error have raised additional 

concerns about the allocation and effectiveness of the nation’s very substantial health care 

expenditures. 

Numerous efforts to improve quality have been attempted, but none have had significant 

impact. Analysts have concluded that the dependence of most major stakeholder groups – 

physicians, hospitals, insurance carriers, politicians, patient advocates – on existing financial 

arrangements continues to limit the possibility of meaningful reforms that might improve 

quality of care or more significantly engage the public in the health system. The U.S. health 

system seems to function to maximize economic benefits to health care organizations and 

professionals, rather than to best meet the health needs of American citizens. 

As a result, reformers have given growing attention to increasing the role of consumers in 

the health system. Consumers provide financing for virtually all care – through taxes and 

withheld wages – and of course are the ultimate recipients of health services, yet have very 





few mechanisms to influence health policy, allocation of resources, or the behavior of health 

professionals. Since the U.S. lacks any centralized health policy mechanism, the sheer 

diffusion of economic and political control has prevented consumers from exerting influence 

over the system. Several factors compound this problem: 

• Consumers typically have more limited access to information and expertise than 

professionals. 

• Consumers lack an organizational mechanism to educate and advocate with 

policymakers on quality issues. 

• Health care organizations are businesses, with substantial research, communication, 

and lobbying resources devoted to protecting their interests, while interested 

consumers do not have time and do not get paid for engaging in health policy 

advocacy. 

• Sympathetic policy leaders do not know how to get more extensive and 

representative consumer involvement. 

Yet these barriers are being eroded by more powerful social forces. Rising educational levels 

and new information technologies are giving patients and consumers equal access to health 

information. The “new consumer” is more insistent on being treated with respect and 

courtesy, and having her voice heard by both policymakers and service providers. Longer 

life and the increasing prevalence of chronic illness in the U.S. population have motivated 

more Americans to learn about how best to manage their own health, day-to-day. And major 

institutions such as employers and governments find it more palatable to work on 

empowering consumers to be responsible for their own care rather than trying to exercise 

paternalistic, protective authority over a large, restive and diverse population. 

The emerging policy strategy in the U.S. is to focus, first, on raising the awareness and 

capacity of the general public to demand more from the health system. Consumers need to 

understand what quality care is, be able to identify and select the most appropriate doctors, 

hospitals, or insurers to meet their needs, be able to interact more effectively with their own 

doctors, and participate in policy debate to support continued changes in the structure of the 

system. 

The strategy in place attempts to leverage the current roles of many credible organizations in 

communicating with some part of the population, by creating a set of uniform messages and 

terms and encouraging many organizations to adopt these common ideas and materials. 

Employers, labor unions, government agencies, patient advocates, insurance funds, 

journalists, professional societies – all engage in direct communication about health care 

with some part of the public and could, by sending a common message, begin to change 

consumer thinking about the health system and their role in it. By collaborating on such a 

communications effort, consumers may become better able to (1) participate in policy 

discussions, (2) interact effectively with their providers, and (3) manage their own health and 

health behaviors to reduce their health risks. 

This campaign will, ultimately, need to address four components: 



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• Science: The public needs to have access to evaluative information about the 

performance of the health system that is based on the best clinical and 

measurement science; 

• Awareness: Broad public attitudes need to shift towards greater recognition that 

quality is uncertain and that personal engagement with health care is essential. 

• Disclosure: The public needs to have access to comprehensive, understandable 

information on all available health care providers, both in comparative terms and 

also to illustrate the absolute level of performance of the care they receive.

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• Decision support: Patients and consumers should have access to performance 

information in a form that helps them make important personal decisions: which 

doctor or hospital to see, which procedure to undergo. 

Significant research has been done in each of these areas, which can make the entire 

campaign more effective. We know, for example, how to construct sound measures of 

quality that speak to the concerns of most patients. These typically blend clinical indicators 

with measures of communication, patient education, and health outcomes. To raise 

awareness, we have tested various types of messages, and understand that performance 

information must be communicated within a structure that makes sense to people and within 

a context that helps them interpret its meaning. And we know that American society 

encompasses many types of people, with varying levels of interest or need or competence 

and a communications strategy must be nuanced enough to touch people where they are. In 

the U.S., we have learned that disclosure of meaningful performance data will not come 

voluntarily from hospitals or doctors or insurance funds. Government action – or massive 

public pressure - will be required to force information into the public arena. And we know 

that decision-making involves difficult trade-offs for many people, so that quality information 

must be provided to consumers within a decision tool that helps them evaluate several 

factors and their own values and needs. Simply publishing data in tables and charts does 

not affect how people make real-life decisions. 

This strategy – to encourage and empower American consumers to become more informed 

and engaged in their health care – faces many challenges. It runs the risk of compounding 

the very American inclination towards individualism at the expense of the social good. It is 

difficult for multiple, independent organizations to agree on the vocabulary and messages of 

a common campaign. And it will take many years to bear fruit. Ultimately, the citizens’ 

agent – its national government – must provide the necessary visibility and leadership to this 

process. Paradoxically, that leadership is only likely to emerge when a sufficient groundswell 

of public discontent is articulated as the result of this grassroots empowerment strategy. 



How to involve citizens in health policy development and 

implementation? Current activities of the European Community 

Walter Baer 

1. Introduction and Background 

On 16 May 2000, the European Commission published a Communication on the health 

strategy of the European Community, together with a proposal for a Decision of the 

European Parliament and of the Council for a new programme of Community action in the 

field of public health39 . 

39 COM (2000) 285 final of 16.5.2000 





As set out in this Communication, a central theme of the new Community approach to health 

is openness and transparency. The Commission therefore announced that it intended to set 

up a European Health Forum as an important element of the new health strategy. This would 

be an information and consultation mechanism to ensure that the aims of the Community’s 

health strategy and how they are being pursued are made clear to the public and respond to 

their needs. It would also allow representative organisations of patients, health professionals 

and other stakeholders, such as health care providers, to have an opportunity to make 

contributions to health policy development and implementation and the setting of priorities 

for action. 

In order to prepare the establishment of the Forum, the Commission prepared a 

comprehensive Consultation document on 20 December 2000. This was distributed to 

interested parties and placed on the Commission’s website to achieve maximum coverage. 

The document raised key issues related to the composition, scope, structure and functioning 

of the Forum. 

While the deadline for putting forward views and responses was initially set at 15 February 

2001, all responses received up till now have been taken into account. The Commission 

wishes to thank all respondents for their contributions which address a wide range of issues 

and questions related to the creation of this body. 

The Commission has received 130 responses from various institutions and organisations to 

date. Respondents can be divided into four main groups: 

• non-governmental organisations (NGOs) in the health field, representing patients 

and citizens views; 

• organisations representing health professionals and trade unions active in the 

health field; 

• organisations representing health care providers and different health and social 

services; 

• organisations representing industry in areas of key relevance to health (e.g. 

pharmaceuticals, medical devices or food). 

A number of individuals also presented their points of view. These were largely either health 

professionals or academics working in the health field. 

Finally, the Commission received a number of reactions from national and regional 

governments in Member States and some candidate countries and organisations representing 

local and regional governments and entities. A contribution was also received from EFTA. 

2. Purpose and scope of the European Health Forum 

The consultation on this point revealed a general consensus among the respondents, 

welcoming the Commission’s initiative to set up a Health Forum. Not surprisingly, most 

organisations also indicated their willingness to participate in it. 

There is also a general view in the replies that a structured approach is needed. This would 

be the only way to guarantee the openness and transparency in the Community’s approach 

to the Forum. However, there have to be different solutions adapted to the needs of different 

actors. Some organisations, for example, may be more interested in exchanging information, 

others would like to make an input into policy development. Some bodies may want to 

influence only a single issue, while others have a broad agenda. Some may be active at 

European level, while yet others are national or regional organisations. 



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The Health Forum should cover issues which are relevant to the Community’s broad health 

agenda, with work in public health at its core (see topics for discussion below). 

A number of respondents raised the issue of whether the European Health Forum or its 

members will be involved in the implementation and follow-up of initiatives. There is also a 

plea to give the European Health Forum a possibility to make an input early in the policy 

cycle, to avoid the possibility that proposals would be submitted to the Forum as ‘a fait 

accompli‘, allowing only minor fine-tuning. 

The Commission welcomes the broad support it has received on its proposal to create a 

European Health Forum. It regards the Forum as an important instrument which can increase 

transparency and openness, help inform partners about health policy at Community level and 

give them a key input into the development of new initiatives. In doing so, the Commission 

is committed to maximising the impact and effectiveness of the Forum. It will therefore aim 

to ensure that the Forum is fully involved at an early stage of the policy process. It also 

intends to report back to the Forum about the follow-up given to its positions and will seek 

to give it an opportunity to revisit issues as appropriate. 

3. Organisation of the European Health Forum 

In its consultation document, the Commission proposed that there should be a three-tier 

structure for the Health Forum, i.e. 

• First, a Health Policy Forum which would have a defined membership by invitation. 

It would discuss key policy areas in a structured way and would, together with the 

Commission services, be in charge of the preparation of the Open Forum; 

• Second, the Open Forum which would focus on one or two main topics for 

discussion and would be all interested parties could attend; 

• Third, a Virtual Forum which would use information technology to enable the 

exchange of information and to foster discussions among the public health 

community in the widest sense. 

The proposal of a three-tiered structure was generally accepted by respondents. Some 

doubts were raised, however, concerning the bureaucracy which could potentially be involved 

and the resulting strain on participating organisations. Respondents agreed that a secretariat 

was needed to act as a permanent contact point. 

On the basis of the consultation, the Commission intends to pursue the three-tiered structure 

set out in the discussion document. It will make every effort to ensure that the process is 

transparent and that bureaucracy is reduced to a minimum. It recognises the need to define 

clearly the role of the different ‘tiers’ and intends to put this in writing for information and 

discussion at the initial meetings of the Forum. The Forum should discuss ways to ensure 

continuity, appropriate follow-up between meetings and effective preparation of meetings. 

This may involve the creation of a small ‘steering group’. The Commission will set up a 

secretariat within its services to act as a focal point and ensure the necessary organisational 

work. 

Health Policy Forum 

Some of the respondents addressed the different ‘tiers’ separately in their contributions. 

There was considerable support among the organisations which responded on this subject 

for the creation of a Health Policy Forum. The general view was that it should have a limited 

attendance to ensure the continuity of the process and provide structured input into health 

policy development. In contrast, the Open Forum (see below) would enable a wider audience 





to take part in the discussions concerning an individual issue, but would not be able to 

provide the same degree of continuity and structured dialogue. The Policy Forum would 

therefore need to play a role in preparing the Open Forum, e.g. in selecting topics for 

discussions, and in securing adequate follow-up. 

In the opinion of respondents, the Policy Forum would need a prepared agenda and should 

hold well-structured discussions. It would formulate and adopt opinions. Contributors agreed 

that a small steering committee should be formed which would support the secretariat in 

preparing the meetings and organising the follow-up. 

Many respondents support using working groups and other substructures to pursue 

individual issues in more detail or to prepare discussions for the whole Forum. The Health 

Policy Forum would decide on the creation of such groups and their mandate, and would 

monitor their work. 

On the basis of the consultation, the Commission intends to organise an initial meeting of 

the Health Policy Forum in November this year. In light of the results of this consultation and 

further discussions in the coming months, it will publish the list of organisations invited to 

send representatives to the initial meeting. This will be done on the basis of the criteria set 

out below (cf. part C – composition). 

A draft agenda will be prepared before the meeting. At this stage, the Commission envisages 

that the initial meeting will focus on certain priorities for the new public health action 

programme. 

Proceedings and results of the Forum will be made publicly available. 

Open Health Forum 

Respondents welcome the Open Health Forum as providing the possibility for a wide 

audience, including organisations and bodies which would normally not take part in the 

Policy Forum, to make an input into health policy development. The Open Forum is seen as a 

platform for general information exchange and discussion. It should have a close link to the 

Policy Forum, but would need a clear and defined role of its own. It could serve to test 

proposals and positions developed in the Health Policy Forum amongst the members of the 

wider public health community. Moreover, it could identify issues which warrant in-depth 

consideration by the Health Policy Forum. People felt that speakers should be selected to 

represent different stakeholder groups. Discussions amongst delegates were seen as the core 

element of this event. 

The Commission intends to discuss the exact structure and functioning of the Open Forum in 

the Health Policy Forum once it is established. The intention is, however, that meetings of 

the Open Forum would take place once a year. They would be organised around a specific 

topic (or possibly two related topics) which would be selected in close co-operation with the 

Health Policy Forum. 

Virtual Forum 

Respondents welcomed the Commission’s intention to make full use of information 

technologies and to create a Virtual Forum as a key tool for information and communication 

with the public health community and the general public at large. It could serve as a 

technical support platform through which important documents of the Health Policy Forum as 

well as the Open Health Forum would be made available. In addition, discussion groups on 

specific topics could be created. Furthermore, the Virtual Forum could help to distribute an 

on-line newsletter and the ordering of documents. Finally, restricted access areas could be 

set up in order to circulate preparatory documents to members of the Health Forum and its 

sub-structures. 



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The Virtual Forum would be developed in connection with the Commission’s initiative on 

“Interactive Policy Making” and should include links to relevant Internet sites, such as the 

websites of the European Commission, national governments, members and participants of 

the Health Forum, and other relevant bodies and organisations. It could thus become an 

Internet portal for health issues at European level. 

It should be accessible to blind and partially sighted people. 

There was also a plea, however, that certain key documents and materials should also be 

circulated in printed form. 

As an integral part of its commitment to openness and transparency, the Commission intends 

to develop the Virtual Forum as a focal point for health-related information at Community 

level and as the main source of documentation and information about the activities of the 

Health Forum. It should be an interactive mechanism which will enable members of the 

public to make an input into the work of the Health Forum and into the policy-making 

process more generally. The Commission is currently seeking the necessary expertise and 

resources to launch the Virtual Forum during the course of this year and to sustain its 

operation in the long term. 

The Virtual Forum will not be the only communication tool used by the Commission in this 

area. Key information will also be made available through other routes, and as printed 

documents. 

4. Composition of and Participation in the European Health Forum 

Many respondents commented on the profile of participating organisations for the Open 

Forum and the Health Policy Forum. Since all stakeholders and organisations interested in 

European public health issues should have the possibility of attending the Open Forum there 

was consensus that participation by invitation only should not be considered. Efforts should 

be made, however, to ensure that it remains a credible and workable structure in spite of its 

size. There was also some concern that even in the Open Forum, efforts should be made to 

ensure that representation among key groups of stakeholders is balanced. 

On the other hand, according to a large number of respondents, the Health Policy Forum 

should be organised by invitation only. A number of contributors supported an approach 

which foresees a ‘core’ of general organisations, while a number of ‘expert organisations’ 

would be invited to take part for the discussion of specific topics in which they hold 

particular expertise or interest. 

Respondents generally support limiting participation in the Health Policy Forum to 

representatives of European (umbrella) organisations. While the political and practical need 

to work with true EU-wide bodies is widely understood, there is, however, a feeling that this 

approach should not be applied too rigidly when it prevents the involvement of leading 

experts not affiliated to a particular body. 

Moreover, respondents pointed to the lack of recognised European-level umbrella 

organisations in some areas. There are, for example, few non-disease specific European 

patients’ organisations. One should also beware of overlap in membership (e.g. the members 

of an organisation representing medical specialists would also be represented by the body 

bringing together the medical associations within the EU. 

There was also a wish to involve local and regional authorities, since they have important 

responsibilities in the health sector in a number of Member States. 





The Commission regards the composition of the European Health Forum as a key issue for 

the success and the acceptance of the process. 

It agrees that in principle any interested body or organisation should be able to participate 

in the Open Forum. However there is a need to ensure that the Open Forum is not so large 

as to be completely unworkable. Prior registration will be required to limit numbers, and it 

may be necessary to introduce some restrictions for reasons of organisation and to ensure 

the workability of the Forum. The Commission will reflect on this issue and on the question 

of how a balanced representation between the key groups of stakeholders can be achieved. 

It will also seek the views of the Health Policy Forum. 

The Health Policy Forum will be by invitation only. The Commission considers that there 

should be a total of about 60 participants. It intends to ask some 40 organisations and 

bodies to nominate a representative to take part in the Policy Forum. These permanent 

members will be reviewed by the Commission every two years. Some 20 places will be 

available for organisations which are invited to take part in an individual meeting where a 

specific issue is being discussed in which they have relevant expertise. 

Participation will be restricted to European (umbrella) organisations and to bodies which 

have members in at least half of the EU Member States. Only in exceptional cases, would the 

Commission invite an organisation with a specific expertise in a given area if it were not 

considered a European organisation as set out above. 

The Commission intends to involve the following key groups of organisations in the Policy 

Forum: (1) Non-governmental organisations in the public health field, and patients’ 

organisations, (2) Organisations representing health professionals and trade unions; (3) 

health service providers and health insurance; (4) Industry with a particular health interest. 

Representation between the groups will be properly balanced. 

A number of representatives from Member States, candidate countries, the other Community 

Institutions, associations representing local and regional governments and international 

organisations will also be invited to attend the meetings as appropriate. 

5. Issues to be discussed 

Many suggestions have been received for the issues to be discussed in the meetings of the 

European Health Forum. Of course many of these reflect the particular interests of the 

organisations that responded. 

Some examples of possible issues are: 



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• the new EU health strategy, public health activities and the new public health action 

programme; 

• the integration of health aspects into other policy areas; 

• health implications of enlargement 

• specific policy areas, such as pharmaceutical policy, technology and IT, drugs, or 

research, and health; 

• cross-border co-operation in health and health services; 

• specific public health concerns, such as inequalities in health, mental health, equity 

of access to treatment and to medicines, tobacco, training of health professionals, 

blood safety, etc. 

• concerns of specific population groups (youth, the elderly, immigrants, women, 

etc.).

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The Commission intends to decide on the issues to be discussed at the meetings related to 

the European Health Forum in full collaboration with the organisations involved. It intends to 

organise the first Health Policy Forum around issues of relevance to the new public health 

programme, and the preparation of the first Open Forum. 

6. Resources 

Many responses underlined that the European Health Forum can operate successfully only if 

adequate resources are made available for its operation. 

A number of respondents emphasised the need for a secretariat within the Commission 

services which should be adequately staffed. One respondent raised the issue of whether 

new approaches, such as public-private co-funding, should be explored. 

Many respondents, especially NGOs, emphasised the need to ensure that resource 

constraints do not prevent relevant partners from taking part in the meetings. They regard 

this as a key issue in creating a balanced and comprehensive structure. 

Some organisations emphasised that systematic consultation requires more than organised 

yearly meetings of the Health Policy and the Open Forums. They argue that the Health Policy 

Forum should meet at least twice a year. If this was not feasible, at least working groups 

should come together more often to prepare documents and papers for this Forum. There 

was general support, however, for holding the Open Health Forum as a yearly event. 

It was also suggested that meetings should be translated into a maximum of Community 

languages. 

The Commission fully shares the view that there must be a balanced representation between 

the key groups of stakeholders. It is committed to setting up a meaningful health forum 

process and will explore possibilities of making appropriate resources available. This covers 

inter alia the following areas: 

First, as mentioned above, a secretariat will be established within the Commission in order to 

prepare the Forum meetings and working group sessions, to organise the necessary followup 

activities and to take charge of information work. It will also be in charge of operating the 

virtual forum. If the Forum considers this to be a viable option, a steering group could 

support the secretariat in these efforts. 

Second, the Commission has taken note of the various points made regarding travel costs. It 

will be reflecting further on this issue with a view to finding ways to assist organisations 

which would otherwise have difficulty in sending representatives to meetings. 

It will also consider whether interpretation in the meetings is needed. 

Third, the Commission will consider whether the frequency of meetings of the Health Policy 

Forum should be increased to two meetings a year. It will also study possibilities to establish 

working groups as a means of securing more continuity in the Forum’s work. The Health 

Policy Forum will be consulted on these points. 

A number of respondents point to the existence of other international fora and congresses in 

the field of health and suggest that the Health Forum meetings could be combined with 

them. There have also been a number of suggestions from individual organisations that they 

might organise meetings of the European Health Forum. 

The Commission takes the view that the Forum must remain separate from any other 

conference or meeting organised by other bodies. The Forum is being established by the 





Commission to play a role in the framework of the development and consideration of 

Community policy and the exchange of information and ideas in relation to this. It should not 

therefore be linked to events which are organised for other purposes. The Commission will 

therefore organise the Forum meetings on its own behalf to ensure the continuity of the 

process, enhance the relevance of discussions and avoid any inference that preference is 

being given to any particular stakeholder in the field. As a general rule, meetings should be 

held in Brussels or Luxembourg. One possibility that will be studied over time is whether 

specific meetings could be held in a Presidency country, or in a candidate country. 

Notwithstanding the need to preserve the independence of the Forum, it may also be 

possible on occasion, to link particular meetings, for example of working groups, to 

conferences or seminars which are being organised by other bodies on a relevant theme, if 

this is considered appropriate. 

7. General conclusions 

There was general support among respondents for the Commission’s initiative to create a 

European Health Forum. The exchange of information and experiences, networking amongst 

the relevant actors in this field and the recognition of the role of civil society in health are 

regarded as key factors for the development and implementation of the European 

Community’s health policy agenda. The three-tiered structure proposed in the consultation 

document has also been endorsed. 

Respondents made considerable input into issues to be discussed, practical arrangements 

and organisational questions. 

The Commission wishes to thank respondents again for their valuable input. If the Forum is 

to succeed it must reflect in its work and organisation the views and wishes of all 

stakeholders. This document shows that most of the key points raised by respondents have 

been taken up by the Commission. The Commission intends to develop further its plans in as 

transparent a way as possible. 

It intends to organise an initial meeting of the Health Policy Forum in November of this year. 

This will have an important say for example in the way the first Open Forum will be set up. 

This is foreseen for the first half of 2002. 

In the meantime, the Commission would emphasise that the process to establish the 

European Health Forum is now underway, and it is as open by a process as possible. Any 

organisation or body which wishes to make further observations on the basis of this 

document is therefore invited to do so. 



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Summary Report of Forum V 

Stipe Oreskovic 








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Forum VI: Health in the Information Age 

Forum VI: Health in the Information 

Age – Health Technology and Policy 

Development 


Ricky Richardson 

The Healthcare sector has firmly embarked on an eHealth journey from which there is no 

turning back. Even the most recalcitrant of supporters of medicine being delivered in the 

“old hands-on way” and also those staunch defenders of the term “telemedicine”, are 

changing their positions and coming behind the term “eHealth”, which embraces so many of 

the healthcare reforms made possible by an IT enabled healthcare environment. 

It is relevant to set out what we mean by eHealth. 



225 

The term eHealth captures four principal pillars of activity, which stand in an ocean of 

opportunity, which in itself perhaps makes up the most interesting component of all. 

The four pillars being: 

� Tele-Consultations - being one of the clinical applications including the transfer of 

electronic medical records for the seeking of more specialist opinions sourced from 

a distant location and also includes clinical decision making support software – 

surely the medical encyclopaedia of the modern age. 

� eDissemination of Healthcare Professional Education – to all members of the 

healthcare professional body (doctors, nurses, technicians and administrators) thus 

improving skill levels and raising standards of medical practice worldwide. 

� Public Health Information - focused on raising the knowledge of the general public 

in healthcare matters such that they take on more responsibility for keeping well. 

� LifeTime Health Records – involving a comprehensive recording and innovative 

usage of prospectively gathered healthcare event information, which enables a sea 

of invaluable information to become available for data mining. This data can be 

supplemented by genomic (Human Genome Project), environmental and socio 

economic information. Such data can be used for national, regional and even 

global, healthcare strategy planning leading to global ePrevention, which is surely 

the essential tool for human development in the future generations. 

� The Ocean of eHealth Opportunity – is where the multiplicity of eHealth services, 

which now become possible through the creation of en eHealth enabled 

environment, reside. National ePrescribing Services linking hospitals, clinics and 

pharmacies, Homecare Monitoring for the more vulnerable (especially the elderly)

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members of our communities, eNursing services and linkage into the Social Services 

are all powerful steps towards an improved health environment for all. 

eHealth for Developing Countries 

We must not forget our responsibilities to those developing nations whose access to 

healthcare services – taken for granted in over developed countries - have long been denied. 

It is to those fellow citizens that we can deliver the greatest prize in eHealth and we should 

not forget our responsibilities because we are all members of the global community and the 

future of our children and our grandchildren lies in our hands now 

Providing eHealth Services in Europe : A case study 

Carl Brandt 






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Online information system for rare diseases in Europe 

Michael Schubert 

The Engelhorn Foundation Database for Rare Diseases (EFFORD) 

The Engelhorn Foundation for Rare Diseases has developed an interactive database and 

information system for rare disorders. 



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• This database allows you to search and receive, in selected European languages 

information about treatments, patient support groups, centres of excellence, 

symptoms and clinical trials. Most of this information we receive from medical 

centres and databases around the world or our collaborating medical teams in 

Europe and the United States. 

• In a separate section, health professionals can consult a symptom based database 

which will help to confirm a proposed diagnose and offer contact details for further 

information and possible referral of the patient. 

• A research database will allow researchers to enter and receive patient-specific 

(anonymous) information across diseases and disease groups. 

• This research database is a joined effort between our Foundation and many 

universities and researchers, which contribute with their information and data about 

specific topics or diseases. Our Foundation supplies the entire IT-structure with the 

datasheets, input- and query models. Although the information as such which we 

get from the various collaborators remains entirely under their control (with 

firewalls, security features and back-ups), it is mirrored into our database which 

then combines the increasing number of these separate databases from the 

collaborating universities and researchers. 

Special programming allows to run extensive queries across the database, 

regardless the disease or disease group and regardless the platform from where the 

information originates. 

The queries are totally flexible and can be presented in many different ways, such 

as graphs or pies: for example, you want to receive information about those 

diseases which present with a specific combination of symptoms, you want to get 

patients in a specific age group, receiving a certain medication, or you want to 

know which disease gets treated with a specific drug, etc.

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Main features of this database: 


• highly flexible input model allowing researchers and universities to design their own 

questions and answers in a very easy way; 

• multi-lingual; 

• enhanced security features with encrypted data which allows researchers and 

universities to control their databases and authorize queries; 

• highly flexible query across all connected databases; 

• fast updating through innovative technology. 




NHS Direct 

Bob Gann 

Abstract 

The presentation will describe social factors leading to the development of online health 

services, and the UK policy context. There will be an update on progress on NHS Direct 

Online to date including levels of use and public reaction. NHS Direct is increasingly 

developing as a multi-channel service using call centres, the Internet, digital TV, touch screen 

kiosks and print channels to reach as wide a user base as possible. New features will be 

introduced at 20 November 2001 relaunch. 



Petra Wilson 

An Update report on the targets of the Health Online Chapter of the eEurope Initiative - An 

Information Society for All prepared 

The European Council meeting Lisbon on 23/24 March 2000 set the ambitious objective for 

Europe to become the most competitive and dynamic economy in the world. In order to 

attain this, the Heads of State and Government invited the Council and the Commission to 

draw up an Action Plan for eEurope which would bring Europe on-line and exploit its strong 

position in the new global digital economy. Coming together again in Feira on 19/20 June 

2000 the European Council endorsed the eEurope – An information Society for All Action 

Plan40 , and charged the Commission to report on its progress in November of the same year. 

The Action Plan adopted set out a series of targets which are clustered into three main 

objectives: a cheaper, faster, secure internet; investment in people and skills; and 

stimulation of the use of the internet. Within the three broad objectives a total of eleven 

target areas are described as follows: 

1. A cheaper, faster, secure Internet 

a) Cheaper and faster Internet access 

b) Faster Internet for researchers and students 

c) Secure networks and smart cards 

2. Investing in people and skills 

a) European youth into the digital age 

40 http://europa.eu.int/comm/information_society/eeurope/documentation 



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b) Working in the knowledge-based economy 

c) Participation for all in the knowledge-based economy 

3. Stimulate the use of the Internet 

a) Accelerating e-commerce 

b) Government online: electronic access to public services 

c) Health online 

d) European digital content for global networks 

e) Intelligent transport systems 

Health Online 

The Health Online action underlines the strategic importance of full exploitation of new 

information technologies in the public administration of health, for the benefit of the citizen 

as consumer of both health care services and health information. The Member State 

administration is of course the key actor in achieving the objectives set out in the Health 

Online action, for it is at this level that the key decisions on implementation of the 

information technology infrastructure in health car provision must be made. However, a 

European dimension to the challenge exists in the identification and dissemination of best 

practices and the joint development of relevant benchmarking criteria for eHealth. 

The Health Online action recognises that the first step towards exploitation of the power of 

information technologies in the health sector is the implementation of an infrastructure which 

will provide user friendly, validated and interoperable systems for medical care, disease 

prevention, and health education through networks which connect citizens, practitioners and 

authorities on-line. 

In order to assist Member States in reaching the stated target of ensuring that primary and 

secondary care providers have the necessary health informatics infrastructure in place, 

Health Online action sets out four action areas: 

Best practices in eHealth will be identified and disseminated, in order to assist 

purchasing departments in decision–making. 

A set of quality criteria for health web sites will be developed to boost consumer 

confidence in use of such sites and foster best practice in the development of sites. 

A series of data networks will be established which will facile the sharing of 

technology, application and product assessment in order to help informed 

purchasing and European level quality assurance. 

A publication on legal aspects of ehealth will be drafted which will clarify the 

existing legislation impacting on eHealth in order to remove some of the 

uncertainties and fears expressed by the health telematics related industry about 

responsibility and data protection, the legality of providing on-line medical 

opinions, as well as on-line pharmaceutical information and product supply. 

It is clear that the targets of the Health Online action, as well as the targets set out in the 

other ten action areas of the Action Plan, herald a great deal of work at both Member State 

and European level. However, in endorsing the Action Plan the Heads of State have shown 

that the political will to undertake that work exists, and thus we will now begin addressing 

the challenge of eEurope, so that by the end of 2002 eHealth is a reality for every 

European citizen. 




The Current Update report focuses on Quality Criteria for Health Related Websites. 

A set of quality criteria for health web sites 

The objective of this action was not to develop a code to be enforced by law or even selfaccreditation, 

but rather to develop a basic set of principles according to which Member 

States could guide national or regional initiatives – the objective is therefore to set only the 

essential outline of good practice, not a strict code of good conduct. 

The objectives of the action may be summarised as follows: 



241 

• To develop guidelines on quality criteria for health related websites which may be 

used to guide Member States in possible implementation of quality assurance 

measures for the health related Internet. 

• The guidelines should address issues of both supplier and user education: one 

document that simultaneously tells suppliers how to comply with key quality criteria 

and educates users as to what they ought to expect from a good health website. 

• The guidelines should be made applicable to both passive information giving sites 

as well as sites that allow for transactions between service or information providers 

and users (i.e. information, products and services). 

• The guidelines should encourage compliance with other current guidelines, EU 

directives and technical standards relevant to this area. 

In order to achieve these objectives a workshop was held on 6-7 June 2001 in Bruxelles of 

experts and Member State representatives to begin working on developing basic guidelines 

for Quality Criteria. As a result the following basic criteria have been elaborated and are 

open for further discussion until October 2001. The basic principles are set out below, full 

details including a report of the workshop, and notes and definition of terms are available on 

the eHealth Website at: 

http://europa.eu.int/information_society/eeurope/ehealth/index_en.htm

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DRAFT GUIDELINES ON QUALITY CRITERIA FOR HEALTH WEBSITES 

Transparency and Honesty 


� Transparency of provider of site - name, physical address and electronic address of 

the person or organisation responsible for the site. 

� Transparency of purpose and objective of the site (including any commercial 

purposes). 

� Target audience clearly defined (further detail on purpose, multiple audience could 

be defined at different levels). 

� Transparency of sources of funding for site (grants, sponsors, advertisers, nonprofit, 

voluntary assistance). 

Authority 

� Clear statement of sources for all information provided and date of publication of 

source. 

� Name and credentials of all human/institutional providers of information put up on 

the site, including dates at which credentials were received. 

� Privacy 

� Privacy, security and confidentiality policy and systems to be clearly defined, 

including required opt-in for the storage of any personal data. 

Currency 

� Clear and regular updating of the site, with up-date date clearly displayed for each 

page and/or item as relevant 

Accountability 

� Accountability - user feedback, and appropriate oversight responsibility (such as a 

key quality compliance officer for each site). 

� Responsible partnering - all efforts should be made to ensure that partnering or 

linking to other websites is undertaken only with trustworthy individuals and 

organisations who themselves comply with relevant codes of good practice. 

� Editorial policy - clear statement describing what procedure was used for selection 

of content 

Accessibility 

� Accessibility - attention to guidelines on physical accessibility as well as general 

findability, searchability, readability, usability, etc. 








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Quality of health information on the Internet - Moderated Panel 

Discussion: Statements of professional interest 

Albert van der Zeijden 

Statement not available. 

Charlotte de Roo 

Health is no longer just the concern of professionals. The patient has developed a far more 

active role in his or her treatment than ever before. Most patients now want to completely 

understand the proposed treatment before accepting it. Freedom of choice is only effective 

if we possess all the information we need in order to choose between the range of 

treatments on offer. And this is where the added value of the internet comes in for a lot of 

people. 

The internet has already given many people an opportunity to find information on their 

specific illness, where they before only had the doctor and maybe the family from whom to 

learn about its characteristics. There is therefore no doubt that the internet can be an 

important tool for health information. 

Clearly there is also a great interest among consumers about health issues and consumers 

are willing to spend time and effort to find information on the internet to acquire knowledge. 

However do they find what they are looking for? Is the information they find correct or 

whether is it pure nonsense. These questions highlight the debate on the internet as an 

information tool. 

There are many questions and concerns over this new market place for health advise and 

medicine. But many of our organisations have found that for the time being consumers who 

are buying drugs or ask for health advice over the internet - in most cases they will be given 

poor advice, biased advice or limited advice, and occasionally they will even be given 

dangerous advice. Therefore a main part of consumer demand on health information on the 

internet must be delivery of basic good quality care, safe advice and safe products. 

However the internet has potential and we must not forget that the development of this new 

market place dynamic has already begun. The real world is far ahead of this policy 

discussion here today. This is due also to the fact that consumers want to find their own 

information and that they want to make their own choices. 

Michèle Thonnet 

Statement not available.

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Petra Wilson 

Statement not available. 


Michèle Thonnet 

Abstract and Speech not available. 


Otmar Kloiber 

Abstract and Speech not available. 





Summary Report of Forum VI 

Rolf Engelbrecht 



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Plenary Session III 


Marc Danzon 




As it concerns a very complex matter, this question can be answered either very briefly and 

quite simply, or in a rather convoluted way. In my following comment I am attempting to find 

a compromise between the two aforementioned possibilities. 

First a brief answer: 

Europe needs a lot of health! So far it has done very little and is, most of all, rather 

unprepared for future challenges. 

Now let me enter into the more complex part: 

What is health? The WHO defines health as a condition of physical, psychological and 

sociological well being. At the same time we say “Life’s most precious gift is good health!” 

Therefore our first goal is to preserve health, and the second to restore it. All serious 

opinion- polls conducted within the EU suggest that its citizens see health, internal safety 

and education by far as the most important precondition for a safeguarded life and hence 

range top of the list. 

In the health-sector, Austria has in the last years, well, in the past decades really, moved far 

too much, meaning that all of us involved in the health-sector have been unable to really 

align- within existing performance structures- the medical progress which has been achieved 

in the meantime to the greater good of man. 

It is therefore our main task to restore the balance between financial backing and the 

required medical performance. Besides, there is the other fact that we cannot really predict, 

where medical progress is going to lead us. 

It is an unwritten law that a society with a high degree of performance and development, as 

is the case in Austria, cannot only be asking for access-guarantees to further medical 

progress, but also has to be prepared to invest into it. This could be achieved either through 

joint contributions, or cost – sharing. 

For we all have to be fully aware that the practiced smoke-screen strategy which conveyed 

the impression that medical care can be available for nothing, is no longer viable 

economically. 



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These rather broadly spoken words are, with a few alterations and considerations applicable 

to most countries, as well as to EU-countries.

252 


The basic ethical question – just how valuable health is to a society has to be put into 

perspective, when faced with data from Western states: Within EU – countries the amount of 

health expenditure in relation to the GDP varies below 7% in GB and Ireland, to 10% in 

Germany and France. Relatively low health expenditure in GB, hardly more for example than 

in Hungary, and even lower than in the Czech Republic, have already led in GB to the 

political objective of increasing expenditure to Western European average, which according to 

the year moves between 8% and 9%, and henceforth put an end to recurring overlong 

waiting lists. 

On the other hand there is also an upper limit beyond which no further benefit in health-care 

can be gained for the population, especially concerning the amount of public health 

expenditure. With 8,3% – split into 6% public funding and 2,3% out of private means (the 

latter figure showing a steady increase) – Austria is ranking mid-field in Europe. We might 

occasionally have the odd bottlenecks in terms of waiting – times, but certainly not in cases 

of emergency. But on the other hand, due to stagnation over the years, our present system 

has become inflexible, so that necessary adjustments, usually with suggestions regarding 

cost – calculation, are not feasible in practical terms. 

The ethical question in connection with financing the health care system is also not primarily 

how much is being invested, but rather, if all groups of the population have access to each 

and individual care, which of course should also be highly comprehensive, as well as of 

utmost quality. 

In principle we are therefore determining reforms in the health care system on the structural 

level. To my knowledge no initiatives are being taken in any countries where social welfare 

has a high standard, which are aiming from the start to restrict care, introduce rationing or 

plan expenditure-cuts. On the contrary, structural changes and adjustments, as well as 

efficiency and better performance of efficiency will have to stem the increase in expenditure. 

In highly developed health care systems there will always be a potential for that. 

What I want to state is that regardless in which area of the health care system they are 

implemented, they must never have any detrimental effects on the patients. 

Now lets move to Central-and Eastern Europe, where new challenges are waiting. With the 

accession of the applicant countries the present member states of the EU will almost double, 

which will have far-reaching consequences not only for medical systems from candidate 

states, but also for medical doctors in the present member states. European health 

organisations will have to face the fact that the economic situation as well as the health 

status of the population in the candidate countries is considerably worse than in the EU. 

The share of health care expenditure in the GDP will have to be increased in most of the 

candidate countries in order to provide the population with health care systems which 

comply with present EU-standards. Medical studies and postgraduate training have to 

guarantee quality which meets the requirements of EU standards. 

The unfavourable economic situation of medical doctors, together with a low social status in 

many candidate countries might cause a migration problem to the prejudice of the EU 

member states as well as of the applicant countries. 

General and particular solutions on a broad consent have to be found with regard to the 

economic and structural conditions to be established in order to provide high quality of 

medical care in all of Europe. 

I would like to stress the point that Austria will immediately be confronted with the applicant 

countries, and not as other EU-countries, after their entry. These countries are already our 

neighbours and, regardless of Eastern expansion they have to be accepted as full partners. 




It is common knowledge that diseases do not know of national borders. We have had to 

accept this to an ever higher degree in the past years. I want to specifically address 

contagious diseases, such as the advance of tuberculosis and the spreading of AIDS and HIVinfections 

respectively. All this is being paired with an overwhelming drug problem. Many 

states have just started to set-up a comprehensive, up-to-date, basic health care system. We 

will be well advised to massively intensify cooperation, which will eventually lead to crossborder 

solutions. 

For each Million of Euro, which the EU will invest in improving the medical structures in 

these countries it can eventually save Billions in its own domain. Should this not be 

possible, the costs for these untackled cross-border problems will hit us a hundredfold. 

Therefore I, as well as the person responsible for the Health Department cannot quite 

comprehend that so far EU-policy has had no room for it’s own domain to maintain and 

expand health in Europe within the public welfare system. On the contrary, health is nearly 

completely left in the hands of the WHO and some idealistic governing bodies. Within the 

E.U- community-law these aforementioned organizations try to level-out questions concerning 

competence or non-competence. 

Fainthearted attempts can be perceived. However, it took until 1993 (Maastricht) until in 

article 129 a skeletal agreement was implemented concerning Community’s activities within 

the public health area. Up till then there was hardly any more than recommendations for 

coordination efforts and no attempts whatsoever for a coordinated, joint health-policy. This 

last mentioned article has also to be seen as having no binding coordination efforts in the 

health care system. Promotional programmes were set-up with the aim to develop addenda 

to autonomous prevention strategies and best practice medicine – models for certain serious 

diseases, such as AIDS, cancer and drug addiction. 

Due to non-existing specifications legally binding measures such as guidelines for quality and 

safety of blood and blood products were not possible for a long time. 

Quite often therefore the Council had to restrict itself to the instrument of recommendation 

only. 

The Amsterdam treaty has appended to in the European charter of 1986 and the Maastricht 

treaty established ameliorations of the EU – Founding Treaty. 

But then again this is not a general concept. It is rather a confirmation that the population’s 

health protection within the Community should not be a side-effect of all the other 

Community’s activities , but that health policy measures have to be positioned equally if not 

pre-eminently within the power play of other policies. Only in some areas does the treaty 

carry a certain extension of Community competence. That is the authority of issuing legally 

binding measures regarding the veterinary sector and plant protection, as well as 

determining high quality and safety standards for organs, substances of human origin, blood 

and blood-derivatives. It has explicitly been established in the so called integration clauses 

of article 152 of the European Founding Treaty. 

This article does not hold any initiatives for coordinating law-and administration regulations, 

but only contains promotional measures for the next six years. 

Fortunately, considerable progress was made at the European Council meeting in 

Gothenburg, where effective development strategies which also included the health sector 

were being addressed. This made it possible that after quite some time a substantial amount 

of money that is 300 million Euro, was set aside in the budget for the purpose of 

establishing a coordinated health-report-system. Based on this data, acquired under 

comparable and methodically coordinated conditions, it will be possible to show EU – wide 

deficiencies in the health sector, and thus enable counter measures. 



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Before I come to the end, let me stress one point which in all our deliberations has not yet 

led to appropriate reflections. For me however, it poses a grave, unsolved and neglected 

problem which, eventually will present itself as a sociological problem. I am talking about 

our children’s situation and their future. 

We live in a society where in an ever increasing way children are being suppressed from our 

minds , a society giving too much thought to its own problems, meaning problems of the 

adult population. This society disregards children and even neglects them to an increasing 

extent. 

It is well known that today more than 3/4 of diseases and fatalities predominantly concern 

the group of chronic, degenerative ”life-style” diseases. For example, cardiovascular diseases 

count for 54% of fatalities, or carcinoma which are responsible for 24%, of fatalities. In 

addition we have diseases relating to the locomotor system and the supporting apparatus, 

as well as metabolic diseases, diseases of the respiratory system and with increasing 

significance psycho-manifested afflictions, including drug-related diseases. In this context we 

can also speak of stress – related diseases. 

These diseases affect adults and children - the latter being actually more affected than 

previously thought. More and more children show early signs of mental and physical health 

defects. Usually children are quite able-bodied to react or even counter-react when faced 

with adverse or taxing situations, as they do for example when they experience starvation 

and at least to some extent when they have to cope with physical suffering. But to an always 

lesser extent can children cope with the psychosocial starvation they are being exposed to 

in our times. 

This vague and not really discernable flaw in our overall feeling of mental and physical wellbeing 

has increased over the years and affects adults and children alike. Alas, in this context 

children represent a forgotten group. According to a Scandinavian survey nearly a half of all 

15-year old girls suffer from recurring headaches, which means the number has doubled 

within 10 years. One fifth of children meet the criteria of a so called anxiety-stress-syndrome, 

each 10th child is suffering due to neglect, lack of contact and physical guidance, or simply 

due to ignorance. 1% is being sexually exploited and abused. 

After school, a half of the children are deprived of suitable leisure time activities which 

consider their requirements and also offer educational value. A quarter of children live in 

families who find it difficult to pay their bills and a fifth live in single-parent families. Each 

3rd child in the first years of Secondary School attends classes with more than 25 pupils. 

This listing could be continued and could be applied to a high degree to many EU-countries. 

After all, big parts of the population in our society are being coined by restrictions and 

disinterest towards our children. Less and less adults want to have children. The share of 

children und juveniles below the age of 17 related to the total population is down to 20% in 

many EU-countries, which means a significant drop compared to the situation 10 years ago. 

One gets the impression that children are being voted out. 

Increasingly today’s children have to grow up in a conflicting environment, where the parents 

are either absent or disinterested - thus resulting in a lack of guidance and support. 

Therefore more and more children show distinct signs of mental, physical and health related 

weaknesses. 

A society unable to look after its children in an appropriate way is sick and decrepit and 

does not merit to be called civilized. Great, discerning and prudent minds always stress the 

fact that weaker vessels have to be supported. Therefore we have to dare to ask this rather 

unpleasant question: How high a price do our children have to pay for our self-fulfilment and 

the liberties we are taking for granted just because we are adults. 




Concluding and so to speak as a postulate for a medicine of the 3rd Millennium I want to 

stress: ”Future does not just happen, it is being prepared in the present”. Therefore longterm 

structural changes in health care either develop coincidentally or, and this procedure is 

my aim, are envisaged, innovative answers to challenges of the future and thereby for the 

health of the European population. 



255

Inserat DaMe


Health across other policies 

David BYRNE 

Dr. Leiner, Ministers, Ladies and Gentlemen, 

I am delighted to have been invited back to Bad Gastein, to address this notable forum on 

health issues, in this unusually healthy conference setting. As in previous years, I understand 

that your deliberations have again provided decision-makers and advocates alike, with a 

breath of fresh mountain air on these complex public policy issues. And I would like to thank 

Dr. Leiner, and his team for facilitating this impressive meeting of minds. I am pleased and 

indeed reassured to note that all this has been achieved in close cooperation with the 

Austrian State Secretary for Health Mr. Waneck, and with our close friends at the WHO under 

Dr. Marc Danzon's ever watchful eye. 

I don’t know whether Dr. Leiner possesses a crystal-ball, or whether you have a unique 

insight into the mind of the European Court of Justice. Because your choice of Health Across 

other Policies as our theme is extremely timely. By the way, if either case is true, I would 

welcome any future tips! Because within a matter of months, the theme of "Integrating 

Health across Policies" has moved centre-stage for European policymakers. The sequence of 

events is familiar to you all. Whether one looks back on the Göteborg Summit, the Global 

Access to Drugs debate, or the more recent European Court of Justice Rulings - a year has 

been a very long time in the politics of health. And without even venturing to include the 

Charter of Fundamental Rights - I think it is fair to say that we are entering uncharted 

territory. At this point, we find ourselves on the threshold of a new approach to health 

issues in the life of our Community. And it is now up to our collective political imaginations 

to map out the future. 

In addressing the theme of Health in other policies, I would like to look at this issue in three 

key respects. First, the importance of Health issues as part of the debate about Governance. 

Secondly, how health can become a driver of community policies - rather than a sideshow. 

And finally, some preliminary reflections about the future role of Health issues in the 

unfolding evolution of European integration. 

1. Health and Governance 

To understand the importance of health in other policies, we need to see the broader 

political horizon which it evokes. Indeed, we need to reflect on the important link between 

effective health policy and good governance in the minds of our citizens. Placing health at 

the centre of other policies is a significant political challenge. And how we respond to this 

challenge in the years to come, will affect not only the machinery of health policy, but the 

health of our political machinery. This will affect decision-makers at European, national, 

regional and local levels. And it will directly impact upon our traditions of social cohesion 

and effective government in the coming years. 

In looking at the issue of health in other policies, we need to accept right from the outset, 

that the political stakes are high. We must recognise, that our success or failure in 

responding to the health policy concerns of our citizens in whichever sector they may arise, 

will have a wider impact on the health of our systems of governance. 



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Increasingly, they will judge us and the value of our systems of governance, by our ability to 

place their health and wellbeing at the centre of other policies. And not as some secondary 

afterthought. It is a challenge we cannot afford to fail. But we will only manage to meet this 

challenge by working closely together with renewed imagination and without preconceptions. 

And we need to work together quickly. Because events are driving the process. And as you 

all know, events are what politicians were invented to manage - not the other way round! 

At the European level, by events, I would go beyond the familiar toll of health-scares and 

emerging threats to health to include a wider picture of dynamic activism. By this I mean not 

only the political and economic activism of summits, campaigns and protests, but the 

increasingly important judicial activism of the Courts. I will come back to the recent ECJ 

judgements regarding the impact of the Single Market acquis on crossborder healthcare later 

in my speech. But I would like to make a general point about who makes and who should be 

making health policy. 

As a former Attorney General, I have a healthy respect for the ability of the Courts to make 

progressive judgements. Without a doubt the Courts have played a definitive role in 

European integration. But I believe that any future discussion of health policy in a European 

context must address the reasons why the Courts are required to be so active in so sensitive 

an area of policy? Because it is becoming increasingly clear that if the Community and the 

Member States do not clarify, coordinate and - where necessary - complete the acquis 

together, then the Courts are in danger of doing so on their behalf. In this light I believe that 

we urgently need to reflect upon how such policy change should be managed in future. And 

who will set the rules of the game? The Member States in partnership with the Community, 

or the Courts? 

2. Health in Community policies 

In turning to address the specific issue of Health in other Community policies, I am aware 

that as the first designated European Commissioner for Public Health I carry a particular 

responsibility. First and foremost the responsibility to reassure our citizens that their health 

comes first when decisions are made at European level. This means ensuring that the 

opportunity offered by the Amsterdam Treaty to raise the level of our citizens health - is 

seized and its potential fulfilled quickly. This also means working within the European 

Institutions and with our stakeholders to turn the innovations of article 152 into concrete 

proposals. And in doing so to build mutual confidence in our capacity to work together for 

the common good in full respect for one another's specific roles. 

When you look at the gathering flow of Community proposals from tobacco, and blood 

safety, to emerging antimicrobial resistance policies, I believe that we are beginning to 

answer the call. This is due in large part to the efforts of Fernand Sauer and his small but 

dedicated team in Luxembourg. Good work on the first generation of health programmes has 

laid a sound foundation for the future. For example, I believe that the early work done on 

cancer, will prove to have been decisive in the longer term. 

And I have no doubt that the organic development of the communicable disease network, 

will prove to be extremely important in the future, particularly with an imminent Enlargement. 

Because the completion of an effective early warning system with adequate coverage and 

quality data for surveillance and monitoring, will prove vital to ensuring co-ordinated 

responses. And history teaches us that such responses may one day arise. Finding the right 

response to pandemics is a public policy priority - which is why I am promoting a conference 

to look at these needs in Brussels in November. Our success in raising our collective game 

on Communicable Diseases, will have an important impact on other policies in the long term. 




Of course, within our public health competence our ability to meet today's challenge would 

be significantly enhanced by the availability of our proposed Euro 300m Health Action 

Programme. Because given adequate resources and sufficient scope, our Health Action 

Programme will provide the kind and quality of information which is needed to make 

informed future policy choices. 

It will facilitate effective health policy by providing "joined-up" analysis at the hub, for 

decision-makers and citizens alike across Europe. By providing intelligent links between 

widely scattered sources, it will facilitate an accelerated learning process for all concerned. 

So the sooner we all manage to get it up and running - the better for all concerned. 

In our Community Health Strategy, the new Health Action Programme stands alongside 

"Health in other Policies" as the cornerstones of a new framework. This framework is being 

put in place to ensure that fulfilling our health potential can become a driver of European 

policies. And not as it sometimes appears – an accidental passenger! But to develop this 

mainstreaming reflex within our institutions, we need to start with some practical first steps. 

Steps such as improving co-ordination, focussing extremely limited resources on priorities, 

providing evidence-based scientific policy input, and developing badly needed new 

institutional arrangements and expertise. I am pleased that progress has already been made 

in developing interservice coordination on health issues within the Commission backed by a 

network of correspondents, and in elaborating the necessary health impact tools for new 

policy proposals. 

In your hectic programme for Gastein I am happy to be able to state that progress is evident 

in each of the areas under discussion in your parallel sessions. You have looked at how to 

influence sectors. With our limited resources we have decided to focus on key proposals in 

areas such as pharmaceuticals, food, the environment, research and social policy. Let me use 

our role in reviewing pharmaceuticals policy as a case in point. 

Many of you will be aware that I have been actively involved in working with Erkki Likanen 

to achieve a balanced approach to the Community's review of pharmaceutical policy. We 

presented our ideas in July. Additionally in the high-level G10 Medicine group which we are 

chairing, we are looking with stakeholders at the future of Innovation and the Provision of 

Medicines. We want an informed debate on the choices ahead, with the widest possible 

consultation along the way. The Consultation Paper should be on the G10 website next week. 

My main concern is to put the patient first. Given safety issues I want to make sure that we 

retain a system that offers maximum health protection, while at the same time ensuring that 

patients have access to new drugs without undue delay. In addition, we need to keep a clear 

eye fixed on the concerns of healthcare purchasers and providers regarding the rising drugs 

bill. We have got to find cost-effective solutions that will also stimulate competition, improve 

patient care and motivate innovation. 

It is in all our interests that we empower patients through appropriate information and 

compassionate access. And that we protect them through effective pharmacovigilance 

systems. Systemic changes affecting patients are taking place in health-related policy areas 

like pharmaceuticals and the Single Market. Therefore, it may well be the moment to look at 

how an independent European advocacy platform for Patient's can be developed. 

You have also extensively discussed information technology and health. Given technology's 

increasing role, it is important to ensure that decisions to introduce particular IT application 

in health systems are driven by health reasons rather than technophilia. Clearly, the quality 

and reliability of information on the internet for our patients is also vital for an integrated 

approach to technology in health. I look forward to seeing the e-Health findings on the 

quality assurance of websites in the coming months. 



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Elsewhere on issues relating to Food and Agriculture, I need not elaborate on what is the 

widest-ranging raft of legislative and institutional measures on Food Safety in the history of 

the Community. But alongside the big ticket items like the new Food Authority, my new 

proposals on Zoonoses will make a significant impact on the control of salmonellosis and 

campylobacter. In other aspects of agriculture and food policy, I have no doubt that our 

emerging initiatives on Nutrition will provide an essential point of reference. Particularly as 

we begin to examine how best to tackle the current links between diet and health outcomes, 

ranging from cardiovascular disease and cancer, to diabetes and obesity. 

At the international level health issues have played a major role in setting the Community 

agenda over the last year. A fact no doubt confirmed in your discussions on the globalisation 

of health. Having formalised our strategic partnership with the World Health Organisation, we 

are busily working together to set out a map for future co-operation on a range of shared 

priorities from Global Tobacco Control, to tackling Communicable Diseases and raising the 

profile of Mental Health. And I think Marc Danzon will agree that we will have much to do 

together in the European region, particularly as Enlargement beckons. We have worked 

closely with the WHO and our DG Development colleagues on "access to drugs" and the 

Global Health Fund. We are now working to ensure that our Development policy and partners 

benefit from a more consistent approach to tobacco policy. And just to prove that our 

approach is yielding benefits, we are currently working with our colleagues in DG Agriculture 

to begin the difficult process of phasing out tobacco subsidies! 

So on balance, I would suggest that whilst there is a long way to go, a promising start has 

been made to mainstreaming health in other policies. Which is all but miraculous - given the 

available resources. 

3. Future orientations 

Turning to the future, in my mind, there is no doubt that health-related issues are moving to 

the very centre of the European policy agenda. This process which was originally provoked 

by the BSE crisis and which has steadily evolved, is entering a period of significant 

transition. Questions continue to arise as to how health is to be understood in the light of 

existing Community competences in other policy areas - from the Internal Market to 

Competition and Enterprise policy. And the pressure to clarify where European health-related 

policies are heading, emanates from a formidable coalition of policymakers, patients, 

providers and indeed judges. But in some cases, the European Union is finding novel ways 

to respond. 

One clear indication of how the European institutions intend to manage this process has 

been signalled by the Göteborg European Council. Because Göteborg endorsed an ambitious 

new policy agenda launched by the Commission called the Sustainable Development 

Strategy, an agenda which deals with the interlinking themes of quality of life and good 

governance. 

The Sustainable Development concept identifies a shortlist of priorities affecting the future 

well-being of our society. It sets in motion a process which will systematically assess the 

impact of Community policies against sustainability criteria. The Strategy sets five priority 

areas for action. These are - combating climate change, ensuring sustainable transport, 

addressing threats to public health, managing natural resources and integrating environment 

into Community policies. 

On public health Sustainable Development has prioritised a number of areas for action 

namely: wrapping up the Food Authority and Food Law preparations; putting in place an 

appropriate chemicals policy; and setting out a clear plan to tackle antimicrobial resistance. 




In fact, I have pre-empted this by presenting a Communication setting out areas for action on 

antimicrobial resistance. 

But it also prioritises the creation of European capacity to monitor and control outbreaks of 

infectious diseases by 2005. In doing so, the European Council has given its blessing to an 

important part of the institutional jigsaw, which we all agree, needs to develop rapidly in the 

coming years. 

And each year as the Community makes its annual Spring stocktaking of economic and social 

progress, we will assess our sustainable development too. Or in other words, how well we 

are serving the needs and well-being of future generations of our citizens. In banking terms 

we will not only be keeping an eye on our current account, but maintaining a watchful eye 

on how our investments are shaping up to leave a decent inheritance for the future. 

This managed European response to Sustainable Development, contrasts with the impact of 

recent European Case law on cross-border health services on policy management. This is 

ironic when one considers that against the background of an ageing society, Göteborg called 

on the Commission to report by Spring 2002 on the possible extension of the "open method 

of coordination" to the field of healthcare and care for the elderly! 

The welcome evolution of new thinking in our capitals witnessed at Göteborg, needs to come 

to terms with the unfolding revolution in case law. And this is increasingly urgent. As the 

debate on "Health in Other Policies" is currently at its keenest among those who are 

responsible for the management and delivery of health services at all levels in our Member 

States. 

Because in its formative judgements, the Court has placed health issues firmly under the 

sway of a range of existing Community policies. We were warned about the likelihood of 

breaches of the Internal market acquis for certain health services within the limits of the 

Kohll-Dekker judgement. Now, after the Judgements on Smits/Peerbooms and VanBraeckel, it 

is clear that such medical activities fall within the Internal Market's meaning of services 

provision. It is also clear, that patient's freedom to normal and necessary treatments in other 

Member States cannot be arbitrarily refused. And it remains to be seen how, what the Court 

refers to as "undue delay", will link in to the extent of patients rights to seek treatment 

elsewhere. This too is likely to be clarified by the Courts in the future. But the likely impact 

of the Internal Market's four freedoms, poses the most significant challenge to date to health 

policymaking in Europe. 

I think it is fair to say that the sustainability of universally accessible healthcare and health 

services is of primary importance to our citizens and to our Member States. In many 

respects, when our citizens try to grasp what is referred to as the European Social Model it is 

the availability of healthcare for all members of society which provides a practical example. 

And the difficulty of meeting citizen expectations by providing a decent quality of care given 

the challenge of cost containment, the role of technology and the impact of demography is 

probably the most difficult problem which our Member States face today. 

The Courts have recognised this by emphasising the primacy of maintaining the financial 

balance of social security systems and the maintenance of hospital services. But the Courts 

have responded to the growing wave of what has been called patient-power in raising the 

spectre of patients needs such as access, speed of treatment and reimbursement. The 

eventual impact on our social security services remains to be determined. 

But in preparing a policy response, attention needs to be paid to the impact on our overall 

health policy at all levels of administration and across the Community acquis. We need to 

see our social security and health experts working together to identify an integrated 



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approach to this complex challenge. And we need to see all actors involved whether as 

providers, purchasers, policymakers or patients. 

But at the Community level, finding an appropriate response will not be easy. And as part of 

this reflection some thought will need to be given to whether the existing Community legal 

environment across the policy range, provides sufficient checks and balances to respond to 

patients, purchasers and providers alike? In all of this I believe that the Commission, and in 

particular the services of Commissioner Diamantopoulou, can play a useful role in facilitating 

a structured discussion on the future. And for this debate to provide durable solutions I 

believe that some kind of inclusive process will be needed in which the principal actors such 

as our Member States, Regions, policymakers, purchasers, patients and providers, can come 

together to seek sustainable solutions. 

In concluding, we should not forget that the Laeken Council will launch a far-reaching debate 

about the future shape and destiny of an enlarged Europe. And whatever the ambition of the 

end product, there can be no doubt that a wide and indeed exotic variety of health policy 

issues, will arise at various stages of the public debate. As such, all the actors in this 

process should be ready to work together to find a politically compelling and economically 

sustainable conclusion. This is doubly true given the nutritionally rich diet of health-related 

policies contained in the Charter of Fundamental Rights! 

Despite all the legal difficulty, economic anxiety and institutional concerns, this is a moment 

to turn what currently looks like a problem, into a real opportunity. An opportunity to set out 

a positive political concept of health as fundamental to the fulfilment of our personal and 

economic well-being - as individuals and collectively. The concept of Health as a driver of 

policies. A concept of Health as both the driver of our economic prosperity, and as a source 

of renewal for citizenship and governance alike. 

I look forward to hearing your views on this fascinating opportunity. 



Special Interest Sessions 




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Public Health Research and the Proposal for a new Framework 

Programme on Research 

Kevin McCarthy 

ON 21 FEBRUARY, the Commission adopted proposals to be submitted to the European 

Parliament and Council for the next framework programme for research and innovation. In 

contrast to that of its predecessors, the context in which the European Union must today 

implement its traditional research activities is fundamentally new and innovative - that of the 

European Research Area (ERA), of which the framework programme is becoming the financing 

arm. 

This initiative, instigated by Philippe Busquin, Commissioner responsible for research, aims 

to provide the Union with a genuinely common strategy – comparable to that of the single 

market and currency - designed to strengthen Europe’s scientific and technological dynamism 

on an increasingly global stage. The concept of the ERA was extremely well received by 

Europe’s politicians who have given the Commission a very clear mandate to implement it. 

The projected global budget (including Euratom activities) is Euro 17.5 billion, a 17% 

increase on the previous framework programme. The framework programme consists of three 

main areas of action which reflect the main thrusts of the ERA. 

1. Integrating research 

The framework programmes to date have been instruments for stimulating and supporting 

collaboration between European researchers. Without actually disappearing, this mission 

must now be adapted to deliver the new strategy of the ERA by incorporating actions that 

will catalyse the integration of European research. In specific terms, this means two key 

changes in the programme concept: 

• concentration on a limited number of priority fields of research to which activities at 

the Union level can add real value (see table); 

• strengthening of links between the Community research effort and national and 

regional research policies. 

In the priority areas, the new framework programme will work mainly by supporting the 

development of cooperation within networks of centres of excellence. These networks will 

bring together the best research capabilities in Europe’s regions to conduct common research 

programmes, enabling the emergence of ‘virtual platforms of excellence’ on a European scale. 

Substantial resources might also be allocated to support integrated projects involving public 

and private partners, with clearly stated scientific and technological objectives and with a 

view to generating new knowledge and/or applications in the priority fields.

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In this respect - and as authorised by the European Treaties - the new framework programme 

will innovate by using its powers of intervention to encourage active participation in research 

programmes jointly implemented by a limited number of Member States. 

2. Structuring the European Research Area 

The ERA aims to correct structural weaknesses or deficiencies which could be described as 

‘transverse’. The most notable of these, already widely covered by previous programmes, 

concern: 

• the strengthening of bridges between research and innovation; 

• the renewal of the human potential for research and mobility of researchers. There 

must be an active policy to make the ERA a more attractive area for scientific and 

technological research, not just to stop the traditional deficit caused by the ‘brain 

drain’, but also so that it attracts the best foreign researchers. 

However, there are two specifically innovative aspects of the programme which are destined 

to play a particularly important role. 

• Support for the development of research infrastructures. Until now the Union has 

mainly tried to attract European researchers to the existing infrastructures of the 

Member States. In addition to this support for the mobility of researchers, the new 

framework programme initiates a policy for the coherent development of 

infrastructures, in the form of integrated actions facilitating their networking and 

ability to deliver scientific services at a European level. 

• The attention given to questions of ‘science and society’. To achieve the necessary 

deepening of the Union’s democratic foundations, better relations between ‘science’ 

and ‘governance’ and an improvement in the scientific and technological culture of 

the average European are seen as priorities by policy-makers, researchers and the 

general public. 

3. Strengthening the foundations of the European Research Area 

The new framework programme will also aim to strengthen one of its fundamental missions, 

which is to meet scientific and technological needs which arise in the implementation of 

Union policies in all fields where Community responsibilities are constantly growing - such as 

agriculture, fisheries, health and consumer protection, the environment, transport and the 

information society. The tasks assigned to the Joint Research Centre will come under this key 

programme activity. 

Another important aspect is support in improving the coordination and coherence of research 

activities, at national and European level. This search for better coordination, which 

embodies the very spirit of the ERA, will aim to create opportunities for the mutual opening 

up of national programmes and cooperation between existing European scientific and 

technological frameworks. 

A third element of this action plan, the flexibility of which will be guaranteed by annual 

budget management, is increased anticipation of the scientific and technological needs of 

European policies and the often rapid responses these require. . 






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Summary Report of Workshop II: EUEnlargement: Implications for 

Health Systems 

Laura MacLehose 

1. ‘Progress in the Health and Enlargement Process. Mr Bernard Merkel, Principal 

Administrator, Health and Consumer Protection Directorate General, European Commission 

The European Commission’s staff working paper on health and enlargement, the European 

Parliament’s Report on public health and consumer protection aspects of enlargement and 

the Council of Ministers’ conclusions identified different health related issues with regard to 

enlargement. These included issues such as health status in the candidate countries (CCs), 

different public health traditions, lack of resources on health, communicable diseases and 

weaknesses in quality assurance and surveillance systems. 

These issues have been addressed in several ways. Regular information exchange, 

international, European Community and bilateral projects and activities targeting particular 

problems, as well as participation in Community networks and programmes are some of the 

measures taken. Co-operation with other European/international organisations is being 

developed further so as to pool resources and avoid duplication of effort in supporting the 

CCs in the enlargement process. 

2. ‘Health and Enlargement: Challenges and Opportunities for Health’. Professor Martin 

McKee, Professor of European Health, London School of Hygiene & Tropical Medicine 

In March 1998 accession negotiations were formally opened with six countries: the Czech 

Republic, Estonia, Hungary, Poland, Slovenia and Cyprus. The process was widened in 

February 2000 to include six additional candidates: Bulgaria, Latvia, Lithuania, Malta, 

Romania and the Slovak Republic. Turkey is also a candidate country for accession to the EU 

although not yet in accession negotiations. Accession of these countries to the EU will bring 

benefits but also challenges for both the EU and those acceding to it. 

Among the challenges for the pre-accession countries is the need to implement the 

accumulated body of existing EU law, the Acquis Communautaire. Although, formally, the EU 

does not have competence in health care, this being a matter reserved for governments of 

member states under the principle of subsidiarity, there is a large number of provisions in 

relation to free movement of goods, services, and people that do affect health care 

arrangements and have implications for health. Other policies, such as parts of the Common 

Agricultural Policy (CAP), can also be considered to have impacts for health status and care 

in member states. These impacts will become clearer as health impact assessment of ‘nonhealth’ 

EU policies is carried out. Among the issues of enlargement to be addressed are: the 

extent to which regulatory systems of acceding countries meet EU standards, how 

comparable EU health priorities are with those of the accession countries, and the extent to 

which existing national legislation of accession countries may conflict with EU law, which will 

have primacy. 

This new round of accession to the EU is simply one further step in a process of enlargement 

that began as long ago as 1973 when Denmark, Ireland and the United Kingdom joined the 

original six members. As recently as 1995, Austria, Sweden and Finland joined. Consequently 

there is now a considerable body of experience that can be drawn upon by those countries 

that are currently negotiating accession. It is, however, essential to recognise that the EU has 

evolved in many ways since it was established in the 1950s, of which some have a direct or 

indirect effect on health. In addition, the relatively wide gap between the wealth and health

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of the EU and pre-accession countries compared to the countries most recently joining the EU 

in 1995 also has implications for health systems in both the EU and the pre-accession 

countries. 

While the candidate countries each differ with respect to health and health care systems, 

taken overall the health status of the candidate countries’ population differs negatively on 

most key indicators in comparison with that of the EU average. Today, a man living in central 

and eastern Europe (CEE) is twice as likely to die before reaching 65 than is a man in the 

European Union. Similarly, a woman living in C&E Europe is 70% more likely to die before 

reaching 65 than is a woman in the EU. 

What are the components of such differences in health? Three leading factors form the basis 

for this pattern: heart disease, cancer and injuries. For both heart disease and injuries, the 

age-specific death rate in CEE is about double that of the EU. Cancer mortality is about a 

quarter higher than the EU rate. Differences between the east and west of Europe were 

apparent in the 1980s. However, progress between east and west has been markedly 

different since 1990 and provides important clues as to why such a large health gap should 

exist. In 1980 the EU average, age-standardised, death rate for ischaemic heart disease was 

around 80 per 100,000 males under 65 years. In Romania it was around 55. However, while 

the countries of the EU showed steady progress dropping this to below 50 by 1997, in 

Romania a reverse of this trend was found and in 1997 there were over 80 deaths per 

100,000. A similar trend is found in some other CEE. Causes of death that are more common 

in eastern Europe, such as heart disease, stomach cancer and childhood injuries, are also 

more common among the poor in the west. 

The ‘usual suspects’, diet and smoking, are two of the key causes explaining the differences 

between east and west. Alcohol, an ‘unusual suspect’, is also, however, a major factor. High 

levels of cirrhosis are found in southern countries (Hungary, Slovenia and Romania) and the 

health effects of binge drinking have been shown to be especially serious. Although 

governments have undertaken a range of measures to respond to the challenges, the efforts 

of implementing health care reform in many countries have preoccupied many 

administrations and some countries have failed to develop broad health policies to address 

these and other underlying health causes. Some health improvements can be attributed to 

government actions, while others are the by-products of improvements such as diet (due to 

improvements in retailing) and the emergence of civil society organisations and self-help 

groups. In terms of healthcare, some countries have made substantial improvements in 

outcomes for cancer survival, low birth-weight baby care and control of hypertension. 

However, at the same time, there are growing inequalities in health in the region. 

Some of the concerns in terms of health related to enlargement include: the increased 

movement of people and related implications for communicable disease control, health care 

provision, drug trafficking and increased tobacco smuggling. Other issues that need further 

review include the movement of health professionals and enlargement (are there risks of 

‘brain-drain’?, is there a need to strengthen regulation of health professionals?), patient 

movement and the regulation and manufacture of pharmaceuticals. The European 

Observatory has begun a study to look at some of these issues. The study, ‘Health and 

Accession: Managing the Transition’, will aim to develop generalisable policy lessons using 

surveys, case-studies and literature reviews. Anybody wishing to know more about the study 

or with suggestions for contributions should contact Laura MacLehose at the European 

Observatory on Health Care Systems at the London School of Hygiene and Tropical Medicine 

on: laura.maclehose@lshtm.ac.uk 

3. Quality policy in the health care systems of the EU accession countries. Dr Ursula 

Fronaschutz, Head of Department VII/B/8, Health Economics and Quality Management, 




Austrian Federal Ministry of Social Security and Generations. Dr Ursula Pueringer, Consultant 

on Health Reform and System Comparison to the Austrian Federal Ministry of Social Security 

and Generations 

This presentation intends to give a short overview about the status quo of health care 

quality issues in the now 12 EU candidate countries. All quality efforts in the 12 EU 

candidate countries have to be seen in the light of the recent political and economic 

developments in the region. Except in Cyprus and Malta, where the health care system is 

financed by general taxation, the health care systems have undergone considerable 

organisational changes over the last decade. The previously dominant Russian Semashko 

Model of health service revision (state centralised planning, controlling, financing and 

provision of health care) with high bed-capacities and predominantly specialist physicians 

has proved to be inefficient, expensive and little patient-oriented. Comprehensive health 

care reforms have taken place, competencies have been shifted, new financing systems 

implemented and health care provision has been completely restructured. Following 

international trends, the state is now responsible for legislation, planning and controlling of 

health care provision, registration of drugs and new medical technologies, licensing 

physicians and setting medical standards. Health care insurance has been introduced in all 

countries. The emphasis lies on primary health care with the introduction of general 

practitioners as gatekeepers. The most prominent problems remaining in the candidate 

countries in CEE are an oversupply of physicians, mainly specialists, large hospital capacities, 

too little long-term and nursing care structures and the ongoing struggle with costcontainment 

in health care. 

The development of quality policy and the introduction of quality assurance measures have 

only recently become a topic on the health care agenda and are not surprisingly very much 

oriented towards structural quality issues. 

The main reasons for implementing quality assurance strategies are usually unacceptable 

variations in performance, practice and outcome; ineffective or inefficient health care 

technologies and/or delivery; customer dissatisfaction; unequal access to health care 

services; waiting lists; high costs to society and the commitment to cost containment. 

In all the countries the importance of a national health care quality policy is well recognised, 

various laws and regulations are in place and often defined responsibilities exist at the 

national level such as quality task forces, expert committees or even a national co-ordinator 

for quality in certain medical fields. However, these functions are not always vested with the 

power and resources to sufficiently co-ordinate ongoing quality activities. 

The main quality approaches used are: registration and licensing of physicians and health 

care institutions, certification, accreditation, registration of drugs, medical devices and blood 

products followed by the development of practice standards / guideline and audit / peer 

reviews. Some countries conduct regular patients satisfaction studies. Latvia has already 

formulated a quality policy including a systematic approach along the quality of structure, 

process and outcome with regard to all health care service delivery. Poland and Hungary 

have installed mechanisms to start Health Technology Assessment. 

Professional organisations in all countries surveyed showed great interest in developing 

diagnostic and treatment guidelines to improve day-to-day practice and basing their work on 

scientific (evidence-based) decision-making. Quality assurance is of particular importance in 

the disciplines that have yet to prove themselves in the health care system (family medicine, 

nursing etc). By providing good quality services their role can be legitimated within the 

health care system. Thus, diagnostic and treatment guidelines exist nearly everywhere for 

diseases of public health importance and / or the most cost-intensive treatments. 



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Continuous medical education (CME) has high priority to enhance the qualifications of 

doctors in all medical specialisation. 

The health insurance companies / institutions play a crucial role in improving external quality 

control of the services they purchase. Via contracting they can influence the quality of 

services delivered by their contract-partners (doctors, health care institutions) to a much 

greater extent than they actually do at present. 

At the hospital level several quality activities take place in all the countries investigated. 

These are mainly: medical audit, quality circle work, participating in quality awards and 

carrying out patient satisfaction surveys. Interestingly, different financing models have been 

worked out, for instance, in Hungary where some 0.1 per cent of total budget of a hospital is 

dedicated to the establishment and operation of a quality system. The main hurdles and 

barriers for broad implementation of quality assurance in the respective health care systems 

are seen at the national level: missing national quality policies, strategies and financing as 

well as a lack of co-ordination of the various activities. In addition, relevant institutions to 

ensure quality implementation may be missing altogether at the national level (quality 

centres, committees or national co-ordinators) and there may be a lack of unified quality 

assessment criteria or clinical indicators. At the institutional level, challenges reported 

included: the resistance of doctors, the lack of adequate information systems and the 

additional (mainly administrative) workload. In addition, quality specialists are not available 

everywhere and have to be trained abroad. On the other hand, having undergone a 

specialisation as a quality manager does not necessary guarantee an adequate position 

within the health care system. 

Possibilities of a cross-border co-operation in the field of quality assurance in the public 

health sector are seen positively and in the following areas closer co-operation with the EU 

would be appreciated: 

• Quality in hospitals, in particular, accreditation and evaluation 

• Establishment of evidence-based guidelines 

• Establishment of central medical databases 

• Establishment of a Health Information System 

• Tele-medicine 

• Management of upcoming challenges concerning electronic health care, e.g. chip 

cards 

• Establishment of standard data sets for electronic patient records (generic and / or 

disease specific) 

• Participation in joint EU projects in the field of quality assurance 

• Participation on workshops, seminars, conferences 

• Training and education for quality 

• Collaboration with the EU institutions running similar activities 

• Co-operation and advice with regard to health care reform 

It is especially emphasised that health care quality issues should have a higher priority on 

the political agenda of the EU. EU-directives should force governments to develop national 

quality strategies and provide the legal framework for organisational change, eg. install 

quality boards and quality managers within organisations. 

Support in research, mutual projects, and the exchange of experiences and quality indicators 

for international comparisons could also be of great help to meet the challenges of the 

future. 

4. ‘Health Systems and EU enlargement – An accession country's view’ Dr Tit Albreht, 

Institute of Public Health of the Republic of Slovenia 




The last decade was marked by intense changes in health care systems around the globe, 

the changes being the most remarkable in the transition (accession) countries. These 

changes will be further supplemented by the intense process of accession to the European 

Union. Even if there is much more stress on economic and administrative reforms, health 

care remains an important issue. Economic constraints, coupled with redefinition of national 

priorities and introduction of market forces into health care pose a threat to the further 

development of health care as a universal, publicly financed service. 

Introduction 

Reforms of health systems are a universal process, dealt with in almost all European 

countries and in many countries around the world. These processes have reached various 

stages – from the early phases when the general ideas are only about to be implemented to 

the actual positive or negative experiences with reforms that had been initiated several years 

ago. As much as the various countries differ, there is also significant variation in how they 

had approached health system reforms. That depended on their historical background or 

economic needs or simply the need to change the delivery of health care. 

Countries of the Central and Eastern European area share the experience of living in the 

same countries (most of them) as well as several aspects of the former political systems. 

They have seen the eve of transition at various points of economic and social development, 

some have had a more favourable starting point and some much less so. 

Current situation from the system's point of view 

Bismarckian-type systems have become the most frequent solution for almost all Central and 

Eastern European (CEE) countries. They have resorted to them for two important reasons: 

1. such systems being part of their historical tradition (for most of these countries) 

2. offering more stability in the period of unstable fiscal policies and especially, 

unsecure national budgets 

Since the role of the State has already become significantly reduced, there is a question 

about how to preserve some of the essential functions that the Ministries of Health usually 

have. Among those are especially: working towards better and more equitable health 

(reducing the differences in both health and disease), maintaining the system and the 

adequate infrastructure of the public health system and ensuring a comprehensive package 

of rights and other health care entitlements under public funding. Many of these principles 

have become challenged over the course of the last few years. On the one hand that was a 

direct result of the deregulation processes in many of the CEE countries and on the other 

hand, the new system approaches, e.g. privatisation of health care provision and facilities, 

insurance system, private and voluntary insurances, fiscal pressures at the level of the State. 

For some of the countries, the independence from the former common state also represented 

a particular challenge. 

Challenges for the accession countries 

1. Changing epidemiologic situation 

Accession countries face two processes in their epidemiological situation: on the one hand 

there is an ongoing process of epidemiological transition coherent with the ageing 

population. On the other hand, there are 'regression' processes that contradict the usual 

trends in epidemiological transition. Some communicable diseases are becoming more 

important again and that poses special challenges on the health care system. There will be a 

need for an overall redefinition of priorities in health care that will require a system support, 

too. Increased movement of people across borders will definitely need to be supported by a 

common and well co-ordinated surveillance system. 



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2. Patient mobility and mutual influences on each other's systems 

According to the established policies of the European Union with respect to the area of 

health care, there is no direct interference of the Union in the definition of a national health 

care system. However, since there are differences both in financing and delivery of health 

care in different existing member states, there is a question whether such an approach is 

viable in the future. The famous Kohl and Dekker cases have triggered many questions that 

arise from the conflict between an open and free market approach pursued by some and the 

integrity of own national health care systems with their specifics. There is a danger that there 

might be too much 'outflow' of patients to more developed member countries and a net 

'deficit' of patients in the domestic health care. 

3. Internal health care markets 

Markets have become a much more important issue and a revival of the old business 

principles for all the accession countries following the political and social processes leading 

to transition. In health care that line of thinking has led to a shift from a more public health 

oriented system (even if often poor on resources) to a more service and production oriented 

one. That in itself should not be that bad if it were not followed by a shift towards more 

purely curative services. 

4. Opening of health care markets and international competition 

That dilemma leads to another important and closely related issue and that is the health 

markets. The accession countries might find themselves at the challenge of not being able to 

compete with the health care facilities of the neighbouring member states. Assistance in 

accreditation procedures and their standardisation seem to be rather important in that sense, 

otherwise, the accession countries might find another obstacle to their more active presence 

on the European health care market. 

5. Defining the common minimum package 

It is becoming increasingly difficult to define a common minimum package. 

Comprehensiveness of health care needs to be preserved in spite of the efforts to make it 

competitive and more market oriented. A regulation that would somehow standardise the 

minimum of care provided by a certain country therefore, seems warranted. If such a 

provision is not made, there might be gradually a wider variation in the type, extent and 

quality of services provided across different countries. That would effectively potentially 

worsen the existing inequities and inequalities within Europe. Both quantity and quality of 

publicly financed services would be at stake then. 

Slovenia's own views 

Slovenia sees both challenges and opportunities in view of the accession to the European 

Union. 

Challenges are related to: 

- opening of borders and free movement of workforce and patients 

- broader and more demanding health care market 

Opportunities are in: 

- more professional development and research 

- offering own facilities on the health care market (especially certain medical 

specialities) 

Slovenia has a quickly ageing population (both bottom-up as well as top-down). That will 

certainly increase the demand for certain types of health care (e.g. long-term care, increases 

in chronic diseases prevalence and incidence rates). Communicable diseases are well 




controlled, both through a well-developed surveillance mechanism as well as through 

interventions (vaccinations). Slovenia's obvious lagging behind EU is in the areas of alcoholrelated 

conditions and injuries (both accidental as well as suicides). In any case, Slovenia 

looks forward to a harmonised effort in defining priorities in health care at the European 

level. 

Slovenia has a longstanding tradition of good quality health services. These will, however, 

become scrutinised with standardised tools when the accession gets closer to completion. 

Full harmonisation of postgraduate training of physicians and dentists has been reached with 

programmes co-ordinated by UEMS. As there have been high increases in salaries of these 

two groups of professionals over the past 5 years, the financial incentives for physician 

movement might not be as strong as in some other accession countries. There should be, 

however, a rather important interest in patient movement to the neighbouring countries. That 

is possible even today but with several restrictions and left to the ultimate decision of the 

national health insurance company. 

Hospitals are still all publicly owned but that does not exclude their need to become 

prepared for an organised presentation on the common European market. They will have to 

work actively and intensely to get adequately accredited to be able to take part in that 

competition. 

Public health needs a serious redefinition and reorganisation. That is true for its coming 

closer to the current European trends and for its internal organisation. The first steps have 

been taken – there is a joint, harmonised programme of Public health medical specialty 

training that will be adopted shortly and preparations for a national School of Public Health 

have also started. 

As much as the development of certain European structures seems reasonable and, 

potentially, even necessary, Slovenia would not be comfortable about seeing supranational 

bureaucratic structures which would try to dominate the member states. That was the main 

negative experience of living in the former State. Still, there are certain system solutions 

where Slovenia's experience can be successfully shared with other countries: 



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- an effective and comprehensive information system to support the vaccination 

programmes 

- an extensive reporting system for the national health and health services statistics. 

It would be important, though, to discuss and reassess the issues related to a common 

minimum package of services publicly financed and available since that harmonisation seems 

to be warranted, too, in spite of some earlier reserves about that. 

Conclusions 

1. The accession to the European Union is an exciting and demanding process that 

has both its challenges and advantages as well as uncertainties. 

2. Health care delivery should be standardised in quality of services and in the 

minimum package available to the European citizen. 

3. A European surveillance system should be developed supported by standardised 

indicators. 

4. Potential brain drain needs to be assessed and forecasted where and if possible. 

5. Providers should be enabled to compete at the common health care market. 

6. Public Health's role needs to be reaffirmed by modernising it, standardising its 

guidelines and ensuring effective responsibility of the State.

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5. Public Health and EU Enlargement: The Stewardship Role of the State. Ms Magdalene 

Rosenmöller, IESE, Barcelona and World Bank and Dr Armin Fidler, World Bank 

When Central and East European countries started far-reaching health care reforms at the 

beginning of the nineties, they did not realise what a challenging endeavour they had 

embarked upon and how significantly it would change the different roles in the sector, 

especially the role of the state. The context of the reforms has been very challenging, marked 

by the serious fiscal crisis at the beginning of the nineties: a context of overall economic 

reform with issues more pressing than that of health, and a fierce struggle for democracy 

combined with permanent political instability, to just name a few of the adverse context 

factors. 

Accession to the European Union, or rather the prospect of accession, has been an important 

driver of health care reform in these countries, as accession has created high expectations 

and a strong reform motivation at all levels of the population. The acquis has played an 

important role as a model in the law making process, and compliance with EU regulations 

has helped to push unpopular bills through parliament. At the same time, EU accession has 

had a reform-inhibiting effect: since health has not been a priority on the accession agenda, 

the health sector has not received the attention it deserves. 

The countries have not been left alone in their efforts. Support for the reform and accession 

process has come mainly from the EC Phare programme. Unfortunately, with the shift in 

Phare from a demand-driven to an accession-driven focus, health has lost importance as it is 

not considered to be an explicit accession priority. Member States have very actively 

supported the reform process with many different bilateral programmes, and more recently 

they have increasingly taken part in twinning projects. The World Bank has been providing 

lending and advisory support to health care reforms in most accession countries. Often the 

Bank’s initial analysis represented the important baseline for reform undertakings. Accession 

has come to be the primary objective of the Bank’s support in the respective countries, for 

instance by backing institutional reform of the ministries of health or the development of 

epidemiological surveillance systems. The Bank’s support for health insurance reform has 

proved to be important in attenuating possible adverse impacts on macroeconomic 

performance. 

Despite all these efforts, now, ten years into the reforms, they seem to have stalled halfway, 

and an overall “reform fatigue” is apparent. Even though there have been advances, most 

countries are still far from having a fully functioning system, especially as regards the new 

‘role of the state’. So what is the role of the state? Why is there a particular role for the state 

in the health sector? Health is an important part of the economy, usually representing 

between 5% and 15% of GDP and 10-40% of public expenditures. The state has the mandate 

to assure the good health of the population, as health is a public good with high 

externalities, as in the control of communicable diseases, which has become particularly 

important in view of the alarming increase in tuberculosis, HIV/AIDS and other communicable 

diseases in Central and Eastern Europe. 

With respect to health systems, the state has to assure the provision of and access to high 

quality health care. In reforming their health systems most of the accession countries have 

moved from highly integrated to more open, decentralised systems with a series of marketoriented 

elements, albeit in different forms and to different degrees. The more decentralised 

systems require a clear definition of the roles of the different players, and comprehensive 

regulations and structures to ensure compliance. This concerns the accreditation of facilities, 

the licensing of professionals or the regulation of the pharmaceutical and medical technical 

industry. Here there is still a lot to be done, and often health ministries in these countries 

have had difficulties in assuming the new role. 




It is also the role of the state to guarantee those health system functions which are not 

explicitly demanded, such as health promotion, which is of particular importance in the 

accession countries in view of the high prevalence of life-style risk factors such as smoking, 

alcoholism and unhealthy diets. This role is far from sufficiently developed and often is 

completely ignored. The accession countries have found it difficult to embrace a modern 

concept of public health, which is so different from the former communist idea of hygienic 

control, which in the SANEP system was limited to the collection of data. At the same time, 

formerly effective vaccination systems are being neglected in favour of other, apparently 

more pressing, system reform issues. 

Another important role of the state is to guard against system failures: protecting the poor 

and assuring access for ethnic minorities. And the state has to respond to citizen’s 

perception of priorities as the social safety net, and catastrophes events (a very real concern 

today). Last but not least, the state has to manage the ever-higher expectations of citizens 

by giving better access to information. In the accession countries, the state’s communication 

role has been particularly neglected, partly due to the heritage of the way information was 

handled in communist times. All this suggests that the countries are not really assuming the 

new role at state level, and so are ill prepared to correctly assume their roles as future EU 

Member States. 

What has been done about these issues? In June 1999 the European Commission published 

the Staff Working Paper on Health and Enlargement, and the 2000 EP Bowis report stresses 

the importance of health in the enlargement process. Actions followed. Health Commissioner 

Byrne initiated a round of visits to accession countries, and officials of those countries are 

increasingly participating in Member State consultation meetings such as the high level 

committee. The Swedish presidency followed up actions taken under previous presidencies 

by organising a specific conference on health and enlargement. Likewise, enlargement has 

been on the agenda of various conferences held under the Belgian presidency. 

We can see that health and enlargement seems to be an unfinished business. Countries are 

lagging behind on compliance with specific acquis, such as the implementation of the 

tobacco directive. Other potential problems are the mutual recognition of health care 

professionals or functioning epidemiological surveillance systems, to just name a few. There 

is still a lot to be done, and support is far from sufficient. Will Phare put health back on the 

priority list for funding? And once countries become full members, will the resource-limited 

public health programme be able to address these needs if they still persist? Or will there be 

a transitory prolongation of the Phare programme, and if so, will health be on the agenda for 

funding? – DG Sanco will surely have an important role here to assure that health protection 

is put high on the agenda of enlargement policies. Despite the efforts made to date, there 

seems to be room for improvement in the coordination between different commission 

services. 

Enlargement means a whole new set of challenges for European health, increasing the EU 

health agenda, in addition to all the challenges related to ‘a high level of health protection’, 

as defined in the treaty of Amsterdam. Health has recently gained momentum at EU level. In 

the last year we have witnessed new challenges for European health: the BSE and Dioxin 

crises, the Lipobay affair putting a question mark on the assurance of quality of drugs. And 

all of this has shown an increasing concern for health on the part of EU citizens. On the 

health system side, the Kohl and Dekker cases and others like it point to a potential 

supranational role in assuring good quality and access to health systems for EU citizens. 

Enlargement will accentuate these problems and bring others, such as the rise in tuberculosis 

and other communicable diseases. As regards communicable diseases, the candidate 

countries’ fire fighting power is not sufficiently developed and coordination structures need 

to be put in place. 



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In this sense, enlargement may trigger the long overdue formulation of a new or extended 

role for health at EU level. The newly proposed and already quite progressive EU public 

health strategy looks only half-hearted in the light of the possible problems related to 

enlargement. There will be important roles for a future European Public Health Coordinating 

Centre, a new institution recently mooted by the Commission. Here some US federal 

institutions might serve as examples. The US Centre for Disease Control and Prevention 

(CDC) and other federal institutes use legal and financial levers to achieve compliance with 

federal regulations and support state and local networks with scientific advice and 

coordinating capacity. 

In conclusion, health accounts for an important share of a country’s economy and is a 

substantial public concern. The state must take responsibility for health as a public good and 

related externalities such as infectious disease control. It has a pivotal role in health care 

systems: regulating financing and provider markets and avoiding market failures, fostering 

good health and preventing health threats. In the specific area of EU enlargement a 

substantial agenda remains to be tackled. For health and accession issues and the reform 

agenda, is there an increased EU “federal” mandate? 

6. Workshop Summary: Ms Laura MacLehose, Research Officer, European Observatory on 

Health Care Systems, London School of Hygiene and Tropical Medicine 

The five papers presented a broad range of issues related to the enlargement of the EU and 

provoked a lively discussion. Issues from patient movement to the stewardship role for the 

European Commission were touched upon. Views from the current EU member states and 

from the accession countries were shared. The wide and varying topics broached throughout 

the session reflected the complex process of enlargement, highlighted the far-reaching effects 

of the move and pointed to many health issues for which the evidence is still unclear. 

The new developments in the enlargement process in relation to health were highlighted by 

Bernie Merkel. The Commission has been active in areas including funding, training, 

information exchange and coordination. Martin McKee provided a broad overview of the 

health situation across the EU and candidate countries. Epidemiological evidence for some of 

the main health issues and their underlying causes were presented. In both presentations, 

some of the challenges and opportunities for health through the enlargement process were 

described. The future movement patterns of patients and health professionals are unknown 

but this is a concern in terms of future planning, quality regulation and funding. The issue of 

whether a minimum package for health was necessary for patients to move between 

countries was raised. Pharmaceutical production, supply, quality and pricing are also issues 

that need ongoing review in light of enlargement. Communicable disease control across 

borders was also touched upon. The challenge of actually putting in place the Acquis 

Communautaire (the complete body of EU law), which is estimated to total around 80,000 

pages of text, and implementing and enforcing this new legislation was also considered. The 

role of informal payments for health, common in many accession countries, was also 

discussed. 

The study carried out by the Austrian Federal Ministry of Social Security and Generations in 

collaboration with candidate countries provided an interesting insight into quality policy in 

the health care systems of the accession countries. The study, which built upon a previous 

exercise of current EU countries, looked at the potential and need for cross-national 

cooperation for quality issues. The study found that while quality policy issues have been 

recently introduced in some of the accession countries, there is much interest in this area 

and some laws and regulations in support of improving quality have been put in place. 

However, although the importance of a having national health care quality policy was 




recognised in many countries, those trying to carry out work in support of this are not 

always vested with the power and resources to do the job. 

The view from an accession country of what the enlargement process means for health was 

presented by Tit Albreht from Slovenia. He gave an overview of health reform measures 

being undertaken in accession countries and presented challenges and opportunities in 

relation to health and accession. Five challenges were presented: the changing 

epidemiological situation, patient mobility, internal health care markets, opening of health 

care markets to international competition and defining a common minimum health service 

package. Opportunities for accession countries lie in professional development and research 

and the potential for offering their health care facilities on the international health care 

market. 

In the presentation on stewardship, Magdalene Rosenmuller reviewed the enlargement 

process in relation to health reform in the accession countries and looked at the profile of 

health in relation to other enlargement priorities. Whether the time has now come for an 

increased role for the European Commission in health was considered. Examples from the US 

were presented as possible models for an alternative model for EU regulation of some public 

health issues. 

Discussion about some of these health issues also raised issues relating to the Commission’s 

role in health itself both for the current EU member states and candidate countries. The 

Commission’s mandate to act directly on health issues is fairly limited. However, the 

question of whether countries should work more closely together through linking national 

centres of expertise or EU level centres of excellence should provide advice across the EU 

was considered. Concerns about too much supra-national bureaucracy were voiced. To what 

extent enlargement will address (or even detract from) solving the health gap between the 

current EU member states and the candidate countries is not yet clear. 

The presentations and discussions highlighted a number of key issues. Firstly, much activity 

and progress has been made by the candidate countries in both preparing for accession and 

in health reform efforts and this should be recognised by EU member states. Secondly, the 

broad public health approach is not yet fully developed across all accession countries and 

further support is needed both from the EU member states and from within the candidate 

countries themselves to achieve this. However, and thirdly, health is not receiving a high 

profile in the accession negotiations process. At the same time, there are a number of health 

issues including quality regulation, patient and professional movement, communicable 

disease control and supporting the development of a broad public health approach that need 

high level political attention and financial support. There are also opportunities for health 

gains through influencing non-health sectors such as the tobacco and agriculture industries 

that have not yet been grasped. Fourthly, further discussion is needed to see whether a 

stronger public health function at the European Commission level would bring benefits to 

member states. However, arguments for strengthening this function have to be balanced 

against concerns about excessive central bureaucracy. 



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Final Programme 2001 

Programme Overview 

Wednesday, September 26th , 2001 

10:30 – 11:45 Official Welcome Addresses 

12:00 – 13:00 Plenary Session I 

14:30 – 18:00 Plenary Session II 

19:30 – 21:15 Special Interest Sessions: Dinner Sessions 

21:30 – 22:30 Official Welcome Reception 


Thursday, September 27th , 2001 

8:30 – 12:00 

14:30 – 18:00 

Parallel Forum Sessions 

Parallel Forum I Health in other Policies and Sectors 

Parallel Forum II Globalisation, World Trade and Health 

Parallel Forum III Health and the Single European Market 

Parallel Forum IV Building a healthy Common Agricultural Policy (CAP) 

Parallel Forum V Health in the Information Age – The informed patient / citizen 

Parallel Forum VI Health in the Information Age – Health Technology and Policy 

Implementation 

12:30 – 14:00 Special Interest Sessions: Lunch Sessions 

14:30 – 18:00 Parallel Forum Sessions continued 

18:15 – 19:00 Reception at the Casino Bad Gastein hosted by the mayor of Bad Gastein 

20:00 President’s Evening 

Friday, September 28th , 2001 

10:00 – 12:30 Plenary Session III 

12:30 – 12:45 Closing Ceremony 

12:45 – 13:45 Reception 

14:00 – 17:00 Special Interest Sessions: Workshops 

18:30 Informal Conclusion Evening 

Saturday, September 29th , 2001 

9:30 – 12:30 Elaboration of Gastein Health Declaration 

9:00 – 18:00 Social Programme 

18:30 Modern Folk Evening Bellevue Alm upon invitation of the President 




Plenary Sessions 

Wednesday, September 26th , 2001 

10:30 – 11:45 Official Welcome Addresses 

Chair: Günther Leiner, Paul Lincoln, Klaus Zapotoczky 

- Herbert Haupt, Minister for Health, Austria 

- Gyula Pulay, Administrative Secretary of State, Hungary 

- James Walsh, EU Committee of the Regions 

- Günther Leiner, President, European Health Forum Gastein 

12:00 – 13:00 Plenary Session I 

The work of WHO in championing health in development 

- David B. Evans, Director, WHO 


- Jane Hutt, Minister for Health, Wales 

14:30 – 18:00 Plenary Session II 

Chair: Paul Lincoln 

• Part A: The art and science of integrating health across policies and programmes 

The potential and limitations of health impact assessment 

- Roscam Abbing, Netherlands School of Public Health 

Progress and prospects for promoting and protecting health across EU policies and actions 

Bernard Merkel, European Commission, DG Health and Consumer Protection 

• Part B: Investment for Health 

Establishing health as a key component of economic policy 

- Sarah Burns, New Economics Foundation 

The WHO Investment for Health project and the Verona Initiative 

- Erio Ziglio, WHO 

Debate: Why do we tolerate high disease burdens, health inequalities and the social and 

economic costs of health crisis and how do we ensure sustainable development? 

Facilitator: Maurice Mittelmark, International Union of Health Promotion and Education 

Discussants: 

Genon Jensen, European Public Health Alliance 

Ilona Kickbusch, Yale University 

Mihaly Kokeny, Member of Parliament, Hungary 

Rolf Krebs, International Federation of Pharmaceutical Manufacturers Associations 

Wilhelm Molterer, Minister for Agriculture and Environment, Austria 

Erio Ziglio, WHO 

Summary of Session 

Introduction to the Parallel Forum Sessions 



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278 

Friday, September 28th , 2001 

09:30 – 12:30 Plenary Session III 


Chair: Günther Leiner, Paul Lincoln, Günther Bernatzky 

Feedback from Rapporteurs from Parallel Forum Sessions and discussion of results 

- Forum I: Cecily Kelleher, National University of Ireland 

- Forum II: Julius Weinberg, University College London 

- Forum III: Philip Berman, European Health Management Association 

- Forum IV: Mike Rayner, British Heart Foundation 

- Forum V: Stipe Oreskovic, University of Zagreb 

- Forum VI: Rolf Engelbrecht, European Federation of Medical Informatics 

Key notes: 

- Marc Danzon, WHO Regional Director for Europe 

- Reinhart Waneck, State Secretary for Health, Austria 

- David Byrne, Member of the European Commission, Health and Consumer 

Protection 

12:30 – 13:45 Closing Ceremony followed by Reception 

Programme co-ordinator: Paul Lincoln, National Heart Forum, UK 






279 

Parallel Forum Sessions - Thursday, September 27th , 8:30 – 12:00 and 

14:30 – 18:00 

Parallel Forum I: Health in other Policies and Sectors 

The purpose of Forum I is to reflect on the challenges which are posed in developing and 

implementing integrated public policy in support of health, and to provide examples of how 

these challenges are being addressed by some of those who are committed to improving 

health status through multisectoral effort. In developing some of the themes of the opening 

plenary sessions, the Forum will: 

Reflect on the conditions which must be created and the challenges to be overcome in 

moving from the policy objective to implementation, including the difficulty of creating 

widespread public awareness of the significance and potential benefits of the policy; 

Provide accounts of how Sweden and Wales are addressing the multisectoral policy approach 

and the lessons which can be drawn from their experience to date; and 

Describe the outcome in the Italian region and in Slovenia of seeking to apply a 

benchmarking system, developed as part of the Verona initiative, to measure progress and 

impact in developing and applying a multisectoral approach to improvement of health status 

Chairman: Dr. Luigi Bertinato, Director Office for International Public Health Projects, 

Veneto Region. 

Rapporteur: Professor Cecily Kelleher, National University of Ireland, (Galway). 


Speakers: John Bowis, European Parliament. 

Shirin Wheeler, BBC (Europe) Brussels 

Carlos Ribeiro, EU Economic and Social Committee 


Speaker: Bosse Pettersson, National Institute of Public Health Sweden 


Speaker: Mike Ponton, Welsh Assembly. 


Speakers: Dr. Mojca Grunter Cinc, State Under Secretary Slovenia. 

Dr. Luigi Bertinato, Director Office for International Public Health Projects, Veneto Region. 

Discussion 

The presentations will be structured to encourage and allow time for discussion between 

speakers and participants. At the closing of the Forum the Chairman, Speakers and 

Rapporteur will form a panel for a general discussion and identification of preliminary 

conclusions. 

Programme organiser: Jerry O’Dwyer, Haughton Institute, Ireland

280 



International trade policies and their potential to impact upon the health of people in Europe; 

Globalisation, a force for good health, or ill? 

Chair and Mediator - Laurie McMahon, Office of Public Management, London 

Rapporteur: Julius Weinberg, City University London 

This will take the form of an informal enquiry into the impact of international trade policies 

on the health of the people of Europe. Particular attention will be given to: 

Trade in health services – GATS 

Access to medicines vs. intellectual property rights - TRIPS 

Citizens across Europe are demonstrating a growing unease at the way in which policy 

decisions which are taken at a transnational level can impact upon their health. In addition, 

while there are undoubted benefits to be gained from the developing global market place, 

there is also a debate as to whether the poorest countries will have the opportunity to 

participate and reap any rewards. However, there are two sides to every story and this 

enquiry is an attempt to reveal the facts without bias and to allow participants to come to 

their own informed decisions as to whether globalisation is a force for good health or ill. 

The enquiry 

Expert witnesses will be called to make a statement of the facts from their particular view 

point to a representative panel of stakeholders. Delegates will have an opportunity to feed 

questions into the enquiry process and are called upon to actively participate in the open 

floor debate. 

The stakeholders – a panel of judges 

Nina Hvid, European Federation of Pharmaceutical Industries and Associations – EFPIA 

Mehtab Currey, Department for International Development Health, UK 

Mihaly Kokeny, Member of Parliament, Hungary 

Ron Labonte, European Public Health Alliance - EPHA 

Maurice Mittelmark, International Union of Health Promotion and Education - IUHPE 

The expert witnesses 

Paul Strickland, European Commission – European trade policies and their impact upon 

health 

Robert Beaglehole, World Health Organization – The role of international agencies in health 

protection and in developing health positive trade policies 

Rolf Adlung, World Trade Organization – The role of health issues in multilateral trade 

agreements 

Petra Laux, GlaxoSmithKline, – The role of commercial enterprises in health 

Programme organiser: Maggie Davies, NHS Health Development Agency, England 





(hosted by the European Commission, DG Health and Consumer Protection) 

The purpose of Forum III will be to explore the impact that the Single European Market 

(SEM) is likely to have on the ways that health services function. This Forum will explore 

three principal aspects of the SEM as it may affect health services: 

• The development of the labour market for doctors and nurses 

• Public procurement of medical goods and services 

• The free movement of patients 

The Forum will also consider the recommendations of a major EU-funded study on the impact 

of SEM regulations on health services which was published recently. 

Chairs: Michael Hübel (morning), European Commission, DG Health and Consumer 

Protection; Nick Boyd (afternoon), UK Department of Health 

Rapporteur: Philip C. Berman, European Health Management Association 

Introduction: The European Union and Healthcare 

Speaker: Philip Berman, European Health Management Association 

The Labour Market for Doctors and Nurses 

Paper: Prof. Bie Nio Ong, Keele University, United Kingdom 

Response: Annette Kennedy, Standing Committee of Nurses of the EU (PCN) and discussion 

Public procurement of goods and services 

Paper: Dr. Fernando Silio, Andalusian School of Public Health and discussion 

Purchasing hospital services – the Swedish experience 

Paper: Soren Berg Director of Information and Communication, both Stockholm County 

Council and discussion 


Speaker: Dr. Matthias Wismar, Hannover Medical School and discussion 

Response: Alain Coheur, Projects Director, Association Internationale de la Mutualité, 

and General Coordinator of the Euroregional project for Meuse-Rhine and discussion 

The SEM and healthcare - policy conclusions from the EHMA project 

Speaker: Dr. Reinhard Busse, European Observatory on Health Care Systems 

Roundtable discussion 

Participants: Hans Stein, EU High Level Health Committee and Federal Ministry of 

Health, Germany 

Catherine Stihler, MEP, President of the European Parliament Intergroup on Health 

Alain Coheur, Projects Director, Association Internationale de la Mutualité, and General 

Coordinator of the Euroregional project for Meuse-Rhine 

Josie Irwin, Royal College of Nursing 

Bram van der Ende, Dutch Council of the Chronicle Ill and Disabled 

Comments 

Rapporteur: Philip Berman, European Health Management Association 



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Concluding comments 

Speaker: Michael Hübel, European Commission, DG Health and Consumer Protection 

Programme organiser: 

Philip Berman and Paul Belcher, European Health Management Association; Michael Hübel, 

European Commission DG Health and Consumer Protection 


Amidst the ongoing food crisises across Europe, decline in consumer confidence and 

increasing globalisation, European agricultural policy is under intense scrutiny by society and 

policy makers alike. A substantial reform of the EU's Common Agricultural Policy (CAP) in the 

near future is inevitable before the Union can expand. For the first time ever, the calls to 

ensure that future agricultural policy supports public health objectives have a reasonable 

chance of being taken on board, particularly as Article 152 of the Amsterdam Treaty requires 

the Community to ensure a high level of health protection in all policies and activities. 

This purpose of Forum IV will be: 

• to highlight how food safety concerns and crises can contribute to change within a 

multi-sectoral approach; 

• aim to increase participants’ knowledge of and participation in CAP reform by 

showcasing the work already being done by the health community and other major 

stakeholders in integrating health, environmental and social concerns in agricultural 

policy; 

• provide recommendations on how CAP can be reformed to provide health benefits 

to Europe's people and create sustainable food and agricultural production 

systems. 

Chair: Dr Tim Lang, Food Institute, University of Thames 

Rapporteur, Dr Mike Rayner, British Heart Foundation 

Common Agricultural Policy reforms and opportunities for transformation 

Shifting CAP's objectives to the provision of healthy, sustainable food production and 

safeguarding the health and vitality of rural communities and landscapes 

Speaker: Dr Aileen Robertson, Acting Director on Nutrition Policy, WHO European Region 

Case studies at local, national and European level which illustrate ways in which social, 

environmental and health concerns can be used for change 

Local level: Using urban agriculture and local sustainable food production to safeguard food 

security, reduce health inequalities and preserve cohesion in rural communities 

Speaker: Jeannette Longfield, Sustain, and coordinator of the European Network of Alliances 

for Sustainable Agriculture (REPAS) 

National level: Austrian farmers call for a radical change in CAP to provide healthy food (BSE, 

small producers, elimination of export subsidies) 

Speaker: Elisabeth Baumhoefer 




EU level: Interpreting the multifunctional role of agriculture and rural development across 

Europe 

Speaker: Elisabeth Guttenstein, WWF, European agricultural advisor 

EU level: The EU farmers’ views on the development of the CAP 

Speaker: Anton Reinl, Austrian Chamber of Agriculture 

European level: European supermarkets set standards for their suppliers in response to 

growing consumer demand for environmentally sustainable and pesticide free products 

Speaker: Nigel Garbutt, EUREPGAP 

Re-assessing CAP: Recommendations for reform 

Roundtable discussion on prospects for CAP reform with panel comprised of speakers and 

consumer representatives. 

Programme organiser: Genon Jensen, European Public Health Alliance 

Forum V: The informed Patient / Citizen: a new partner in the political health arena 

Chair: Stipe Oreskovic, University of Zagreb 

1. What are the information needs of citizens? Results from research & academia 

Speaker: Angela Coulter, Picker Institute Europe 

The Right to Health and Patients’Rights: Population-based assessment 

Speaker: Anne Brunner, University Eichstätt 

Manfred Wildner, Bavarian Health Research Centre 


Speaker: Albert Jovell, Josep Laporte Foundation 

2. How to involve citizens in the decision making process? Experience from NGO- and 

business & industry- partnerships in different countries 


Speaker: Theresa Petrangolini, Tribunale per i Diritti del Malato 


Speaker: Rodney Elgie, GAMIAN-Europe 


Speaker: David Lansky, Foundation for Accountability 

3. How to involve citizens in Health Policy Development and Implementation? Current 

activities of the European Community 

Speaker: Walter Baer, European Commission, DG Health and Consumer Protection 

Closing Remarks and Summary by Chair 

Programme organiser: Monika Kaiser, Gesellschaft für Versicherungswissenschaft und – 

gestaltung 



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Forum VI: Health in the Information Age -Health Technology and Policy Development 

(organised with financial support from the European Commission, DG Information Society) 

Chair: Jürgen Dolle, Aktionsforum Telematik im Gesundheitswesen 

Rapporteur: Rolf Engelbrecht, European Federation of Medical Informatics 


Speaker: Ricky Richardson, UK Telemedicine Association and International eHealth 

Association 

Providing eHealth Services in Europe 

Case study 1: 

Speaker: Carl Brandt, Netdoktor 

Case study 2: Online information system for rare diseases in Europe 

Speaker: Michael Schubert, Engelhorn Foundation for Rare Diseases 

Case study 3: NHS Direct 

Speaker: Bob Gann, Director NHS Direct 


Speaker: Petra Wilson, European Commission, DG Information Society 

Patients and Health Information on the Internet 

Quality of health information on the Internet 

Moderated Panel Discussion 

Moderator: Bob Gann, NHS Direct 

Members of the panel: 

Albert van der Zeijden, International Alliance of Patients Organisations - IAPO 

Charlotte de Roo, European Consumers Organisation – BEUC 

Michèle Thonnet, Ministry of Health, France 

Petra Wilson, European Commission, DG INFSO 

Conclusions: Implementing eHealth solutions 


Speaker: Michèle Thonnet, Ministry of Health, France 


Speaker: Otmar Kloiber, professional organisation of German doctors (BÄK) 

Closing Remarks and Summary by Chair 





Wednesday, September 26th 2001 19:30 – 21:15 

Social Health Insurance Countries in Western Europe, organised by: European Observatory on 

Health Care Systems; Speaker: Reinhard Busse 

Developments in EU public health policy - informal dinner session, hosted by: European 

Commission, DG Health and Consumer Protection, Directorate G; Speaker: TBA 

Health Impact Assessment: An opportunity for considering policy options in Europe; Speaker: 

Anna Ritsatakis 

National Health Promotion: The benefits of an international network; Speaker: Bosse 

Pettersson 

Tackling health inequalities in England, hosted by Department of Health, England, Speaker: 

TBA 

Thursday, September 27th 2001 12:30 – 14:00 

Patient access to innovative medicines in Europe, hosted by: GlaxoSmithKline; 

Speakers: Prof. Angela Coulter Chief Executive, Picker Institute 

Mr. Rodney Elgie President, GAMIAN Europe (Global Alliance of Mental Illness Advocacy) 

Rare Diseases in Europe; hosted by: Engelhorn Foundation for Rare Diseases – EFFORD; 

Speaker: Dr. Michael Schubert 

Public health research and the Proposal for a new Framework Programme on Research, 

organised by European Commission DG Research; Speaker: Mr. Kevin McCarthy, European 

Commission 

Developing Health Targets in Germany - the Federal Initiative; Speaker: Dr. Matthias Wismar, 

Medical School Hannover 

Title: TBA,, organised by: WHO Regional Office; Speaker, Aileen Robertson, Acting Regional 

Adviser for Nutrition, WHO - Europe 

Friday, September 28th 2001 14:00 – 17:00 

Workshop I: „Health Advocacy: Integrating Health into the EU political process“ 

Organised by: BSMG Worldwide 

Introduction: The EU’s new approach to public health action: towards better consultation 

mechanisms for non-governmental health stakeholders? 

Chair and introduction: Dr. Hans Stein, Federal Ministry of Health, Germany 

Help or hindrance? Involving outside groups in EU policy development 

Speakers: Michael Hübel, European Commission, Directorate General for Health and 


Paul Belcher, European Health Management Association 

Influencing Europe’s health agenda from the perspective of a national NGO: the tobacco case 

Speaker: Dr. Martina Poetschke-Langer, Head of Cancer Prevention Unit, Deutsches 

Krebsforschungszentrum, Heidelberg 

Case study: Mental Health and the EU 

Speaker: Rodney Elgie - Gamian 



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Advocating for better health action: Is the European Parliament becoming a driving force? 

Speaker: John Bowis, Member of the European Parliament 

The role of the Council: health advocacy at the interface between Member States and the EU 

Speaker: Nick Boyd, Department of Health, United Kingdom 

Open discussion: Obstacles and opportunities to influencing the EU agenda 

Facilitator: Andrew Hayes, European Public Health Alliance 

Workshop II: „EU Enlargement: Implications for Health Systems“ 

organised in co-operation with: European Observatory on Health Care Systems 

Chair: Armin Fidler, IBRD / World Bank 

Rapporteur: Laura MacLehose, European Observatory in Health Care Systems 

Progress in the EU enlargement process 

Speaker: Bernard Merkel, European Commission 

Quality policy in the health care systems of the EU accession countries 

Speakers: Ursula Fronaschuetz, Federal Ministry for social Security and Generations 

Ursula Püringer, health care consultant 

Health and Accession to the European Union – Managing the Transition 

Speakers: Martin McKee, London School of Hygiene and Tropical Medicine 

Health Systems and EU Enlargement: An Accession Country’s View 

Speaker: Tit Albreht, Institute of Public Health, Slovenia 

Public Health and EU Enlargement: The stewardship role of the state 

Speaker: Magdalene Rosenmöller, IESE – Business School and IBRD / World Bank 

Open Panel Discussion: Implications of enlargement for health systems 



List of Authors, Who is who 

List of Authors, Who is Who 

Biographic Information 

Ernst Roscam Abbing (1945), Dutch, medicine and laws, Senior Professor of social medicine 

at the University of Nijmegen in the Netherlands and Chief Inspector of public health at the 

Ministry of Health , Chair of the HIA-project of the Ministry of Health., former Deputy Director- 

General at the Ministry of Health and Director-General of the Rotterdam public health service. 

Tit Albreht, Head of the centre for health care organisations, economics & information, 

Institute of Public Health of the Republic of Slovenia 

Walter Baer is the Assistant of the Director for Public Health of the European Commission in 

Luxembourg and in particular responsible for the staff management and administrative 

dossiers at directorate level as well as information activities in the field of public health 

including the co-ordination of dossiers on enlargement, international co-operation and policy 

development. Mr. Baer is working in the public health area within the Commission services 

since 1994, he joined at that time the unit for policy development, analysis and health in 

other policies, where he was responsible for the secretariat of the High Level Committee on 

Health, enlargement issues as well as information activities in the field of public health. After 

finishing his studies in public administration and legal affairs in Germany, he worked for 2 

years at the German Ministry of Economics before he joined the European Commission 

services in 1984. 

Elisabeth Baumhoefer, (1957) Austria, agricultural studies at the University of Agricultural 

Studies, Vienna; since 1990 general secretary of the Austrian Mountain Farmers Association 

(OEBV); representing the OEBV in the European Farmers Coordination CPE. 

Dr Robert Beaglehole (1945), New Zealander, Public Health Physician, trained in medicine in 

New Zealand and then in epidemiology and public health at the London School of Hygiene 

and Tropical Medicine and the University of North Carolina at Chapel Hill. He is on leave 

from his position as Professor of Community Health at the University of Auckland, New 

Zealand. He is currently working as a public health adviser in the Department of Health and 

Development at WHO, Geneva on several emerging public health issues including the public 

health implications of the WTO Multilateral Trade Agreements. He has published several 

books on epidemiology and public health. 

Soren Berg, Director of Information and Communication in Stockholm County Council, 

Medical Services Committee. Board member; Information for Medical Purpose (Infomedica). 

Former positions in The Swedish Federation of County Councils; project manager on 

structural changes in health care and project director on projects concerning long term 

challenges for health care. Earlier: senior management consultant and partner, Sinova 

Management Consultants. 

Philip C. Berman (1947), British, Director European Health Management Association. Recently 

completed study for the European Commission on the impact of EU directives on health 

services in the European Union, focusing in particular on Germany, Spain, the UK and 

Sweden. A major new 3 year project began in March on managing services for older people“. 

Has been World Bank and WHO consultant, advising on healthcare management strategies in 

Poland, Hungary, Romania and Turkey. Member of the Editorial Board of International Journal 

of Health Planning and Management; Fellow Royal Society of Medicine. 



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Luigi Bertinato, M.D., (1955), Italian, Medical Doctor, Director of the Office for International 

Public Health Projects at the Department of Health of the Veneto Region (Venice, Italy), PhD 

in Internal Medicine, member of Italian Society for Tropical Diseases and member of IUHPE, 

focal point for the Veneto Region for the WHO project on health promotion and investment 

for health called “The Verona Initiative”, lecturer in public health at the University of Verona 

(Italy). 

John Bowis (1945), British Conservative (EPP/ED) Member of the European Parliament for 

London; Spokesman Environment, Health & Consumer Committee, Rapporteur on Food 

Safety White Paper and on the Health Impact of Enlargement, Member of the Development 

Committee. Member of the British Parliament (1987 – 1997), Health Minister (1993 – 1996), 

Transport Minister (1996 – 1997), Policy Adviser to the Institute of Psychiatry and the WHO 

Collaborating Centre. WHO Global Campaigns on Mental Health and Epilepsy. 

Nick Boyd (1952), British, Government Official; Head of International Affairs at the 

Department of Health in London (since 1997). Leads a team of 25 people with responsibility 

for the UK for international health policy both in Europe and globally. From 1991-3 worked 

on EU public health policy within the Federal Ministry of Health in Bonn. 

Prof. Dr. Anne Brunner, MPH (1961), German, Medicine, Public Health, Continuing Education; 

Professorship for Social Medicine and Public Health (Catholic University of Eichstaett) in 

Eichstaett; Dean of Studies; Consultant of the Academy of Medicine and Health in the Media, 

Munich; Member of the German Society for Social and Preventive Medicine. 

Dr. Gabi Burgstaller, Deputy Governor of Salzburg, member of the Government responsible 

for health affairs. 

Sarah Burns (1972), British, New Economics Foundation, London. Leads work on alternative 

approaches to health care provision - including mutual health care models. Set up Rushey 

Green Time Bank - time bank based in health centre. Speaker at People's Health Assembly 

(2000) Savar, Bangladesh. Co-ordinator of London Time Bank. 

Dr. Reinhard Busse MPH (1963), German, Medicine and Public Health; head of the Madrid 

hub of the European Observatory on Health Care Systems (www.observatory.dk); "Profesor 

Visitante" at Escuela Nacional de Sanidad in Madrid and "Privatdozent" (adjunct associate 

professor) for epidemiology, social medicine and health system research at Medizinische 

Hochschule Hannover (www.epi.mh-hannover.de); working in comparative European health 

system research and health technology assessment (HTA). 

David Byrne (1947), Ireland, Law, Barrister, Member of the European Commission, Health & 

Consumer Protection, Member of Cabinet Subcommittees on Social Inclusion, on European 

Affairs, and on Child Abuse, Member of the Council of State, 1997-1999 Attorney General, 

1990-1997 Member, ICC International Court of Arbitration, Paris, 1995-1996 Member 

Constitution Review Group, 1988-1997 Member, National Committee, International Chamber of 

Commerce, 1974-1992 Member Executive Committee, Irish Maritime Law Association. 

Dr. Mojca Gruntar Cinc (1960), Slovenian, MD, State Under-secretary, Ministry of Health, 

Ljubljana, Slovenija; responsible for Public Health, Health Promotion and Prevention Policies 

and Programmes. 

Alain Coheur (1964), Belgian, Degree on Public Health (specialization on hospital 

management) and economics. Projects director at the International Association of Mutual 

Health Funds (AIM), leader of the Task Force International Cooperation of AIM. General 

Coordinator of the Euroregional project Meuse-Rhin for health care during 1997 - 2001. Expert 

specialised for ILO on health. 




Prof. Angela Coulter (1948); British; research and policy analysis; Chief Executive, Picker 

Institute Europe, based in Oxford, England responsible also for branch offices in Hamburg, 

Zug and Gothenburg; Visiting Professor in Health Services Research at University of Oxford. 

Dr Mehtab Currey; British; Public Health and Population; Deputy Chief Adviser, Health and 

Population, DFID. Formal training in India and the US in Public Health and Population; over 

25 years experience in developed and developing countries, working in the public sector, in 

Academic and Research Institutions as well as in multilateral and bilateral institutions; 

particular interest in management and in the health of the poor. 

Dr. Marc Danzon, (1947), France, medical doctor, specialisation in public health, psychiatry, 

health administration and economics, WHO Regional Director for Europe, 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. 

Jürgen Dolle, M.Phil., Senior Project Manager. After his graduation in political Philosophy in 

Aberystwyth, Wales, in 1991, Mr Dolle worked as a research and personal assistant for 

members of the German parliament. Beside this he was lecturer and training teacher for the 

Friedrich-Ebert-Foundation. He joined the GVG in January 2000. Since then he is coordinating 

the Health Telematics Action Forum for Germany (Aktionsforum Telematik im 

Gesundheitswesen, ATG). Mr. Dolle is fluent in English. 

Rodney Elgie (1944), British, formerly a commercial lawyer; President of Gamian-Europe 

(Global Alliance of Mental Illness Advocacy Networks) and responsible for European-wide 

political activities and training programmes of the organisation; Life Vice- President of the 

Imperial Cancer Research Fund, Board member of the European Brain Council, the European 

Federation of Neurological Associations and The Men's Health Forum. 

Dr. Rolf Engelbrecht (1944), German, Senior researcher in medical informatics, Head of 

department “Telemedicine and electronic health care records” at GSF National Research 

Centre for Environment and Health in Munich-Neuherberg, President of EFMI (European 

Federation for Medical Informatics), co-ordinator and partner in several European and German 

research projects in telemedicine and knowledge management, e.g. TOSCA, DIABCARD, 

DIADOQ. Member of the board of GMDS (Deutsche Gesellschaft für Medizinische Informatik, 

Biometrie und Epidemiologie), AIME (European Association for Artificial Intelligence in 

Medicine), Advisor to WHO, Honorary member of the Romanian Academy of Medical Sciences. 

Dr. David B. Evans, Director Evidence for Health Policy, WHO, Geneva. 

Dr. Armin Fidler, Economics, Health Sector Manager, International Bank for Reconstruction 

and Development, World Bank. 

Dr. Mag. Ursula Fronaschütz (1966); Austrian; Studies of Economics and Business 

Administration; Federal Ministry of social Security and Generations: 1993-1996: Health 

Attaché at the Austrian Permanent Representation to the E.U. (Brussels); since 1998: Head of 

Department VII/B/8-Health Economics and Quality Management (Vienna). 

Bob Gann is Director of NHS Direct Online, the NHS website for patients and the public. He 

was until March 2001 Chief Executive of The Help for Health Trust, a registered charity 

involved in the provision of a range of consumer health information services. Bob has served 

on a number of national committees and advisory groups and was a signatory to the NHS 

Plan. He has published and lectured extensively on health information topics and has visiting 

academic appointments at the Universities of Southampton and Brighton in the UK. 



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Nigel Garbutt (1960) United Kingdom. Graduate in Agricultural Botany.12 years in Food 

Technology Management in UK retailer Safeway. Now independent Chairman of EUREPGAP a 

partnership of Food Retailers and suppliers implementing independently verifiable Good 

Agricultural Practices on a global basis. 

Costa Golfidis, Committee of Agricultural Organisation in the European Union. 

Elisabeth Guttenstein, European agricultural advisor, World Wildlife Fund (WWF). 

Mag Herbert Haupt (1947) Austria, Federal Minister for Health, veterinary medicine, third 

President of the Austrian Parliament (1994 – 1996), member of the Austrian Parliament (1986 

– 2000), member of the party executive of the province of Carinthia, executive director of the 

Austrian Freedom Party in Carinthia (1995 – 1997). member of the national party executive of 

the Austrian Freedom Party, member of the executive committee of the Austrian Freedom 

Party. 

Andrew Hayes, European, EU Liaison Officer for the International Union against Cancer and 

the Association of European Cancer Leagues (advocacy for tobacco control), member of the 

WHO Committee for a Tobacco Free Europe, President of the European Public Health Alliance. 

Michael Hübel, M.A. (1962), German, living and working in Luxembourg; Political Science; 

European Commission, Health and Consumer Protection Directorate General, Public Health 

Directorate, Luxembourg. He joined the European Commission in 1995, and started in the DG 

on Employment and Social Affairs. He is now working on Public health policy development, 

and on its links to other Community policies related to health. Previously, he was European 

representative of the German Red Cross and worked for different organisations in the social 

and youth field. 

Josie Irwin (1961), British, Trade Union Officer, Senior Employment Relations Adviser for the 

Royal College of Nursing. National Staff Side Secretary of the Nursing and Midwifery Staffs 

Negotiating Council. Educated at Oxford University (BA Hons PPE) and currently Warwick 

(MPA). 

Génon K. Jensen (1965), American, Journalist/Political Affairs Specialist; General Secretary, 

European Public Health Alliance; Master’s Degree in European Administrative Studies with 

distinction, College of Europe; BA degree with honours in international affairs, George 

Washington University; Member of the WHO European and Health Environment Committee 

(www.eehc.dk), Pesticide Action Network Europe Executive Board; Frequent contributor to 

European and international journals on health issues. 

Dr Albert J. Jovell holds an MD and a PhD in Sociology from the Universitiy of Barcelona 

(Spain); a Master of Public Health (MPH) in Epidemiology, a Master of Science (MS) in Health 

Policy and Management, and a Doctor of Public Health (DPH) degrees from Harvard 

University (USA), and a MA degree in Political and Social Sciences from the University 

Autonoma of Barcelona (Spain). 

He is the Chief Executive Officer of the Josep Laporte’s Library Foundation and Associate 

Professor of the Department of Preventive Medicine and Public Health of the School of 

Medicine of the University Autonoma of Barcelona. 

Dr Cecily Kelleher is the holder of the foundation chair of health promotion at the National 

University of Ireland, Galway and also a Director of both the national Centre for Health 

Promotion Studies and the National Nutrition Surveillance Centre in the Republic of Ireland. 

Projects include the first ever National Health and Lifestyle surveys for the country's 

Department of Health and Children, a variety of health promotion settings projects in school, 

workplace, community and primary care and a national Health Research Board research unit 




for Health Status and Health Gain. She has a longstanding research interest in cardiovascular 

disease particularly. 

She is a member of various national and international committees including the Cross Border 

Food Safety Promotions Board, National Task Force on Cardiovascular Disease, National 

Advisory Group on Fluoridation, European Science Foundation Programme on Social 

Variations, and European Health Risk Monitoring Project. 

Annette Kennedy, Irish, Nurse, Director of Professional Development, Irish Nurses 

Organisation (INO). MSc, BNS. Bachelor in Nursing Education, Masters in Science in Public 

Sector Analysis. Responsible for setting up and development of an education and library and 

information centre for the INO for registered nurse/midwives. Member of PCN (Standing 

Committee for Nurses in Europe). Steering Group Member of WENR (Workgroup of European 

Nurse Researchers). Member of ICN/ANCC Credentialing Forum. Member of several Irish 

Committees developing strategies on such issues as manpower development, education, 

recruitment and retention practices, skill mix, research and partnership, transition of nurse 

education to third level colleges. 

Dr. Otmar Kloiber, professional organisation of German doctors (BÄK) 

Prof. Dr. Ilona Kickbusch, Professor and Head Division of Global Health, School of Public 

Health, Yale University. 

Dr. Mihály Kökény, (1950), M.D.,M.P. Medicine (Cardiology), Health care management; 

Member of the Hungarian Parliament, Chairman of the Health and Social Affairs Committee; 

Visiting Professor in the Department of Health Studies at the University of York (UK); former 

Minister of the Welfare; adviser to the World Health Organization; regular participant in 

international health policy events; has nearly 100 publications on health promotion, health 

policy. 

Prof. Rolf Krebs M.D., Ph.D. (1940), German, Professor of Pharmacology, Chairman Boehringer 

Ingelheim; President, International Federation of Pharmaceuticals Manufacturers Associations 

(IFPMA), Geneva; President (1996 – 1998), European Federation of Pharmaceutical Industries 

and Associations (EFPIA), Brussels; Honorary Doctor award from the Pharmaceutical Faculty 

of the University of Athens/Greece; Honorary member of the Bulgarian Pharmacological 

Society - Section Clinical Pharmacology -; Grand Decoration of Honour in silver for services to 

the Republic of Austria. 

Dr. Ronald Labonte (1953), Canadian, Sociologist, Health Promotion and Population Health; 

Director, Saskatchewan Population Health and Evaluation Research Unit (SPHERU); Professor, 

Community Health and Epidemiology, University of Saskatchewan and Professor, Physical 

Activity Studies, University of Regina; Board member, Canadian Society for International 

Health, Advocacy Committee member International Union for Health Promotion and 

Education; Leader, SPHERU research program on health impacts of globalization. 

Tim Lang (1948), British, Professor of Food Policy at Thames Valley University’s Centre for 

Food Policy since 1994. Over the last 25 years, he has worked as an academic, a farmer, in 

NGOs and as a consultant to local, national and international bodies. Director of the London 

Food Commission, 1984 - 1990 and Director of Parents for Safe Food, 1990-1994. Chair of 

Sustain, UK’s 105 Food NGO Alliance, member of the International Forum on Globalisation. 

He works on food policy and the public interest, linking public and environmental health with 

consumers and social justice. 

David Lansky, PhD (1953), United States, health services and policy research; Director of 

Outcomes Research and Clinical Information Services for large regional hospital and health 

system; analyst for Jackson Hole Group; Founding President of FACCT--The Foundation for 



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Accountability, non-governmental organization developing quality measures and 

communications systems to help consumers make better health care decisions. FACCT was 

created and has been governed by major consumer organizations, corporate health care 

purchasers and government purchasers representing 80 million Americans. 

Dr. Petra Laux (1962), German, Pharmacist, PhD in Neurochemistry, Master of Public Health 

(Hannover Medical School, Germany), currently Director Pan European Government Affairs at 

GlaxoSmithKline (GSK) in Brussels, responsible for liaising with Member States and GSK 

country organisations with regard to health policies; previously various positions in 

pharmaceutical industry, including country management team. 

Dr. Günther Leiner (1939), Austria, M.D., an internal specialist, medical superintendent at the 

Institute of Rheumatology, Rehabilitation and Psychosomatic Medicine at Bad Gastein, 

Member of the Austrian Parliament, speaker of the conservative party in the Health 

Committee. President of the International Forum Gastein. 

Paul Lincoln (1956), English, Public Health, Health Promotion; Chief Executive of the UK 

National Heart Forum based in London and Public Health Policy consultant; Has been 

involved with developing public health policy, strategy and actions in a wide range of areas 

at international, national and local levels. 

Jeanette Longfield (1957), English, Co-ordinator of Sustain: The alliance for better food and 

farming, a network of over 100 British public interest organisations; International Relations 

and Development Studies; publications and appearances in food, health and consumer 

media. Recently appointed to Royal Society Inquiry into Infectious Diseases in Livestock. 

Laurie Mac Mahon, British, Office of Public Management, UK 

Kevin Mc Carthy, European Commission, Directorate-General for Research 

Prof. Dr. Martin McKee, British, Medicine, Professor of European Public Health, London 

School of Hygiene and Tropical Medicine, Research Director, European Observatory on Health 

Care Systems 

Miguel Ridriguez Mendoza, Venezuela, Law, Economics, Political Sociology, Deputy Director- 

General, World Trade Organization; 1994 – 1998 Chief Trade Advisor at the Organization of 

Am,erican States (OAS); 1991 – 1994, Minister of State responsible for Trade Affairs; 1989 – 

1991 Special Advisor to the President of Venezuela on International Economic Affairs. 

Dr. Bernard Merkel (1949), British, Political Theory, Social Science; Head of Unit in the Public 

Health Directorate of the European Commission in Luxembourg. Responsible for the 

development and analysis of policy, in particular in relation to assessment of health 

interventions and technologies, priority setting, pharmaceuticals and quality assurance and 

best practice; Visiting Fellow at LSE Health in the London School of Economics and Honorary 

Senior Lecturer at the London School of Hygiene; member of the Editorial Board of 

Eurohealth and author of a number of articles on European health policy. 

Maurice B. Mittelmark (1946), Norwegian, Professor, Ph.D in psychology, Fellow, American 

College of Epidemiology; Director, Graduate Programme in Health Promotion, University of 

Bergen (UB); Director, UB World Health Organisation Collaborating Centre for Health 

Promotion; President, International Union for Health Promotion and Education. 

Mag. Wilhelm Molterer (1955), Austria, Federal Minister for Agriculture, Forestry, Environment 

and Water Supply, Economic and Social Sciences, since 1994 Federal Minister for Agriculture 

and Forestry, 1993 – 1994 Secretary General of the Austrian Conservative Party (ÖVP), 1990 – 

1994 Member of Parliament, 1989 – 1993 Director of the Austrian Farmers Association, 1989 

head of cabinet of Minister Franz Fischler. 




Professor Bie Nio (Pauline) Ong (1951), Dutch, Social Scientist. Professor of Health Services 

Research, Faculty of Health, Keele University, UK. Responsible for research development 

between the university and the health service. Board member of South Cheshire Health 

Authority and Crewe and district Primary Care Group. 

Prof. Stipe Oreskovic (1960), Croat, Behavioural Sciences, Health Economics, Director of the 

Andrija Stampar School of Public Health in Zagreb; Responsible for Health System Project in 

Croatia. Member of Executive Boards of ESHMS and IAHP. Consultant to WHO and EU 

Commission. More than 70 publications in referenced journals. 

Teresa Petrangolini, Tribunale per i Diritti del Malato 

Bosse Pettersson (1946), Swede, Director of strategic policy development and deputy 

Director-general at the National Institute of Public Health (NIPH) in Sweden. He has academic 

graduation in social and political sciences and public administration and post-graduate 

training in public health. He is contracted by the Karolinska institute as a senior lecturer in 

public health sciences. In 1991 he was Secretary-General of the 3rd International Conference 

in Sundsvall, Sweden. In the Secretariat of the National Public Health Committee worked as 

an adviser 1997-2001. He represents Sweden in EU and WHO bodies and has published a 

number of articles, book-chapters, reports etc since 1976. 

Dr. Martina Poetschke-Langer, Head of Cancer Prevention Unit, Deutsches 

Krebsforschungszentrum, Heidelberg 

Mike Ponton, Project Director for NHS Plan, National Assemble for Wales 

Dr. Ursula Püringer, M.D., MSc. (1962) is a General Practitioner and Public Health Expert 

working as a free lance health care consultant in Austria and Europe mostly concerned with 

health reform and health system comparison in middle and east European countries. She is 

currently involved in organising the first Public Health curriculum in Austria. 

Dr. Gyula Pulay, Administrative Secretary of State, Hungary 

Dr Mike Rayner (1955) British, Director, British Heart Foundation Health Promotion Research 

Group, University of Oxford; Chair: Nutrition Expert Group, European Heart Network; 

Treasurer: Joint Health Claims Initiative, UK; Trustee: National Heart Forum and Sustain: the 

alliance for better food and farming (UK). (For more details see www.dphpc.ox.ac.uk/bhfhprg) 

Dato Dr Ricky J Richardson (1947), British, Consultant Paediatrician with an honours degree 

in Cell Biology and Immunology. Chairman of the UK Telemedicine Association, Chairman of 

T2 eHealth (Working Group of European Health Telematics Association), co-founder and 

Board Member of International eHealth Association, Founder of Richardson Consulting UK Ltd 

and co-founder of Whizz-Kidz (National Children’s Charity), Consultant Physician at Great 

Ormond Street Hospital for Children and Consultant Physician at the Portland Hospital for 

Women and Children, Personal Medical Adviser to His Majesty The Sultan of Brunei; Fellow 

of the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the 

Royal Society of Medicine and the Royal Society of Tropical Medicine. 

Dr. Carlos Ribeiro, Member of the European Economic and Social Comittee 

Dr. Aileen Robertson, (1952), British; Nutrition; Acting Regional Adviser for Nutrition and 

Food Security, World Health Organisation Regional Office for Europe, Copenhagen, Denmark. 

Charlotte de Roo (1965) is Policy Adviser at BEUC, the European Consumer’s Organisation, on 

EU Environment, Health and Safety issues. She is responsible for co-ordinating policy 

positions with consumer organisations around Europe and for developing and implementing 

political strategy to force change to EU policy in the consumer interest. Charlotte joined BEUC 



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294 


in November 1999 straight from the European Parliament where she was political adviser for 

a national delegation on the Environment, Public Health and Consumer Policy Committee. 

Her six-year experience within the EP began after her traineeship in the European 

Commission followed by her graduation in Environmental Planning and International Law 

from a leading Danish University. 

Dr. Magda Rosenmöller, IESE Business School and World Bank. 

Fernand Sauer is the Director for Public Health of the European Commission (Directorate- 

General Health and Consumer Protection) since December 2000. He qualified in pharmacy at 

the University of Strasbourg. He subsequently received a Masters in European and 

International Law from the University of Paris II and various post-graduate diplomas in public 

health, pharmaceutical legislation and European Community Studies. From 1972 to 1979 Mr 

Sauer held various positions in France as a hospital pharmacist and pharmaceutical inspector 

at the Ministry of Health. In 1979 he joined the European Commission in Brussels and in 

1986 became Head of Pharmaceuticals. He has been involved in the completion of the 

European Internal Market, trilateral harmonisation of regulatory requirements (ICH) between 

Europe, the US and Japan, the accession of the Community to the European Pharmacopoeia 

Convention and the development of pricing transparency and industrial policy in the 

pharmaceutical sector. He became the first Executive Director of the Agency for the 

Evaluation of Medicinal Products (EMEA) based in London, from September 1994 to 

November 2000. 

Dr. Michael Schubert, Managing Director, Engelhorn Foundation for Rare Diseases. 

Dr. Fernando Silió (1959), Spanish, Master of Public Health (University of Glasgow). Director 

of Consultancy and lecturer in Health Services Management, Andalusian School of Public 

Health, Granada, Spain. 

Dr. Hans Stein (1937), German, Lawyer, Government Official, European Liaison Officer at the 

Federal Ministry for Health (Bonn), Member of the EU High Level Health Committee of the EU 

Commission, Chairman of the Working Group „EU Internal Market and Health“. 

Catherine Stihler (1973) United Kingdom, Member of the European Parliament, Member 

Committee on the Environment, Public Health and Consumer Policy and Committee on 

Fisheries, MA Hons. (Geography and International Relations), St Andrews University (1996); 

M.Litt. (International Security Studies), St Andrews University (1998). Researcher and 

facilitator to Anne Begg, MP (1997-1999). President, St Andrews University Students' 

Association (1994-1995). Young Labour representative on the Labour Party Scottish Executive 

Committee (1993-1995) and the National Executive Committee (1995-1997). Represented local 

organisations and women's sections on the Scottish Executive Comm ittee (1997-1999). 

Parliamentary candidate (1997). Auditor to the European Parliamentary Labour Party (since 

1999). President of Public Health Intergroup, 2000. Honorary life member of the University of 

St Andrews Students' Association. 

Michèle Thonnet, Ministry of Health, France 

Drs. Bram van der Ende (1943), Netherlands, disability pension because of a rheumatic 

disease, social scientist, in former days management consultant and head of a post-academic 

management school in Amsterdam (until 1993), at the moment member of the board of the 

Dutch Council of the Chronicle Ill and Disabled (portfolio health care and medical devices) 

and of different boards within or outside the Dutch patient movement and of advisory 

boards of the Dutch government. 

Albert van der Zeijden (1942), Netherlands, didactic, teaching management, Chrohns'and 

Bechterew patient, Vice - Chair Council of the Chronically Ill and the Handicapped in the 




Netherlands (CG - Council) and International Alliance of Patients Organisations (IAPO) in 

London, Member of the Dutch Advisory Council for Health Research. 

Paul Vandoren is Head of Unit of "New technologies, intellectual property and public 

procurement" in the Directorate General for Trade of the European Commission. He was 

previously the Head of Unit of "Copyright and neighbouring rights, including international 

aspects" in the Directorate General for Internal Market and Financial Services of the 

European Commission. Before that, he was Deputy Head of Unit for Relations with the United 

States. He graduated in law at the Katholieke Universiteit Leuven and at the College of 

Europe (Bruges). He also holds a Master's Degree in Comparative Law from the University of 

Michigan (Ann Arbor). He has published several articles in the following areas: competition 

law; anti-dumping policy; interface between competition and anti-dumping; EU-US economic 

relations; copyright and related rights. 

Ms Katarina Veres, Project manager in Stockholm County Council, Medical Services 

Committee, the project for procurement of hospital care. Background as political advisor in 

the liberal party. Former positions in the Swedish International Development and Aid 

organisation and the Swedish Red Cross. Masters degree in Political Science and Economics 

(Sweden) and Bachelor's Degree in Eastern European Politics (including studies in Russia and 

Hungary). 

Mikael Vissing, Chief Strategy Officer, Netdoktor 

Dr. James Walsh, English, Medicine Member of the Committee of the Regions 

Prof. Dr. Reinhart Waneck (1945) Austria, medical doctor, specialist for radiology, professor 

for radiology, Secretary of State for Health, since 1985 Head of the Department for Radiology 

at the Hospital of the „Barmherzigen Schwestern des Hl. Vinzenz von Paul“, Vienna, 1995- 

1999 medical Director, member of the Austrian Association for Radiology, American Institut 

of Ultrasound in Medicine, European Society of Cardiovascular and Interventional Radiology, 

International College of Angiology (FICA), Committee of Austrian Doctors. 

Julius Weinberg is Director of the Institute of Health Sciences and ProVice Chancellor for 

Research at City University, London. He qualified in Medicine from the University of Oxford. 

After completion of specialist training in Infectious Disease and General Medicine he worked 

in Zimbabwe. This was followed by training in Public Health. He then worked for WHO in 

Bosnia and the UK Communicable Disease Surveillance Centre as an Epidemiologist. He was 

responsible for developing international infectious disease surveillance activities, in particular 

the developing collaborations between the EU Member States. His current research interest 

is in Policy pertaining to the development of international disease surveillance. 

Shirin Wheeler (1963), British, Europe Correspondent BBC Brussels since 1995; Currently 

presenting political discussion programme Eurofocus for BBC Parliament and regular features 

for BBC World TV and World Service radio on mainly health , social and environment issues. 

Previously health Correspondent for BBC South East . 

Dr. Manfred Wildner, MPH (1959), German, Medicine, Public Health; Scientific Director of the 

Bavarian Public Health Research Center (Ludwig-Maximilians-University) in Munich; Deputy 

Head of the PR-Committee of the German Society for Public Health; Member of the German 

Society for Social and Preventive Medicine, the Society for Epidemiological Research, the 

International Epidemiological Association, the American Public Health Association. 

Dr. Petra Wilson, European Commission, Directorate-General Information Society 

Dr. Matthias Wismar, (1965), German, research fellow, head of the Research Focus on Health 

Policy, Department of Epidemiology, Social Medicine and Health System Research (Director: 



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296 


Prof. Schwartz), Medical School Hannover, Political Scientist (Frankfurt FRG, Southampton UK, 

Nuffield College Oxford UK), Member of the Scientific Advisory Committee of the European 

Health Management Association, Hannover. 

Dr. Erio Ziglio (1952), Italian, Regional Adviser for Social and Economic Development at the 

World Health Organization Regional Office for Europe in Copenhagen; Honorary Professor, 

University of York; Honorary research fellow, University of Edinburgh, Lecturer at Yale 

University, USA. Field of expertise: decision-making applied to the area of health and social 

economic developments, social and economic determinants of health, futures‘ research and 

organizational development; degree in medical sociology, post-graduate studies in evaluation 

research and a Ph.D. in social policy. 



List of Participants 


Title First Name Last Name Position Organisation Country 

Dr. Brigitte Abbühl Health Care Consultant A 

Mr. Rolf Adlung Counsellor World Trade Organisation CH 

Mr. Tit Albreht Head of the centre for health Institute of Public Health of the SI 

care organisations, Republic of Slovenia 

economics & informations 

Mr. Padraig Allen Parliament of Ireland IRL 

Ms. Simona Alunni Associate Manager Merck Sharp & Dohme I 

Ms. Annita Anastassiadou EU coordinator Ministry of Health CYP 

Prof. Daina Andersone Head of Latvian Latvian University Hospital LV 

Rheumatologists Association 

Ms. Efi Angelidis Ethniki Hellenic Gen. Ins. Co. GR 

S.A. 

Mr. Philippe Arhets Scientific Officer Assistance Publique - Hopitaux F 

de Paris 

Ms. Edith Bachkönig Österreichischer Rundfunk A 

Dr. Peter Baeckström Director Medical Services Örebro County Council S 

Dr. Walter Baer European Commission L 

Ms. Rita Baeten Observatoire Social Europeen B 

Dr. Ekkehard Bahlo President Deutsche Gesellschaft für D 

Versicherte und Patienten e.V. 

Mr. Angelo Bargiggia Consulente sanità Regione Lombardia I 

Dr. Alicia Barwicka Director Polish Institution of Social PL 

Insurance 

Dr. Manfred Bauer World Health Network UK 

Dr. Bauer Bundesministerium für Land- 

und Forstwirtschaft 

Mrs. Eva-Maria Baumer Expertin für Qualität Bundesministerium für Soziale A 

Sicherheit & Generationen 

Ms. Elisabeth Baumhöfer Österreichische 

Bergbauernvereinigung 

Prof. Robert Beaglehole World Health Organisation CH 

Mr. Paul Belcher EHMA UK 

Ms. Kerstin Belfrage Adviser R.N.M.B.SC Swedish Association of Health SE 

Professionals 

Mr. John Bell Member of the Cabinet of European Commission 

Commissioner David Byrne 

B 

Mr. Igor Belov "Rossijskij Kurier", Radio A 

"Voice of Russia" 

Dr. Alastair Benbow GlaxoSmithKline UK 

Ms. Karin Berensson Federation of Swedish County SE 

Councils 

Mr. Sören Berg Director Stockholm County Council SE 



A 

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298 


Dr. Ken Berger Lecturer, Physician University of Toronto, Canada; CAN 

Bathurst-Richmond 

Centre 

Medical 

Mr. Philip Berman Director European Health Management IRL 

Association 

Prof.Dr. Günther Bernatzky Universität Salzburg A 

Mr. Luigi Bertinato Direttore Rapporti OMS Regione Veneto I 

Ms. Maria Luisa Bianchi Segretario Generale LIOS I 

Mr. Finn Z. Bielefeld Public Policy Director GlaxoSmithKline UK 

Ms. Claire Birckel Administrative Officer Assistance Publique - Hopitaux F 

de Paris 

Dr. Ulrich Bode President Pharmig Austria A 

Ms. Christa Bogath Obmannstellvertreterin Niederösterr. 

Gebietskrankenkasse 

Mr. Lluis Bohigas General Director for Health Department of Health 

Planning 

E 

Mr. Jozsef Borsi Ministry of Health H 

Ms. Sunita Bosnic- 

Pilipovic 

Korrespondentin Radio 

Posta 

Sarajevo, Bosanska A 

Mr. John Bowis Member of the European European Parliament 

Parliament 

B 

Mr. Nick Boyd Department of Health UK 

Mr. Carl Brandt Netdoctors 

Ms. Sissel Brinchmann Director 

Affairs 

European Public Merck Sharp and Dohme Inc. B 

Dr. Peter Brosch Abteilungsleiter Bundesministerium für Soziale A 

Sicherheit und Generationen 

Ms. Vanda Brown Head Of Active Age Unit Age Concern 

Prof. Anne Brunner Professor of Social Medicine 

and Public Health 

Katholische Universität D 

Eichstätt 

Ms. Ralica Budu Office Assistant Universitatea 

Constanta 

ovidius RO 

Mag. Gabi Burgstaller Deputy Governor Land Salzburg 

Ms. Catriona Burness European Parliament B 

Ms. Tjasa Burnik External Affairs Manager Merck Sharp & Dohme IDEA, SL 

Inc. 

Ms. Sarah Burns New Economics Foundation UK 

Dr. Reinhard Busse Visiting Professor National 


School of Public E 

Mr. David Byrne Commissioner for Health and European Commission 


B 

Dr. Alessandro Campana Partner SGC - Sviluppo Gestione I 

Controllo S.r.l. 

Mr. Joaquin Camprubi External Affairs Manager Merck Sharp & Dohme E 

Ms. Francesca Caprari Dirigente Ag. San. Servizi Regionali I 

Mr. Gilberto Carraro Group Manager Merck Sharp & Dohme I 

Mr. Jim Casey Member of Health Board Mid-Western Health Board IRL 



A


Ms. Marina Cerbo Dirigente Ser. o Progr.ne Regione Lazio 

Assessorato Sanità 

I 

Dr. Renè Chahrour Gesundheitsreferent Fonds Gesundes Österreich A 

Mr. Graham Chambers European Parliament L 

Dr. Yves Charpack Senior Adivser to the World Health Organization DK 

Regional Director 

Mr. Joseph Church Ministry of Health MT 

Ms. Vicky Claeys Advocacy Manager IPPF European Network B 

Ms. Renia Coghlan Health Policy & Gov. Serono International CH 

Relations Manager 

Mr. Alain Coheur Project Director Association International de la B 

Mutualité 

Dr. Joan Colom Farran Director General of Departement of Health and E 

Substance Abuse and AIDS Social Security, Government of 

Catalonia 

Prof. Angela Coulter Chief Executive Picker Institute Europe UK 

Ms. Andrea Crevato- 

Szabady 

Managemed A 

Dr. Jorge Cunha President Associacao Antigos Alunos P 

Faculdade Ciencias 

Ms. Mehtab Currey Deputy Chief Health and 

Population Adviser 

Department 

Development 

for International UK 

Mr. Marc Danzon Regional Director WHO 

Europe 

Regional Office for DK 

Ms Maggie Davies European & International Health Development Agency UK 

Policy Adviser 

Ms Margareth Davies The National Assembly for 

Wales 

Ms. Kirsty Davis Assistant Editor Healthcare Equipment UK 

Supplies International 

Mr Charlotte de Roo Environment, Safety and 

Health Policy Adviser 

BEUC, the European B 

Consumers' Organisation 

Ms. Francoise Debart Freelance Journalist B 

Dr. Johann Dengler Ambassador ret. Vjesnik Zagreb A 

Mr. Hervé Doaré Executive Director EHTEL F 

Mr. Günther Drda Med.ökonm. Planungsbüro, A 

Projektmanagement f. Praxis- 

Wirtschaftsbetriebe 

Dr. Hubert Dreszler General Manager Aventis Pharma GmbH A 

Ms. Annette Dumas European Community Affairs Merck Sharp & Dohme 

Associate 

B 

Mr. Benjamin Duncan BMA News UK 

Ms. Sophie Edwards Merck Sharp & Dohme UK 

Mr. Angelos Eftychidis Executive Manager & Claims Allianz Life (Greece) 

Manager 

GR 

Ms. Isabella Egidi Journalista Repubblica Salute 

Mr. Rodney J. Elgie President Gamian Europe - Global UK 

Alliance of Mental Illness 

Advocacy Networks 



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300 


Mr. Melvyn Ellis Chief executive South Staffordshire Health UK 

Authority 

Dr. Rolf Engelbrecht President European Federation of D 

Medical Informatics 

Dr. Carolin Engelhorn Mitglied des 

Verwaltungsrates 

Engelhorn Foundation for Rare D 

Diseases 

Mr. Eddy Engelsman Ministry of Health, Welfare and NL 

Sport 

Dr. David B. Evans Director World Health Organisation CH 

Dr. Albrecht Falkenbach Krankenanstalt 

Heilstollen 

Gasteiner A 

DI Dr. Klaus Fankhauser Vorstandsdirektor Steirische 

Krankenanstaltengesm.b.H. 

Ms. Giuliana Farinelli Associazione 

Reumatici 

Laziale Malati I 

Prof.Dr. Lothar Feige Fachhochschule 

Braunschweig/Wolfenbüttel 

Dr. Armin Fidler Health Sector Manager for World Bank 

Europe and Central Asia 

USA 

Ms. Elisabeth Fiedler Präsidentin Österreichische Morbus A 

Crohn/Colitis 

Vereinigung 

Ulcerosa 

Dr. Josep Figueras Head of Secretariat and 

Research Director 

WHO 

Europe 

Regional Office for DK 

Ms. Fulvia Filippini Senior Associate Merck Sharp & Dohme I 

Ms. Maria Fladl Permanent 

Representation 

Austrian A 

Dr. Ingo Flenker Präsident Ärztekammer Westfalen-Lippe D 

Mr. Padraig Flynn Former Commissioner for 

Employment, Industrial 

Relations and Social Affaires 

Prof. Antonia Fraioli Professore associato di Redazione Libertà I 

Medicina Interna 

Mr. Thomas A. Friedrich Ärztezeitung, 

Wissenschaft 

Die Welt B 

Dr. Ursula Fronaschütz Abteilungsleitung Qualität & 

Gesundheitsökonomie 



A 

D 

IRL 

Bundesministerium für Soziale A 

Sicherheit & Generationen 

Ms. Poli Gaki Health Care Consultant GR 

Mr. Bob Gann Director NHS Direct UK 

Mr. Nigel Garbutt Chairman EUREPGAP 

Dr. Karoly Garda Österreichreferent der UÄK, 

Geschäftsführer Cepco H 

Ärztekammer Ungarn / CEPCO H 

Ges.m.b.H 

Mr. Pascal Garel French Hospital Federation F 

Mr. Glenn Gathercole Brussels Co-ordinatior Standing Committee of Nurses B 

of The EU (PCN) 

Mr. Antonio Gaudioso Responsabile 

Esterne 

Relazioni Cittadinanzattiva I 

Mr. Harald Gaugg Sektionschef Bundesministerium für Soziale A 


Dr. Pál Géher Deputy State Secretary Ministry of Health H


Ms. Elmire Af Geijerstam Director International Affairs Swedish Federation of County B 

Councils 

Dr. Antoni Gelonch General 

Manager 

External Affairs Merck Sharp & Dohme Spain E 

Ms. Elita Georgana Committee of the Regions B 

Ms. Michaela Giner Client Executive Cerner Deutschland GmbH A 

Ms. Sonja Glahn Europabeauftragte DEGE MED e.V. D 

Dr. Walter Glueck Verein für Homöopathie A 

Mr. Camillus Glynn Member of Parliament Parliament of Ireland IRL 

Ms. Barbara Gobbi Giornalista Il Sole 24 ore I 

Dr. Jens Gobrecht World 

WHO 

Health Organization CH 

Ms. Fiona Godfrey Consultant European Respiratory Society D 

Ms. Raquel Goicoechea Executive Secretary Fundacio 

Economia 

Salut, Empresa i E 

Dr. Gouvras Ministry of Health and Welfare GR 

Dr. Anneliese Grafinger Obfrau & Geschäftsführerin Selbsthilfe Salzburg A 

Mr. Martin Green Chief Executive Counsel and Care for the UK 

Elderly 

Ms. Julie Griffith Head of Health Practice Interel European Public Affairs B 

Mr. John Griffiths Assembly Member National Assembly for Wales UK 

Dr. Katharina Grimm Gesundheitssprechstunge 

MSD Chibret AG 

- CH 

Mr. Xavier Grosclaude Official Representative Mutualité Francaise P 

Mag. Isabella Grubenthal mymed.cc AG A 

Dr. Alois Grüner Hofrat Salzburger Landesregierung A 

Dr. Mojca Grunter Cinc State Under Secretary for Institute of Public Health 


SLO 

Ms. Elisabeth Guttenstein World Wide Fund for Nature - B 

European Policy Office 

Ms. Aziza G. Haas Bundesministerium für soziale B 


Mr. Helmuth Hahn-Klimroth Geschäftsführer Kliniken des Main-Taunus- D 

Kreises GmbH 

Dr. Günther Hammer Bundesministerium für Soziale A 


Ms. Melinda Hanisch Manager Merck & Co. Inc., USA USA 

Ms. Mette Harder Consultant DKK - The Danish DK 

Confederation 

Employees 

of Municipal 

Dr. Hubert Hart Bundesminsiterium für Soziale A 


Dr. Herbert Haupt Bundesminister Bundesministerium für Soziale A 


Mr. Petr Hava Director Institute of Health Policy and CZ 

Economics 

Mr. Andrew Hayes President European 

Alliance 

Public Health B 



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302 


Mr. Claude A. Hemmer Chef de Cabinet - Staatsrat Ministerium für Gesundheit und L 

Soziale Sicherheit 

Ms. Henriette Hentschel Director Health Politics MSD Sharp & Dohme GmbH D 

Ms. Dawn Hill Chairperson Blackliners 

Organisation 

- HIV/AIDS UK 

Dr. Flora Hobdari Head of Programming and 

Developing Dept. 


Albania 

Insurance Institute Albania 

Mr. Tony Hockley Director Policy Analysis Centre UK 

Dr. Susanne Hof Leiterin der Europa- ABDA-Bundesvereinigung B 

Vertretung 

Deutscher Apothekerverbände 

Ms. Judith Hoffmann NTV Berlin D 

Ms. Anna Holécyová Ministry of Health SK 

Mr. Joachim Hombach Director GlaxoSmithKline Biologicals B 

Ms. Gisela Hopfmüller ORF Salzburg 

Ms. Veronika Horvath Referentin Bundesministerium für Soziale A 


Mr. Tom Hourigan Assistant 

Officer 

Chief Executive Mid-Western Health Board IRL 

Dr. Hubert Hrabcik Kabinettchef Bundesministerium für Soziale A 


Mr. Michael Hübel European Commission L 

Dr. Josée Hulshof Director Health Care Policy Eli Lilly & Co 

Europe 

NL 

Ms. Maria Husarova Director General Ministry of Health of the Slovak SK 

Republic 

Ms. Jane Hutt Minister of Health The National Assembly for 

Wales 

Ms. Nina Hvid Trade and IP Advisor European Federation of B 

Pharmaceutical Industries and 

Association (EFPIA) 

Ms. Sabine Hybasek Projektassistentin Wirtschaftsuniversität Wien A 

Mr. Stefano Inglese Segretario Nazionale CNAMC I 

Ms. Josie Irwin Senior Employment Royal College of Nursing UK 

Relations Adviser 

Prof. Mary Jackman Member of Parliament Parliament of Ireland IRL 

Ms. Helga Jäniche Board Member Deutsche Rheuma-Liga D 

Bundesverband e.V. 

Ms. Sladjana Jelisavcic Assistent to Director General Health Insurance Institute of SL 

Slovenia 

Ms. Genon Jensen Secretary General European 

Alliance 

Public Health B 

Mr. Maris Jesse Director Estonian 

Fund 

Health Insurance EE 

Mr. Franzisc Jeszenszki Zentrul de sanatate publica RO 

Dr. Albert Jovell General Director Josep Laporte Foundation E 

Ms. Monika Kaiser Projektkoordinatorin Gesellschaft für D 

Versicherungswissenschaft u. - 

gestaltung (GVG) 




Ms. Jana Kárniková Head of Department General Insurance Fund of CZ 

Czech Republic 

Prof. Cecily Kelleher Lecturer National University of Ireland IRL 

Ms. Annette Kennedy Irish representative to PCN Standing Committee of Nurses IRL 

to the EU 

Mr. Janko Kersnik National Coordinator for Kranjska Gora Health Centre SLO 

Quality in Health 

Prof. Mykola Khobzey Head of Health Care Lviv State Administration UKRAINE 

Departement 

Dr. Andreas Kiefer Land Salzburg A 

Mr. Gabor Kiss Ministry of Health H 

Mr. H. Dieter Kleinstoll Koordinator Patienteninitiative 

Ganzheitsmedizin 

Dr. Othmar Kloiber Bundesärztekammer D 

Dr. Wojciech Kobielski Director Agricultural Social Insurance PL 

Fund - KRUS 

Dr. Birgit Kofler People + Dr. Med Money A 

Mr. Mihaly Kökény Chairman of Health and Hungarian Parliament H 

Social Affairs 

Ms. Ruki Kondaj Secretary General Ministry of Health ALB 

Mr. Peter Körössy Head of Department - 

Goferment official 

National Health Insurance H 

Fund Hungary 

Mr. Franc Kosir Director General Health Insurance Institute of SL 

Slovenia 

Dr. Jacek Kossakowski Vice-director Agricultural Social Insurance PL 

Fund - KRUS 

Dr. Lajos Kovacs Managing Director Railway Health Care Service H 

Mr. Boris Kramberger Advisor Dir.Gen. for Public 

Relations 

Health Insurance Institute of SL 

Slovenia 

Prof.Dr. Rolf Krebs President International Federation of D 

Pharmaceutical Manufacturers 

and Associations 

Dr. Michael 

Thomas 

Kris MarketingReport Health D 

Mr. Roman Kunyik Klubsekretär ÖVP- Parlamentsklub A 

Prof. Roland Labonte Universities of Regina and CAN 

Saskatchewan 

NR Manfred Lackner Landesparteivorsitzender, 

Gesundheitssprecher 

SPÖ Vorarlberg A 

Mr. Eero Lahtinen Ministry of Social Affairs and FIN 


Dr. Tim Lang Thames Valley University UK 

Mr. David Lansky FACCT USA 

Ms. Annemarie Lautermüller CBMG / Verband der A 

Brauereien Österreichs 

Dr. Petra Laux Director Pan European GlaxoSmithKline B 

Government Affairs 

Dr. Volker Leienbach Geschäftsführer Gesellschaft für D 

Versicherungswissenschaft u. - 

gestaltung (GVG) 



D 

303

304 


Prof. Jeffrey Levett National 


School of Public GR 

Ms. Marianne Lidbrink RN BSC Adviser Swedish Association of Health SE 

Professionals 

Mr. Matthew Limb Editor Campden Publishing Ltd UK 

Mr. Paul Lincoln National Heart Forum UK 

Ms. Susanne Logstrup Director European Heart Network B 

Ms. Jeanette Longfield Co-ordinator Sustrain: The Alliance for UK 

Better Food and Farming 

Ms. Helena Lovincic Radio Slovenija SL 

Ms. Carin Lyckéus Senior Adviser Swedish Association of Health SE 

Professionals 

Prof. H. Maarse Maastricht University NL 

Ms. Laura Maclehose London School of Hygiene and UK 

Tropical Medicine 

Dr. Brigitte Magistris Bundesministerium für Soziale A 


Ms. Peggy Maguire Director General European Institution of 

Women's Health 

Mr. Reinhold Mainz Telematikbeauftragter Kassenärztliche 

Bundesvereinigung 

Mr. Asko Maki Ombudsman of Interests The Finnish Rheumatism FIN 

Association 

Dr. Gloria Malaspina Responsible Health Policies CGIL Nazionale - Labour I 

Dept. 

Italian General Confederation 

(Trade Union Confederation at 

National Level) 

Dr. Daniela Manuc Chief Ministry of Health and Family RO 

Dr. Gaspar Maroth Secretary National Health Council B 

Ms. Annie Marott Head of Department Danish Nurses Organisation DK 

Dr. Daniel Mart Secretary General AMMD - Association des L 

Medecins et Medecins- 

Dentistes de Grand Duche de 

Luxembourg 

Mr. Berndt Martetschläger Vorstandsdirektor Stmk. 

Krankenanstaltengesellschaft 

mbH 

Ms. Eugenia Matiushko Financial Director LVIV Regional State UKRAINE 

Administration 

Dr. Jozica Maucec 

Zakotnik 

State Secretary Ministry of Health SL 

Mr. Stefan Mayer Landespressebüro Salzburg A 

Prof. Mark McCarthy University College London UK 

Mr. Kevin McCarthy European 

Official 

Commission The European Commission B 

Prof. Martin McKee London School of Hygiene & UK 

Tropical Medicine 

Ms. Sylvia McShane Lecturer in School of Nursing University College Dublin 

+ Midwifery 

IRL 

Mr. Peter Meglic Präsident Österreichische Vereinigung A 

Morbus Bechterew 



D 

A


Dr. Igor Melnikov Pravda (Moskau) A 

Dr. Bernard Merkel European Commission L 

Mr Owen Metcalfe Associate Director Institute of Public Health IRL 

Mr. Helmut Millinger Welle 1 Salzburg A 

Prof.Dr. Helmut Milz Honorarprof. Public Health Universität Bremen, FB 11 D 

Mr. Rodney G. Mitchell European Federation of UK 

Crohn's and Ulcerative Colitis 

Association 

Prof. Maurice Mittelmark University of Bergen S 

Dr. Michaela Moritz Geschäftsführerin Österr. Bundesinstitut für A 

Gesundheitswesen 

Ms. Margit Moser Die Apotheke A 

Ms. Jirina Musílková General Director General Health Insurance CZ 

Company 

Republic 

of the Czech 

Prof. Maria 

Helena 

Nazaré Director from Health School University of Aveiro P 

Ms. Marjut Niemistö Public Affairs Manager MSD Finland FIN 

Prof.Dr. Richard 

Horst 

Noack Vorstand Institut für Sozialmedizin und A 

Epidemiologie 

Mr. Wlodzimierz Nowacki National Centre for Health PL 

System Management 

Mr. Jerry O'Dwyer Former Secretary of State Haughton Institute IRL 

Mr. Batt O'Keeffe Member of Parliament Parliament of Ireland IRL 

Dr. Isabel Oliver Departement of Health UK 

Dr. Isabel Oliver Specialist Registrar Department of Health UK 

Ms. Dara O'Mahony Administrator The Haughton Institute IRL 

Prof. Pauline B.N. Ong Keele University UK 

Mr. Stipe Oreskovic Director University of Zagreb Medical HR 

School 

Mr. Kim Ost-Jacobsen Consultant Danish Nurses Organisation DK 

Ms. Dace Ozola Agricultural Counsellour Mission of Latvia to the B 

European Union 

Dr. Renzo Pace Asciak Consultant Department 

Information 

of Health Malta 

Ms. Julia Pai President The Association for the TAIWAN 

Advancement of Patients 

Rights of the Republic of China 

Ms. Grazina Paliokiene Chairperson Lithuanian Catholic Women's LT 

Union 

Dr. Vojtech Parrak Consultant University 

Bratislava 

Komenskeho, SK 

Ms. Lili Pasat State Inspector Romanian Ministry of Health RO 

and Family 

Dr. Antonin Pecenka Deputy of Health Care General Health Insurance CZ 

Company 

Republic 

of the Czech 

Mr. Giovanni Pedini Manager Merck Sharp & Dohme I 



305

306 


Mr. Antonio Perelli Resp. Ass. Sanitaria e Regione Umbria I 

Farmaceutica 

Mr. Govin Permanand Editor, Euro Observer LSE 

Health and Social Care 

London School of Economics UK 

and Political Science 

Mrs. Teresa Petrangolini Tribunale per i Diritti del Malato I 

Ms. Elisabeth Petsetakis National 


School of Public GR 

Mr. Bosse Pettersson Director National 


Institute of Public S 

Mr. Peter Pfarrmeier Director Kur- und Kongressbetriebe A 

Bad Gastein 

Prof.Dr. Eva Pichler Institutsvorstand Wirtschaftsuniversität Wien A 

Ms. Audrone Piestiniene Ministry of Health LT 

Dr. Franz Piribauer Stellvertr. 

Landessanitätsdirektor 

Steiermark, Lehrgangsleiter 

Universität Krems A 

KR Dr. Eberhard Pirich Obmann Fachverband der Chemischen A 

Industrie Österreichs 

Dr. Otto Pjeta Präsident Österreichische Ärztekammer A 

Ms. Zinta Podniece Ministry of Health and Welfare LV 

Ms. Martina Poetschke- 

Langer 

Krebsforschungszentrum 

Heidelberg 

Dr. Gerhard Polak Auslandsreferent Ärztekammer für Wien A 

Ms. Kaja Polluste University of Tartu EE 

Mr. Mike Ponton Project 

Plan 

Director for NHS National Assemble for Wales UK 

Mr. Florin Popovici Deputy Director of Public 

Health Direction of 

Romanian Ministry of Health RO 

and Family 

Dr. Günter Porsch Abteilungsleiter Bundesministerium für Soziale A 


Ms. Maija Porsnova State Secretary Ministry of Welfare of Latvia LV 

Ms. Brigitte Pripisni Bau-Berufsgenossenschaft 

Rheinland + Westfalen 

Mr. Hans 

Christian 

Pruszinsky Editor European Hospital A 

Ms. Iveta Pudule Head of Department of Health Promotion Centre LV 

Health Risk Factors Analysis 

Dr. Gyula Pulay Administrative Secretary of Ministry of Health 

State 

H 

Dr. Ursula Püringer A 

Mag. Sonja Ramskogler Gemeinderätin Gemeinderatsausschuss A 

"Gesundheits- 

Spitalwesen" 

und 

Dr. Peter Ransmayr Direktor Landesstelle 

Salzburg 

Sozialversicherungsanstalt der A 

gewerblichen Wirtschaft 

Mr. Andrea Rappagliosi Vice President Health Policy Serono International 

& Government Relations 

CH 

Mr. Bengt Rastén Consultant DKK - The Danish DK 

Confederation 

Employees 

of Municipal 



D


Dr. Mike Rayner University of Oxford UK 

Ms. Kathy Redmond Consultant European School of Oncology I 

Ms. Helene Reemann Bundeszentrale 

gesundheitliche Aufklärung 

für D 

Ms. Vera Reimarova Hewlett-Packard CZ 

Dr. Anton Reinl Austrian 

Agriculture 

Chambers of A 

Dr. Eduard Ribas Head of the Technical and 

Information Cabinet 

Departement of Health and E 

Social Security 

Prof. Carlos Ribeiro Member European Economic and Social P 

Comittee 

Prof. Gualtiero Ricciardi Professor of Hygiene University of Cassino I 

Prof. Mary Rice Practice Area Manager Adamson BSMG Worldwide B 

Dr. Tessa Richards British Medical Journal UK 

Dr. Ricky Richardson Richardson Consulting Ltd. UK 

Dr. Christian Richner Owner RICHNER Interdisciplinary CH 


Services 

Care Consulting 

Ms. Milena Richter Senior Consultant Adamson BSMG Worldwide B 

Dr. David Rickerby European Commission - Joint I 

Research Center Ispra 

Ms. Maria Risi Junior Secretary Merck Sharp & Dohme I 

Dr. Anna Ritsatakis Head of The European World Health Organization B 

Centre for Health Policy 

Dr. Eduard Rius Minister of Health and Social 

Security 

Autonomous Government of E 

Catalonia (Generalitat) 

Dr. Aileen Robertson Acting Regional Adviser for World Health Organization 

Nutrition 

DK 

Mr. Graham Robertson Acting Chief Executive Health Education Board for UK 

Scotland (HEBS) 

Dr. Karin Rodegra SF DRS / c/o MSD-Chibret CH 

AG 

Prof.Dr. Wolfgang Rohrbach Chefredakteur "Med Diabetes", "Diabetes A 

Aktuell", "Uniqa team" 

Prof. Ernst W. Roscam 

Abbing 

Nederlands School of Public NL 


Ms. Magdalene Rosenmöller IESE - University of Navarra E 

Mr. Martin Rümmele Redakteur Wirtschaftsblatt A 

Dr. Martin Rusnak Verwaltungsdirektor Internationale Gesellschaft zur A 

Erforschung von Hirntraumata 

Ms. Anne-Marie Sacre-Bastin Head 

Departement 

International Ministry of Public Health B 

Dr. Vigan Saljasi General Director Health 

Albania 

Insurance Institute Albania 

Mr. Gavino Sanna Segretario Generale Movimento Consumatori I 

Ms. Valentina Santirocco Junior Secretary Merck Sharp & Dohme I 

Mr. Vincenzo 

Maria 

Saraceni Assessore alla Sanità Regione Lazio I 

Mr. Fernand Sauer Director European Commission L 



307

308 

Ms. Regina Sauto Information and Policy 

Officer 


EPHA - European Public B 

Health Alliance 

Dr. Xenia Scheil-Adlung Programme Manager International 

Association 

Social Security CH 

Konsul Francois Schiltz Vice President European Foundation for the CH 

Advancement of Medicine 

Dr. Walter Schmidjell Chairman AMREF Austria A 

Dr. Michael Schubert Engelhorn Foundation for Rare L 

Diseases 

Ms. Rosemarie Schüchtle Direktorin Physiotherapieschule Konstanz D 

Mr. Helmut Schüchtle Geschäftsführer Physiotherapieschule Konstanz D 

Dr. Markus Schwarz Wirtschaftsdirektor Christian-Doppler-Klinik (LNK) A 

Mr. Michael Sedgley Editor LSE Health and Social Care, UK 

London School of Economics 

Mr. Fernando Silio Andalusian School of Public E 


Ms. Ilona Skuja Social Counsellor The Mission of Latvia to the EU B 

Mr. Marcel Smeets European Affairs Zorg Verzekeraars Nederland NL 

Ms. Elske Smith Ministry of Health, Welfare and NL 

Sport 

Ms. Gertrude Stabauer ORF Salzburg 

Dr. Alena Steflova Ministry of Health of the Czech CZ 

Republic 

Dr. Hans Stein Referatsleiter Bundesministerium 

Gesundheit 

für D 

Ms. Cathrine Stihler President 


Intergroup on European Parliament B 

KR Klaus Stochl Generaldirektor Boehringer Ingelheim Austria A 

GmbH 

Mr. Janko Stok Assistent to Director General Health Insurance Institute of SL 

Slovenia 

Mr. Bernd Stracke Leiter der Vorarlberg- Forum Gesundheit A 

Redaktion 

Mr. Paul Strickland European Commission B 

Dr. Gerhard Stummerer Mitglied des Vorstandes AESGP - The Association of B 

the European Self Medication 

Industry 

Ms. Hildrun Sundseth Director EC Affairs Merck Sharp Dohme B 

Mr. Brian Synnott Officer European Federation of Public B 

Service Unions EPSU 

Mr. Tális Talents Under State secretary in Ministry of Welfare of Latvia 

Medical Issues 

LV 

Ms. Nicoline Tamsma Senior Adviser Nederlands Institute for Care NL 

and Welfare 

Dr. Kancho Tchamov Medical University - Sofia BG 

Mr. Franco Tempesta Presidente CNAMC I 




Mr. Eric Teunkens Legal Advisor Institut National d'Assurance B 

Maladie Invalidité 

Dr. Michèle Thonnet Ministère du Travail et des F 

Affaires Sociales 

Mr. Tilman Tögel Landtagsabgeordneter 

Sachsen-Anhalt 

Mr. Kutukeev Toktogazy Director of Republican Blood 

Centre 

Ausschuss der Regionen D 

Ministry of Health of Kyrgyz Kyrgyz 

Republic 

Republic 

Mr. Ricard Tresserras Merck Sharp & Dohme Spain E 

Ms. Gillian Turner National 

ordinator 

CJD Case Co- CJD Support Network UK 

Mr. Anders Ulstein Liasion Officer Eurocare B 

Mr. Andras Vajda Merck 

Hungary 

Sharp & Dohme H 

Ms. Marja Valtonen Kauneus ja Terveys S 

Mr. Bram van der Ende Member of the Board Dutch Council of the Chronicle 

III and Disabled 

Mr. Albert van der 

Zeijden 

Chairman International Alliance of Nl 

Patients Organisations 

Mr. Richard van Oostrom Guidant Europe B 

Ms. Irina Velinova Ministry of Health BG 

Dr. Karen Vella Ministry of Health MT 

Mr. Henk Vermaat Senior Policy Adviser Netherlands Heart Foundation NL 

Mr. Jean Marie Vlassembrouck Vice President Global Baxter B 

Industry Affairs 

Mr. Rüdiger von Plüskow Staatssekretär Ministerium für ländliche D 

Räume, Landesplanung, 

Landwirtschft u. Tourismus des 

Landes Schleswig-Holstein 

Mr. Simon Vrhunec State Secretary Ministry of Health SLO 

Dr. James Walsh Member Committee of the Regions UK 

Mag. Evelyne Walter Wirtschaftsuniversität Wien A 

Mr. Reinhart Waneck Staatssekretär für 

Gesundheit 

Bundesministerium für Soziale A 


Prof. Morton Warner Director University of Glamorgan UK 

Mr. Watters Primary 

Association 

Immunodeficiency UK 

Mr. Nigel Webb Chief Executive Solihull Health Authority UK 

Mr. Colin Webb Executive Director European Coalition of Positive UK 

People 

Prof. Julius Weinberg City University UK 

Ms. Shirin Wheeler BBC B 

Mr. Wiesinger NTV Berlin D 

Dr. Manfred Wildner Bayrischer Forschungsverband D 

Ms. Susan Williams European Officer Royal College of Nursing UK 

Prof. Anna Wilmowska Chief Medical Officer Social Insurance Institution PL 



309

310 


Ms. Petra Wilson European Commission B 

Dr. Robert Wiraszka Doctor in Regional Branch in 

Radom 

Agricultural Social Insurance PL 

Fund - KRUS 

Dr. Matthias Wismar Medizinische 

Hannover 

Hochschule D 

Ms. Birgitta Wittorp Deputy Director Ministry of Health and Social S 

Affairs 

Dr. Andrea Wolf Journalistin Medical Tribune A 

Mr. Seamus Woods Director of Welfare Services Mid-Western Health Board IRL 

Mr. Steve Wright Head of Division European Investment Bank L 

Mag. Alfred Wurzer Direktor Kärntner Gebietskrankenkasse A 

Ms. Agneta Yngve Karolinska Institutet SE 

Ms. Diana Zajec Journalist DELO SL 

Prof.Dr. Klaus Zapotoczky Institutsvorstand Joh.-Kepler-Universität Linz A 

Dr. Mario Zappacosta European Commission, Joint E 

Reserch Center 

Dr. Susanne Ziesenitz Südzucker AG D 

Dr. Erio Ziglio Regional Advisor World Health Organisation DK 

Mr. Athanasios Zikopoulos Senior Manager Health Care 

Affairs 

Merck Sharp & Dohme Chibret CH 

AG

Congress report - European Health Forum Gastein

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