GHF2006 – PS07 – Addressing Health Inequalities in Modern Europe

Session Outline

Parallel session PS07, Thursday, August 31 2006, 11:00-12:30
Chair(s): John-Paul Vader, Switzerland, Gaudenz Silberschmidt, Switzerland
Public Versus Private: Is the Debate Still Valid? 
Josep Figueras, Director, The European Observatory on Health Systems and Policies, Brussels, Belgium 
Using Private Providers to Improve Patient Experience
Wiliam H. Wells, Chairman, NHS Appointments Commission, London, UK
Health Systems in Eastern Europe
Bakhuti Shengelia, Country Health Systems and Policies, World Health Organization, Regional Office for Europe, Copenhagen, Denmark

Session Document

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Session Report

Submitted by: Brooke Bishara (ICVolunteers); Contributors: Asta Lim (ICVolunteers)

Image: courtesy of The Public Health Image Library (PHIL) http://phil.cdc.gov/Phil/

Populations of modern Europe live in different national socio-economic settings, making the study, evaluation and comparison of their respective healthcare systems a complex exercise. Correspondingly, health inequalities within this vast region are also intricate and multiple. The three speakers provided interesting insights on the different determinants of these inequalities, mainly focusing on the roles played by the public and private sectors, whilst revealing the often misconceived correlation between the inequality in access to healthcare and the private and/or public delivery of healthcare services.

Dr. Willy Palm, Dissemination Development Officer of the European Observatory on Health Systems and Policies in Brussels, Belgium, argued that while soaring health care costs is a draw for private sector involvement, it is unclear what private sector involvement in healthcare entails. Advocates for privatization of healthcare services favour the potential for increased efficiency, choice, service, and quality of care.  Opposing groups, however, believe that privatization will undermine the solidarity principle, whereby the rich and healthy subsidize the care of the poor and sick. Dr. Palm's slides showed a private-public continuum, in which various 'hybrid' health systems are revealed. His graphs demonstrated that all European countries have a mixed stream of funding to pay for health care, including taxes, social security, user charges, and private insurance. On average, governments funding covers 75% of all health care costs. Dr. Palm stressed that governments considering change should first identify their goals for health care, followed by an assessment of the benefits and tradeoffs of introducing private actors into a public system. Results of such assessments may sometimes be contrary to expectations. For example, improved efficiency in privately run primary care facilities in Estonia increased the number of people receiving care, and therefore led to increased spending. In the Netherlands, the principles of competition and solidarity are combined in its health system reforms. He concluded that governments should act as careful stewards of health systems, providing clear regulations for all involved public and private actors.

Sir William Wells, Chairman of the NHS Appointment Commission, gave a documented overview of the British Public National Healthcare System (NHS), discussing the problems it now faces and the solutions which have been implemented. A well established system of 60 years and a widely used "role model" in many countries, the NHS is nevertheless, according to William Wells, "in need of rejuvenation". Living in a general misconception about its initial objectives (a system that was meant to provide healthcare to all who need it but it was not designated to provide ALL healthcare services), the NHS will have to quickly tackle its low productivity. Measured in terms of number of patients treated per doctors, the 4% rise in productivity is astonishingly low compared to the increased amount of taxpayers' money received by the NHS (30 billion £ in 1997, 70 billion £ in 2006, and 90 billion £ in 2008). For the system to be "fit for purpose", it will require a reorientation of staff towards a more patient/customer friendly attitude, increased competition and smaller management groupings. Thus, by introducing contracts for private healthcare providers, which started in 2003, NHS is progressively opening to the private sector and encouraging competition. This phenomenon is uprooting the traditional staff culture and clearly pointing the way forward for the entire system. William Wells emphasized both the importance of these reforms and the fact that the system would not be entirely changed; after a major national debate it was decided that taxpayers should continue paying for healthcare service but that in return, the increase in taxes meant the NHS should provide the patient/customer "value for money". The controversial and "revolutionary" approach of allowing the private sector into NHS is part of a new trend in creating hybrid health systems.

Dr. Bakhuti Shengelia, Regional Adviser for Health Policy and Equity, Division of Country Health Systems at the WHO, examined the health systems of Central and Eastern Europe, where the former Soviet Republics have seen a five to eight year decrease in average life expectancy since the collapse of the Soviet Union in the early 90's. An estimated 3.2 million deaths, concentrated among men aged 20 to 60, would not have occurred in these countries had the health systems not suffered in the wake of political collapse. Since 1995, the rate of HIV infections has also increased at an alarming rate, making this one of the fastest growing AIDS epidemic region in the world. While public health has taken a setback in the Central and Eastern European societies, the poor are the most affected. Even though governments often promise a public health care system to meet the populations' needs, in reality they fail to provide these services, allowing for the growth of a de facto private system of informal payments. Other increased health risks among the uneducated and the poor such as higher incidence of smoking and heavy drinking also adds to the burden on existing health care systems. The dramatic disparity in access to health care is ironic, given the level of solidarity that once existed in these countries' health systems. In Georgia and Azerbaijan, for example, out of pocket payments by patients cover approximately 90% of all health care costs. To ameliorate the inequalities of the system, out of pocket payments by patients need to be drastically reduced and funding redistributed to target vulnerable groups. Aid from the European Union could be instrumental in achieving these goals.

All three speakers seemed to agree that the public vs. private debate is no longer relevant because the definitions of these terms have blurred considerably. The most effective health systems should well utilize both public and private actors. As one forum participant well pointed out, we should focus on the functionality of the system in reaching performance benchmarks, rather than the type of system.

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