ACCESS
TO HEALTH CARE SYSTEMS AND MEDICINE IN EUROPE
Giorgio
Berchicci
In
France the accounts are out of order: eleven months after the approval and
application of the new National Health System, for the instant year, the
forecast unbalance is due in 11, 6 billions Euro and not, as many hoped, in 10,
6 billions.
The
French Government decided to introduce this new reform with the precise aim to
reduce the high expenses for the Health Care Services. Similar signals arrive
from other European Countries, among which Italy ( And only tree weeks ago, the
Finance and Economy Minister accused italian practioners to make illicit
prescriptions of drugs ). The increasing expense reasons are different, but some
of them are shared in every country: an older and older population that has to
thank a spread wealth ness and medicine progress. The senior population of Italy
and Sweden have reached a range between 12% and 19%, biotechnology grants better
and better performances serving the big technique called Medicine and the more
and more sophisticated diagnostic items, the defensive medicine that proceeds
opening the market to new medications played a big role in increasing the age
average. On the same paths drive the policy of diminish pathology index promoted
by medical brand industries and supported by Scientific Societies (consider
cholesterol max limit, blood pressure max limit and glycaemia that are always
lower to increase ever more the potential market. Even the most natural event of
our life, pregnancy, became a medical event...).
The
E.U. is now living a big difficult moment, caused from the lack of acceptance of
a Constitutional Treaty not signed by Founding Countries as France and Holland.
In this important historical moment soon after the joining of the sole currency,
that carried unbelievable benefit, together with some problems putting national
government in need to renew old pats on some rules to stop the economical
recession so they asked to rearrange the 3% percentage designed to have
stability all over Europe. This problem was generate from high level of national
debt not affordable for many countries, as Italy, or from structural relevant
problems, or problems coming from competition with other developing countries
such as China, which can count on low cost working force compared with European
range.
The
European dream, that hundred of millions citizens, male or female, dreamed for
so long, has to end miserably?
Probably
the monetary union was not the only answer to continue to live together in a
world without boundary where everybody is a citizen with same rights and without
sex, religion, racial and political discriminations.
It
is useless to think that, among these rights, the right of health is the most
appealing one as the right to work. So how can we list it? At the beginning, the
health protection appeared as a freedom right to oppose to the government as
habeas
corpus, right to body integrity. Nowadays we could list this right
among the senior citizens rights as well as human being right, right that can be
realized with general cooperation related to everybody as well as to next
generation. But this kind of right, at least in Italy, are called
agreed
rights, which are under the influence of agreements between national
governments and Europe, according with International Law. Sometimes these rights
are exceptionable as the peace rights and the environment rights; rarely they
are exacted rights as the social economical development. The health right could
be passed as a fourth generation one, where it’s into Constitution and says
that the health right is both exceptionable and exacted, as it carries inside
the government compelling activities as being jointly liable and the
acknowledgment of the human being. Moreover it is a linked right to other rights,
as the right to live in a healthy environment or the right to work or to
increase personal wealth ness. Recently, some observers noted that the
increasing of average life didn’t occur simply in the most developed countries
but where within the wealth ness governments adopt correct social policy, where
culture develops and the environment is protect, the law system is good as well
as cooperation.
Wealthy
countries not always have the best life system to improve the citizen life it is
important that inside the system don’t occur unevenness between poor and rich.
We
can assert that this right can be considered effective for each Countries of the
United Europe, as each country has a National Health Service, but from another
point of view the European Government showed sort of sensibility to defend the
right of Health, only recently.
The
Treaty that establishes the United Europe provide the right of Health only in
indirect way, in article 136 says “ The Union and the member states … have
as aim to promote working occupation and to improve
life
and work conditions» as well in article 30 pointing out on exception
to the rule of free goods circulation, talks of
defence
of human health and life”.
In
the Treaty that established the United Europe on atomic energy (CEEA or
EURATOM), signed in Rome on March 25th, 1957, one of the chapter is
completely dedicated to citizen and workers Health and Safety, but only with the
European Sole Act, February 17th, 1986, it is possible to find some
referring to healthy environment for consumers on high protection level based on
scientific issue and developing.
Thanks
to Maastricht Treaty the Health Protection becomes a priority in E.U. policy, as
to the subject it is dedicated a specific document (document XIII) article 152,
but in 1992 the Public Health does not rise to a real and concrete E.U. policy
as it remains in an crosswise sphere and referred as: “ part of different E.U.
Policies”. (Art. 129, par. 3).
Amsterdam
Treaty changed, in a relevant way, article 152 of U.E Establishing Treaty: the
new article 152, par.1, changes it clearly from a simple “part” of other
policies to a undeniable assumption of all ones («
In
both definitions and accomplishments of every E.U. policy or activity is
warranted a high level of human health protection”). The article
152 foresees an
Open
Method of Co-ordination among the E.U.
Members and Brussels Committee, but it also confers to the Member
Government
the
sole competence to organise and perform the health services and medical welfare,
in this way it is hard to realise an unique health right throughout the United
European territories.
From
1996 on we can see a long list of programmatic activities in E.U. referred to
Health Services, throughout some Decisions listed bellowed:
1-
First
Community Action Programme to promote Health (Decision 96/645/EC);
2-
Community
Action Programme for rare diseases (Decision 1295/1999/EC);
3-
Community
Action Programme to prevent diseases (Decision 372/99/EC);
4-
Community
Action Programme to prevent diseases relate with pollution (Decision
1296/99/EC);
5-
Community
Action Programme about Public Health in years 2003 – 2008 (Decisions
1786/2002/EC).
In
December 2000 the E.U. Fundamental Right Charter clearly declared, within
article 35,
the
right to health
“each
citizen has the right of access to preventive medicine and to obtain medical
treatments on the basis of established rights of his own home country. In each
definition and accomplishment of E.U. policy or activity is warranted a high
human health protection level”.
Moreover
the latest Community Jurisprudence has definitively asserted:
“general
principle: the tutelage of public health must have an unquestionable and
prevalence significance referring to economical consideration”
(TPG, nov., 26 2002, T-14/00, Artegodan and others versus E.C. Commission.
On
April 4th 1997, E.U. issued “Convention for the protection on Human
Rights and dignity of human being with regard to the application of biology and
medicine: Convention on Human Rights and Biomedicine”, better known as
“Convention of Oviedo”. I want to underline some peculiarities: above all it
has been promoted by all member Countries within the European Council, then the
formulation methods (took part the Member Countries of European Council, but
also United States, Canada, Vatican and others), the approbation was signed by
19 States, among which Italy but the latest never bailed it to the European
Council.
The
most important point in “Convention of Oviedo” seems to be article 2
“Primacy of the human being – The interests and welfare of the human being
shall prevail over the sole interest of society or science”. Meanwhile the
article 3 relates about our main interest “ Equitable access to health care.
Parties, taking into account health needs and available resources, shall take
fair measures with a view to providing, within their jurisdiction, equitable
access to health care of fair quality ”. As you can see we are not longer
speaking about a high level of welfare protection but about a suitable quality
and suitable measures. In this passage they impress the E.U estranged to give
medical care to its citizens leaving all welfare services to the member States (herewith
called parties) that signed the agreement, they underline the economical aspect
importance referring to medical care and referring to available resources, they
also introduce the idea of fairness related to medical care admittance. But
there are some papers that explain in very large manner what means the the word
“ fair ”, as the paper “ Orientamenti bioetici per l’equità nella
salute” wrote by italian National Bioethic Committee.
But
Constitutional Treaty, actually rejected from France and Holland, the Public
Health Service is consigned among “sectors in which EC may decide to have a
supporting, co-ordinating or complementary role”.
In
the end I would refer, for a clear definition of the word “Health”, to
article 25 of Universal Declaration of Human Rights: “Each person has the
right to have a fair income to ensure his family and himself welfare and wealth,
food, cloths, house, health service and needed social welfare”. Reading this
passage it is clear that the subjects, we have interest in, are inside two
different dimension: one is in the general idea of Health care the other in the
more precise Medical assistance. The health is considered as a needed resource
in everyday life, considered as a social and personal resource moreover than
physical ability. Promote the Health care is not a precise responsibility of
medical sector, but must be considered in a wider way embracing culture, food,
work, house, justice, and social fairness policies.
It
is within the sign of Rome Treaty that the free circulation of men and goods
starts among the European Union in 1957, nowadays there are 25 countries in the
Union.
From
then, were founded a lot of medical associations with the precise aim to seize
this great opportunity to level the vocational training of medicine graduate.
My
Association, European Union of Medicine Specialits, U.E.M.S., is the first
established of european medical associations ( 1958 ), and is the representative
organisation for specialists doctors from the national Associations of EU. Its
activities cover all issues associated with specialised medical practice, an
are jointly carried out by doctors serving as representatives on its
Management Council and on its more than thirty Specialists Sections and Boards.
The
initial objectives of the UEMS were:
1-
the study and promotion of the highest level of training of medical
specialists, medical practice and health care within the EU
2-
the study and promotion of free movement of specialist doctors within the
EU
the
representation within this framework of the medical specialist profession in the
Member States of the EU, to EU authorities and any other authority and or
organisation.
These
were subsequently updated:
1-
To promote the highest level of patient care in the EU
2-
To emphasise the title of the “ medical specialist “ as the doctor
who practices the highest quality of medical care in his field of expertise
3-
To uphold his professional and ethical status
4-
To promote the harmonisation of high quality training programmes within
the various specialists throughout the EU
5-
To endorse, encourage and facilitate continuing medical education ( CME )
and professional development ( CPD )
The
UEMS recognises and value differences in the structure, funding and priorities
of healthcare systems in Europe, but believes that the principles required for
the regulation of medical practice – which are based on common standards and
ethics – are applicable in all the countries.
Regulation
can be defined as the means of controlling the quality of a professional service.
In the case of healthcare its primary purpose is focused on the protection of
patients, who rely on regulatory systems to ensure that the doctorsthey consult
will practise in accordance with the high standards expected of a medical-
qualified practiitoner.
Actually
in Europe we have two systems of funding and remuneration of National Health
Systems:
Bismarkian
social
protection systems, that is in Germany, France and southern Europe, are financed
by payroll deductions with a mix of public (salaried) and private (fee for item
of service) providers. This may lead to uneven distribution of risk protection.
In addition there can be institutional fragmentation leading to inequalities
between professional groups and in the provision of healthcare for different
localities as a result of weak state influence in social protection.
It
should be noted that in several East European Countries the critical economic
situation has had a severe effect on the health care system with high level of
stress, poor working conditions and saaries not infrequently below the minimum
wage level sometimes not be paid at all resulting in significant arrears.
Beveridge
type
health systems, as in great Bretain, Sweden, Spain, Denmark and Italy, are
funded trough taxation with mainly public providers and staff employed directly
by the State. These in general have a lower expenditure and have more effective
control on overall expenditure abd have more amenable to reform. There is
however in most cases private sector provision – fee for item of service –
running parallel with the State system although this is relatively limited.
An
important function on high level of care is played by Clinical Guidelines, that
are expression of Evidence Based Medicine and are generally compiled by
Scientific Societies. The doctor following discussion of the options with the
patient in the light of the diagnostic choices available must make the ultimate
judgement regarding a particular clinical proceure or treatment plan. The next
aggreement of UEMS is the collaboration with G.I.N. Guideline International
Network, that is one of the most important indipendent european association for
elaboration of medicine guidelines.
We
mean that the application of medicine guidelines is an ethical manner to make
medicine, because our first aim is the protection of patients and the sole
guarantee for him is to have health care with Evidence Based Medicine.
But
one of the most important problems is the free movement of patients and doctors:
we need of a regulation, of a harmonisation, because in this EU we have 25
Health National Systems, and in some countries, as Italy, is possible to have 20
regional Health systems, one for every region... This is a brake to access to
health system by patients, and also EU don’t sufficiently take into
consideration the specific nature of health services.
A
first step can be the card that is
in distribution to all european citizens ( and also this can be a good emotion :
to be european citizens ), from each member State, the European Health insurance
card, that give to everyone citizen to possibility to have gratis all the cure
that he need into the Union Countries. This card permit the direct access,
without long waiting, into an Hospital or in a doctor’s study of an other
european countrie, but not for ever: this card permit only the cure that a
citizen need during a short travel or a short holiday. Could be this the
beginning of an European Health care system that put everyone on the same floor
and guarantee at all the people the access to medicine and to cure of the
highest level? I think that this is our hope.
