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Doc. 9903
11 September 2003
The reform of health care systems in Europe: reconciling equity, quality and efficiency
Report
Social, Health and Family Affairs Committee
Rapporteur: Mr Ovidiu Brînzan, Romania, SOC
Summary
Reform of health care systems in the member states of the Council of Europe has been a virtually continuous process which seeks to reconcile the often contradictory aims of maximising quality, efficiency and equality of access as well as guaranteeing the viability of the system, against a background of limited government resources and rapid demographic and technological change.
The countries of central and eastern Europe have faced the particularly difficult challenge of achieving equitable, balanced and sustainable systems in the context of transition to a mixed economy.
The Assembly considers that, in line with the objective of greater social cohesion and solidarity, the main criterion for judging the success of health system reforms should be effective access to health care for all without discrimination, a basic human right. Measures to raise additional revenue and contain costs must be sought without affecting equality of access and greater emphasis should be placed on prevention and primary care.
In a number of member states, this summer’s heat wave has dramatically highlighted existing weaknesses in healthcare systems in terms of prevention, capacity of emergency units, lack of hospital beds, understaffing and more generally lack of adequate funds - not only in healthcare but equally in financing home aid support for independent living and care services for the elderly.
The Assembly recommends considering prevention as an independent “fourth pillar” in addition to acute care, long-term care and rehabilitation; giving greater priority to primary care and the role of GPs and strengthening the respect for patients’ rights. It recommends to the Committee of Ministers to step up assistance programmes in the health field with a view to strengthening the implementation of its recommendations, to instruct the appropriate committee to pursue its work on the revision of Articles 11 and 13 of the European Social Charter to widen their scope and to study the trends in member states’ health policies that may have the effect of reducing equality of access to health care.
I. Draft recommendation
1. The Parliamentary Assembly recalls the pledge made in 1996 by the Health Ministers of the European member states of the World Health Organization (WHO), all member states of the Council of Europe, to promote the principles outlined in the Ljubljana Charter on reforming health care in Europe. These are that the reform of European health care systems should be driven by the values of human dignity, equity, solidarity and professional ethics; targeted on health improvement; centred on the needs and expectations of citizens sharing responsibility for their own health; focused on improvement in quality and cost-effectiveness; based on sound financing in order to allow universal coverage and equitable access; and oriented towards primary health care.
2. Seven years on, the Parliamentary Assembly notes that reform of health care systems in the member states of the Council of Europe has been a virtually continuous process which seeks to reconcile the often contradictory aims of maximising quality, efficiency and equality of access as well as guaranteeing the viability of the system, against a background of limited government resources and rapid demographic and technological change. This process has led to a certain convergence between the “Bismarck” systems, contribution-based and managed by the social partners, and the “Beveridge” systems, which are universal, revenue-financed and state-controlled.
3. The countries of central and eastern Europe have faced the particularly difficult challenge of achieving equitable, balanced and sustainable systems in the context of transition to a mixed economy.
4. The Assembly considers that, in line with the objective of greater social cohesion and solidarity set by the Second Council of Europe Summit of Heads of State and Government in 1997, the main criterion for judging the success of health system reforms should be effective access to health care for all without discrimination, a basic human right, and, as a consequence, improvement in the general standard of health and welfare of the entire population.
5. In order to counter the financial pressure involved in providing universal health coverage and the increasing costs associated with secondary care, greater emphasis must be placed on prevention and primary care. Moreover, measures to raise additional revenue and contain costs must be sought without affecting equality of access. The effects of co-payments and private insurance should be studied in this regard and best practice identified.
6. The Parliamentary Assembly welcomes the considerable recent achievements of the Committee of Ministers in the health field, and notably Recommendation (97) 17 on quality improvement systems; Recommendation (98) 7 on ethical and organisation aspects of health care in prison; Recommendation (99) 21 on criteria for managing waiting lists and waiting times; Recommendation (2000) 5 on the development of citizen and patient participation in the decision making process; Recommendation (2001) 12 on the health care needs of people in marginal situations; and Recommendation (2001) 13 on a methodology for drawing up best practice guidelines.
7. The Parliamentary Assembly emphasises the need to systematically promote the implementation by the member states of these and other recommendations of the Committee of Ministers in the health field, as well as those of the Conferences of European Health Ministers, the latest of which was held in Oslo on 12-13 June 2003 on “Health, Dignity and Human Rights”.
8. The Parliamentary Assembly welcomes the work done in the health field by the Organisation for Economic Cooperation and Development (OECD) and looks forward in particular to the results of its current health project (2001-2004) designed to measure and analyse the performance of health care systems in its member countries and factors affecting performance, inter alia waiting times for elective surgery.
9. Given the increasingly international nature of threats to health and demands on health care systems, for example through epidemics, “health tourism”, recruitment of medical staff, or bio-terrorism, the Parliamentary Assembly considers that health policies should be made part of European Union/Community competence in the Constitutional Treaty.
10. The Parliamentary Assembly therefore recommends that the Committee of Ministers:
i. reaffirm the role of the state in regulating healthcare systems;
ii. step up its assistance programmes in the health field with a view to strengthening the implementation of its recommendations to the governments of the member states;
iii. instruct the appropriate committee to pursue its work on the revision of Articles 11 and 13 of the European Social Charter with a view to widening their scope;
iv. study the trends in member states’ health policies that may have the effect of reducing equality of access to health care, for example increasing patients’ contributions (“co-payments”), promoting the expansion of private insurance or concentrating resources on flagship hospitals;
v. call on the member states to take as their main criterion for judging the success of health system reforms the effective access to health care for all without discrimination, as a basic human right and, as a consequence, the improvement of the general standard of health and welfare of the entire population;
vi. call on the member states to consider prevention as an independent “fourth pillar” in addition to acute care, long-term care and rehabilitation;
vii. call on the member states to give greater priority to primary care and the role of general practitioners in order to reduce costs and improve general health and welfare;
viii. call on the member states to strengthen respect for patients’ rights.
II. Explanatory memorandum by Mr Brînzan
Introduction
1. European health care systems have seen several waves of different types of reforms, and can expect to frame new ones. The latest radical reforms in Western Europe date from the end of 1970 to the beginning of 1980, and occurred in the Mediterranean countries. The reforms of the 1980s attempted to control expenditure in order to adapt it to the slackening of growth caused by the oil shocks (1973-79), growth having fallen from 5% on average to below 2% in the major countries. The reforms of the 1990s differ according to whether Western or Eastern Europe is considered. In the first instance, in the West, reform is constant, occurring every 3-5 years on average, but does not affect the traditional organisation and structure; the concerns are quality of care and equity in access. In the second instance, in the Central and Eastern European countries (CEECs) fundamental reforms are being worked out after the downfall of the Soviet-inspired Semashko systems.
2. The Ljubljana Charter in 1996 laid down the fundamental principles meant to inspire these reforms: a comprehensive health policy aimed at improving the standard of health and meeting the individual needs of citizens now more responsible for their own health, and founded on prevention, input from the other sectors, and on primary care, guaranteeing a good cost-effectiveness ratio, justified by an intelligible assessment, and capable of gaining a broad consensus. These principles make it imperative to reallocate resources, build networks, introduce financial incentives or forms of competition, greater administrative independence, contracts between officials, and finally more responsibility and autonomy among carers.
3. These principles remain generally accepted. But it is difficult to transpose grand ideas and principles like this into a concrete system and still preserve them! What is the position regarding their application in 2003.
4. Firstly, what proportion of their GDP do the European countries spend on their public health? In Western Europe, a consensus seems to emerge as regards public expenditure (taxes and compulsory contributions): 6-8% of GDP. This resembles the USA or Japan (6.5% and 6% respectively). Conversely, private spending (patient’s share of cost and optional insurance schemes) varies between countries: 7.5% in the United States, 1.5% in Japan, and from 1% to 2.6% in Europe (United Kingdom and France or Germany). Direct participation by patients or private insurance remains marginal in Europe, France and Germany excepted. Everywhere, public expenditure covers non-insurable care (poverty relief, the elderly, serious illnesses), thus contributing to solidarity, but apparently cannot go higher than 6-8% of GDP whatever the country’s wealth. Private spending makes it possible to increase total expenditure and hence employment, as in the United States, but entails inequality of funding and access; Europe and Japan rely on it less. It is noteworthy that the USA commits about the same percentage of public expenditure as the United Kingdom (in the region of 6%) whereas total expenditure in the USA is double that of the United Kingdom (13.5% and 7% of GDP respectively). Nevertheless, the USA leaves 15% of its population without cover, while the United Kingdom covers 100%. The idea of convergence, i.e. catching up with the average level achieved in Europe, played a major part in the British decision to increase public spending on health in 2002.
5. The CEECs, which used to spend a very low percentage (4-5%) of what was also a low GDP on their public health, are increasing the proportion; however, the recession that followed the transition of the early 1990s reduced the purchasing power of the amount available over several years in certain countries (by half in the Asian republics formerly attached to the USSR). As they become wealthier, these countries are gradually regaining the levels (around 7%) recorded in countries of Western Europe that spent the least. Thus, health expenditure increased from 3.4% to 6.7% of Lithuania’s GDP between 1990 and 2000, 4.5% of it being public money. Nearly all have borrowed from Germany the concept of “compulsory health insurance” strictly regulated by law.
6. A ceiling of 6-8% of GDP therefore seems to apply to public spending on health; to exceed this in the current economic situation, where fresh priorities such as education or security are asserting themselves, does not appear realistic in any country. The biggest-spending countries will probably make up the difference through private contributions, as witness France in Western Europe and Lithuania in Eastern Europe, and in so doing must accept greater inequality.
Guiding principles for reform
7. The European principles remain very much alive and no country challenges them. These principles are: sharing of risks, prior financing of care, universal coverage of the population by a care system in which each person provides finance according to his contributory capacities but benefits according to his medical needs from the services offered. They are found compatible with the stability of the financing mechanisms, i.e. taxation or welfare contributions depending on the group of countries. Questions have been raised concerning the difference between the “Bismarck” systems, contribution-based and managed by the social partners, and the “Beveridge” systems, which are universal, revenue-financed and State-controlled. This distinction tends to fade where financing is concerned, while it persists for the organisational structure. Yet reforms bring about a kind of convergence in order to address problems that differ by nature. This trend implies that the toolbox of administrative and organisational instruments tested in the pioneering countries is gradually becoming universal and is partly used in all reforms.
8. The Bismarck style systems control their total expenditure with difficulty and supply more services to their members, but their very conception embodies inequalities in treatment between occupations or sectors of the economy; the Beveridge type have better mastery of their total expenditure but generate queues or restrictions of choice and have met with persistent, if not worsening, inequalities. Reforms are therefore prompted by different goals in either group of systems, but often result in solutions that converge by using common or similar tools of remuneration or regulation. Each country implements recurrent reforms every three or four years on average, as the German or British reforms testify; each reform has involved adjustments in means of regulation, without fundamentally altering the system in its principles
9. Germany is gradually imposing the pooling of the cost of risks among compulsory health insurance schemes, which amounts to making this principle universal; the corporatist structures managing the health care system are being compelled to limit their public spending, and are being provided with rational financing mechanisms: floating index for specialists, ceiling prices for medicines, fixed fees for hospitals according to the pathology, and rational management of serious illnesses; the see-sawing of these attempts indicates the difficulties encountered in adjusting the mechanisms. England for its part is introducing bargaining procedures into its bureaucratic, universal system with the same misgivings and vacillation in the timetabling of the reforms. The Bismarck system is introducing budgetary limits and financial incentives within a corporatist scheme organised on the bargaining principle. The Beveridge system has unbent its rigidity to admit market procedures (1991 reform), then bargaining (2002 reform). A certain convergence results. All countries in Western Europe are facing the question how they are to reconcile quality, efficiency and solidarity in an ageing society under the pressure of constant technological innovation.
10. What new regulative processes are at work? Greater freedom of choice and more responsibility have led to the introduction of competition between the compulsory statutory health insurance funds in Germany, the Netherlands, and Switzerland. Where beneficiaries have a free choice of health insurance schemes, they tend to form clusters according to degree of risk, and so this solution calls for a strong legislative framework, a strict definition of the insurance bodies’ obligations, and redistribution of funds according to the risk borne by each individual. Competition actually remains limited, but the choice offered opens up an area of freedom to the public and makes the insurance bodies ponder their effectiveness. Private insurance remains marginal except in France.
11. The successes achieved in adapting expenditure to economic growth since 1980 have placed nearly all Europe’s health care systems in a limited budget situation. This has compelled them to favour the most efficacious actions, and consequently to evaluate the types of care, particularly the new technologies, and to define criteria for prioritising them or even excluding care deemed not to be efficacious or high-priority. No country is immune, whether the United Kingdom or France. Many have set up evaluation agencies with the task of establishing what is efficacious or unnecessary care, such as NICE in the United Kingdom or AFSSA in France. The worth of the resultant debates has equalled the difficulty or impossibility of curtailing the “basket of assets and services” approved for collective financing. France presents a good example of it with the medicines designated non-SMR (medical service rendered) whose reimbursement is so difficult to renounce. Pressure from the pharmaceutical industry or the (principally maternity) hospitals proves sometimes impossible to circumvent. When the patient cannot be made to pay, for reasons of justice and social cohesion, when there is no technical or political notion of how availability of care is to be limited, and when economic growth sets a ceiling on spending, rationing is implicit and results in queuing as in England or in staff shortages, plainly observable in several countries such as France. An inescapable reality is that where prices are not the means of rationing, it must be explicit, otherwise it results in either queues (Italy and England) or payments on the side (less advanced East European countries).
12. The OECD is trying to determine the origin of these queues, for instance in surgery, which exist in a majority of European countries. In particular, it is observed that surgeons who perform operations in both the public and the private context may be prompted to let a queue form for the public operations in order to raise private demand. Appropriate financial inducements or controls to limit these undesirable incentives will therefore need to be introduced.
13. The WHO data bases (Health for All) have been most useful for identifying the merits and defects of the national systems, as well as for raising awareness of the urgency of reforms or choosing their direction. But simplistic classifications such as the one published in 2000, placing France in the foreground, can provide justification for opposing a necessary reform. Current WHO work is geared to the production of health, on the basis of research at Cambridge University. In this work, WHO makes use of the HALE (Health Active Life Expectancy) concept and sets out to determine the degree of responsibility and equity in financing. All this work demonstrates how actions conducted outside the health care system, such as education, nutrition and prevention of risk behaviour like smoking, alcoholism and speeding, have a decisive effect on the health of male adults in particular. But the reforms do not readily accommodate this multidisciplinary aspect, especially in the CEECs, more subject to industrial pressure and the urge for a Western lifestyle. The work of WHO has also highlighted the health-related effects of migration movements and of the new poverty in Europe, due to exclusion of populations lacking occupational skills in Western Europe or to redeployment of the State combines in Eastern Europe, generating a new unemployment and a drastic growth of poverty among women, children and the elderly. The present reforms meet the pressing demand of the middle class but take little account of this marginal demand for disaster or emergency medicine, not to be resolved by the health system alone. Inequality is thus growing markedly, in contradiction both to the European principles and the situation which prevailed under communism.
14. The West European health systems achieve a high degree of equality in access to care, often virtually free of charge, to the extent that the reforms make them move increasingly towards universal provision. France for example introduced CMU (Couverture Médicale Universelle) in 2000 for the underprivileged. However, universal systems have an inherent contradiction: by covering the average population, they become more and more expensive and thus encounter insuperable difficulties in covering an increasing number of poor. Marginalisation of entire populations in the Balkans for instance, causing large-scale migrations, confronts the Europe region with problems of “social cohesion” comparable to those of the post-war period.
Reforms in central and eastern Europe
15. Reforms in the CEECs are of a different nature. Their health care systems were both deficient in resources and over-scaled, especially in terms of hospital facilities and medical staff, but ill-provided with modern technologies; their doctors, most on salaries, and their nursing staff were underpaid and consequently both inefficient and inclined to seek illicit payments to offset this injustice; the management and information systems were bureaucratic. General health was deficient: poor life expectancy, high adult mortality, excessive number of deaths by cancer, suicide and cardiovascular disease. A certain proportion of these deaths had external causes such as accidents at work, smoking or alcoholism. The economic recession with which the transition began caused the reappearance of mortality through infections or tuberculosis and an increase in accidents or poisonings. Cigarette and vehicle manufacturers took advantage of the transition to encourage risk behaviour, equated with the “capitalist lifestyle”. As soon as the transition began, it was necessary to reduce the number of hospital beds drastically and often high-handedly, and to meet a strong public demand for quality care and freedom of choice and a need for adjustment of doctors’ incomes and their relative share. Also, resources had to be transferred from the hospitals to the long-stay facilities, to general practice and to preventive medicine. Lastly, financial resources had to be raised via new channels from fragile new enterprises, initially causing large financial deficits.
16. Reform has thus taken place in a difficult macroeconomic environment, with a dwindling GDP, rising unemployment, and a great deal of atypical work on which it is difficult to levy a contribution to the cost - a situation nonetheless considered inimical to reforms in Western Europe. For these countries, it was a matter of radical reforms: they had to do no less than adopt or devise new health systems. Many of them were guided by the principles and instruments tested in the most advanced Western countries and sometimes combined them fearlessly.
17. Hungary provides one of the most coherent examples of this type of reform. With the creation of independent funds under the State budget for financing, Hungary geared its organisation to prevention and primary care. Private facilities (pharmacies) and public ones (hospitals) were made to cohabit. This country borrowed and adapted the remuneration methods which had been tried and proven in the West: freedom to choose among general practitioners remunerated by capitation payment on the British model; hospitals financed by fixed fees tied either to the pathology (on the American DRG – Diagnosis Related Groups - pattern) for care in acute cases, or to the price of a hospital day, European style, for long stays; points system as in Germany for remunerating the specialists financed per item of service. A masterful blend and a remarkable degree of modernity that no Western country can claim. Hungary has also introduced quasi-market devices in setting up treatment management organisations funded by an individual levy, responsible for concluding primary care contracts with the general practitioners, 92% of whom are self-employed while the remainder are employed by the local authorities. They are required to treat the population of the area for which they have contracted, and to abide by treatment protocols. Five years on, the reform has enhanced efficiency: doctors are using treatment protocols and their incomes have doubled; lengths of stay in hospital have decreased by 20% and the number of long-stay beds has grown. Hungary perceives reform as a “process” that destroys the original organisation and shifts the financial balance but in exchange is bound to produce winners and losers. This definition exactly fits the evolution of the more advanced CEECs.
Trends of health care management
18. What reforms are needed to meet two megatrends: technological progress which will stimulate care provision and demand; and ageing of the post-war baby boom generation which will cause a powerful surge of demand between 2010 and 2040? To understand what is at stake for the not far distant future, one should bear in mind the fundamental macroeconomic equivalence that links the three aspects of care in any public health system.
1) Care provision or the professionals’ incomes (product of their salaries S or fees H and their number N); 2) demand or consumption (product of the unit cost of care P and the quantity of care consumed Q; 3) the means of financing or expenditure (sum of the public funds or compulsory levies, taxes I and contributions C, patients’ cost participation M and insurance premiums A). The equivalence is formulated as follows:
Provision = Demand = Resources
Professionals’ = Care = Means of
income = expenditure = financing
(H + S) x N = P x Q = (I + C) + M + A
H + S = fees and/or salary and N = number of carers
P = unit cost of care and Q = volume of care consumed
I + C = taxes or contributions, M = cost borne by the patient and A = insurance premiums
19. A coalition of interests is always formed between, on the one hand, the population who want more care and thus wish to see an increase in P and Q, price and volume of care, and on the other hand the health workers and doctors in practice and in hospitals, who want their incomes H and S and their number N to be higher, and their employment level likewise; it is a coalition to the disadvantage of the payers disbursing the taxes and contributions. Lastly, public funds bring equality but must be controlled by parliament in democratic economies, whereas private funds are at the expense of the patients or the more prosperous citizens and thus carry inequality but can increase indefinitely just like spending on cars.
20. Ageing will firstly affect the “younger old people” reaching retirement who want conventional types of care, principally medicines, who will exert strong pressure chiefly in the CEECs; then twenty years later, the over-80s requiring personal care which means work, just when the working population is due to decrease throughout the European area. Germany and the Mediterranean countries will suffer most from this because of their low fertility. Health expenditure will therefore tend to increase. The financing of pensions, still more demanding, should be added. Thus, assuming the situation remains constant, the aggregate expenditure on health and pensions, now amounting to 16-25% of GDP depending on the country, would reach 25-30% of GDP. This is impossible to finance without a minimum growth rate of 5% per year, and never in the 20th century was this level of performance attained except in the boom period from 1945 to 1975. It seems unlikely that a continent with an exceptionally low workforce participation rate, 66% as against more than 75% in the USA or Japan, and low fertility, could achieve such a performance level without drastic transformation of the labour market. Consequently, three reform scenarios inform the decisions to be taken and show their possible implications having regard to the structural realities of our health systems. They all involve rifts and conflicts.
Concluding remarks: three scenarios for the future
21. 1st scenario: an intergenerational conflict. The governments, irresolute at the extent of the reappraisals, increase the level of health and retirement contributions at the same time. The cost of unemployment need not be mentioned. The burden placed on the depleted active generations absorbs almost one-third of Europe’s GDP, slowing down growth since the necessary levies weigh upon the economy and employment. This gives rise to conflict between the young, active, healthy people who pay the bill and the old, retired, ailing beneficiaries. The graph in annex, relating to Lithuania, clearly illustrates this difference between an active, income-producing population spending little on its health, and a pensioner population that spends more than it receives in retirement income. The necessary redistribution of resources between generations for funding health care can be understood from the graph. The financial burden imposed by people not in active ages tends to become too heavy for the active population.
22. The economically active thus question the established rights defined by their elders for their benefit. Inflation or a political conflict, the possible outcome of this scenario, can be avoided - while still preserving the present entitlements - only by considerably increasing the rate of full activity beyond the age of 60, up to 65 or even 70 years on a part-time basis, both to stimulate economic growth and to provide the requisite labour for the care to be given to the oldest citizens. This adaptation will principally affect the women, active at present, on whom the care of these persons will devolve. Sweden illustrates this adaptation with a high employment rate and a late retirement age after a term of part-time work. It is the only way to rescue the European welfare state as we know it.
23. 2nd scenario: a philosophical conflict. This scenario unfolds in two phases. The governments begin by strengthening the controls already applied during the 1980s and 1990s to contain spending on care and preserve a high rate of reimbursement. This action limits employment in the health sector, while demand increases sharply. Thus a coalition of interests is brought into being between the health professionals, whose jobs and incomes are threatened, and the pensioner population whose needs remain unsatisfied. Europe’s now fragile democracies react with painless regulation by raising patients’ financial participation for most types of care, as Italy and France have already done. The fundamental principles of the European systems – availability free of charge; solidarity – are called into question, and an atmosphere of rationing gains ground in terms of health care and progress in medical technology gains ground. Reforms are carried out in staggered order, with the countries furthest advanced in regulation, such as the small Northern countries, suffering least. This scenario could generate opposition to the process of European integration. Certain budgetary reforms have already sparked this type of reaction in Sweden or Denmark, countries that voted against belonging to the euro zone.
24. 3rd scenario: a political conflict. A final possibility is founded on economic reality and challenges the present conception of the right to care in Europe. Some health expenditure has indeed become mere everyday consumption in the advanced societies, or even spending for the sake of well-being or comfort. This part of health expenditure is not very concentrated, each person spending a moderate amount in proportion to his income, and more or less equally distributed among the population. It is therefore affordable for the majority of the population. It concerns some medicines, those taken otherwise than as directed, sold in supermarkets. It also concerns certain physiotherapy or thermal treatment, treatment which the community does not deem essential, against impotence, minor risks such as influenza, slight pain, stress and fatigue, and products on the borderline between diet and treatment; vitamins, “nutraceuticals” (foods acting as medicine), etc. Care of this kind would cease to be reimbursed. A real health consumerism would then develop, with the people concerned freely choosing from treatments of which they would be well-informed. Collective health spending could decrease by 20-30%, although total expenditure would increase concurrently, supporting activity and employment. Many countries, in “blacklisting” medicines (United Kingdom), or in adopting “reference prices” (Germany), have already taken this course. This scenario is hard to put into practice: for one thing, it would require that the governments define with precision the “basket of goods and services” reimbursed, which they are either unable or unwilling to do at present, and furthermore that prescribing physicians actively co-operate in the screening process and in honouring this collective choice. It is an attitude difficult to elicit in the Latin countries and France. This scenario along Dutch lines avoids limitation of growth as the compulsory levies do not increase as much, the effective demand for care generates activity and jobs as in the United States, and the European ethic is retained where the major contingencies are concerned. By its modernity, and if akin to an American style development in creating two-track medicine, this scenario could cause political conflict. It would in fact be at odds with the social democratic tradition of increasing the European welfare state’s coverage of health care expenses.
25. At all events, there does not seem to be a solution without very extensive reform. A new wave of reforms should be planned promptly as five years are required on average to frame, implement and see the effect of such reform. But any reform will produce winners and losers, inevitably causing conflicts. The question today is which conflict Europe’s governments are best able to face and manage considering the values that they want to safeguard.
2003 heat wave crisis highlighted healthcare deficiencies
26. In what is widely being called one of the hottest summers in 50 years, temperatures in Europe have continued to rise up to 40°C provoking mortality peaks, particularly among elderly. The consequences of prolonged heat wave have particularly badly hit France, Portugal, Spain, and Italy but also Belgium, the Netherlands, Germany, countries in Central Europe and the Balkans.
27. In France, the Government estimates1 that at least 11 500 have died from heat stroke, dehydration and other effects of the withering heat in the first two weeks of August. Four times the number of victims of the World Trade Center. 80% of deceased were elderly above 75 years of age.
28. The heat wave crisis drew public attention to the existing problems of understaffing in hospitals, in homes for elderly, and amongst home aid personnel. The crisis has also revealed the consequences of budgetary cuts, particularly concerning training for nursing staff and cuts in welfare benefits for independent living of elderly.
Reference to committee: Doc. 9249, Reference No. 2666 of 8 November 2001
Draft recommendation adopted on 5 September 2003
Members of the committee: Mrs Belohorská (Chair), MM Christodoulides (1st Vice-Chairman), Surján (2nd Vice-Chairman), Mrs McCafferty (3rd Vice-Chair), Mrs Ahlqvist, MM. Alís Font, Arnau, Mrs Bargholtz, Mr Berzinš, Mrs Biga-Friganović, Mrs Bolognesi (alternate: M. Piscitello), MM. Brînzan, Brunhart, Buzatu (alternate: Ionescu), Çavuşoğlu, Colombier, Cox, Dees, Donabauer, Drljević, Evin, Flynn, Ms Gamzatova, MM. Geveaux, Giertych, Glesener, Gonzi, Gregory, Gülçiçek, Gündüz, Gusenbauer, Hegyi, Herrera (alternate: Mrs Fernández-Capel), Hladiy (alternate: Borzykh), Høie, Ms Hurskainen, MM. Jacquat, Kastanidis, Klympush, Baroness Knight, MM. Lomakin-Rumiantsev, Ms Lotz (alternate: Mrs Rupprecht), Ms Lučić, MM. Makhachev, Małachowski, Manukyan, Markowski, Marty, Maštálka, Mrs Milićević, Mrs Milotinova, MM. Mladenov, Monfils, Ouzký, Padilla, Pavlidis, Mrs Pétursdóttir, MM. Podobnik, Popa, Poty (alternate: Timmermans), Poulsen, Provera (alternate: Tirelli), Pysarenko, Rauber, Riester, Rigoni, Rizzi (alternate: Mrs Paoletti Tangheroni), Mrs Roseira, Ms Saks, MM. Santos, Seyidov, Mrs Shakhtakhtinskaya, MM. Slutsky, Sysas, Ms Tevdoradze, Ms Topalli, Mrs Vermot-Mangold, Mr Volpinari, Mrs Wegener (alternate: Mr Haack), MM. Van Winsen (alternate: Mrs Zwerver), Zernovski, ZZ…
NB: The names of those members present at the meeting are printed in italics.
Secretariat of the Committee: Mr Mezei, Ms Meunier, Ms Karanjac, Mr Chahbazian
1 Communiqué of the French Minister of Health, Family and Disabled persons of 31.08.03.