Print
See related documents
A. Draft
resolution
(open)
B. Draft
recommendation
(open)
5. The impact of the
economic crisis on access to health care: the example of Greece
Report | Doc. 13225 | 07 June 2013
Equal access to health care
Committee on Social Affairs, Health and Sustainable Development
Summary
Access to care is a key aspect of the fundamental right to health. Inequalities in access to health care are growing in the Council of Europe member States due to financial, geographical and language barriers, corruption, socio-economic inequalities, certain migration and security policies and the economic crisis which had repercussions on health systems. These inequalities particularly affect vulnerable groups and lead to a phenomenon of non-recourse or delayed recourse to care, which could have disastrous implications for both individual and public health and lead in the long term to an increase in health expenditure.
With a view to reducing inequalities in access, States should, inter alia, reduce the proportion of health-care expenditure payable by the most disadvantaged patients, ensure that health professionals are accessible throughout the territory as well as access to information on the health system. They should dissociate their security and immigration policies from health policies. Having regard to the importance of continuing to protect the right to health enshrined in Article 11 of the revised European Social Charter, the Committee of Ministers should enhance the role of the European Committee of Social Rights.
A. Draft
resolution 
(open)1. The right to health is a fundamental human right.
Protection of health is an essential condition for social cohesion
and economic stability and represents one of the indispensable pillars
of development. Access to care is a key aspect of the right to health.
2. The Parliamentary Assembly observes that inequalities in access
to health care are growing in the Council of Europe member States.
Various factors are at the root of this phenomenon, including financial, geographical
and language barriers, corruption, socio-economic inequalities and
certain migration and security policies which are unmindful of health
needs. The economic crisis led to budget cuts in many countries,
forced by austerity policies, thereby putting pressure on the health
systems. Several countries have therefore introduced or increased
charges payable by patients, particularly for essential health services.
3. The Assembly notes that inequalities in access to care particularly
affect vulnerable groups, including people experiencing financial
problems such as the unemployed, single parent families, children,
the elderly, as well as Roma, migrants, especially those in an irregular
situation, and homeless people. These inequalities lead to a phenomenon
of non-recourse or delayed recourse to care, which could have disastrous
implications for both individual and public health and lead in the
long term to an increase in health expenditure.
4. Recalling its Resolution
1884 (2012) “Austerity measures – a danger for democracy and social
rights”, the Assembly once again draws attention to the negative
impact of austerity measures on social rights and their effects
on the most vulnerable categories. In this connection, it notes
with concern the impact which the economic crisis and austerity
measures have had on the accessibility of care in several member
countries, including Greece, which is now faced with a health, and
even humanitarian crisis and an increase in xenophobic and racist
acts against refugees and migrants.
5. The Assembly believes that the crisis should be viewed as
an opportunity to rethink health systems and be used to increase
their efficiency and not as an excuse for taking retrograde measures.
6. The Assembly therefore calls on the Council of Europe member
States to:
6.1. reduce, where appropriate,
the proportion of health expenditure payable by the most disadvantaged
patients and take all other necessary measures to ensure that the
cost of care does not hinder access to care, including the promotion
of increased use of generic drugs;
6.2. ensure the accessibility of health-care facilities and
health professionals throughout the territory by taking appropriate
measures, having recourse where appropriate to incentive measures;
6.3. ensure the accessibility of information on the health
system, including vaccination and screening programmes, and set
up health education programmes, while taking account of the specific
needs of the different vulnerable groups and of the requirement
to reduce language barriers to a minimum;
6.4. simplify the administrative procedures required to be
able to receive health care;
6.5. introduce measures to combat corruption in the health
sector, in close co-operation with the Group of States against Corruption
(GRECO);
6.6. dissociate their security and immigration policies from
health policy, where appropriate by abolishing the obligation on
health professionals to report migrants in an irregular situation;
6.7. introduce training policies for health professionals stressing
the need to combat arbitrary applications, discrimination and corruption
in the health sector.
B. Draft
recommendation
(open)1. The Parliamentary Assembly refers to its Resolution
… (2013) on equal access to health care.
2. The Assembly welcomes the recent work of the Committee of
Ministers in the health field, resulting in particular in the adoption
of Recommendation CM/Rec(2010)6 on good governance in health systems, Recommendation
CM/Rec(2011)13 on mobility, migration and access to health care,
the 2011 Committee of Ministers’ Guidelines on child-friendly health
care and Recommendation CM/Rec(2012)8 on the implementation of good
governance principles in health systems.
3. The Assembly regrets, however, that since 2012 the Council
of Europe has been without an intergovernmental committee specifically
responsible for facilitating policy development and exchange of
good practices in the health field.
4. Having regard to the Council of Europe’s principles and values,
it is of paramount importance to continue to protect the right to
health enshrined in Article 11 of the European Social Charter (revised)
(ETS No. 163) and to enhance the role of the European Committee
of Social Rights so that it can perform this task as effectively as
possible.
5. In the light of the foregoing, the Assembly recommends that
the Committee of Ministers:
5.1. urge
those member States which have not yet done so to sign and ratify
the European Social Charter (revised) and the protocols thereto;
5.2. take measures to ensure rapid progress towards implementation
of the Charter in line with the conclusions and decisions of the
European Committee of Social Rights;
5.3. encourage other sectors of the Council of Europe to include
health-related issues in their work, based on a cross-sectoral approach.
C. Explanatory memorandum by Mr Lorrain, rapporteur
(open)1. Introduction
1. The right to health is a fundamental human right.
Protection of health is an essential condition for social cohesion
and economic stability and
represents one of the indispensable pillars of development. Access to care is a key aspect of
the right to health.
and
represents one of the indispensable pillars of development. Access to care is a key aspect of
the right to health. 2. The principles of universality, equity and solidarity are
among the key principles of good governance in health systems. These
principles, including that of equity, require that equal access
to health care be guaranteed both in law and in practice. Unfortunately,
inequalities in access to health care are growing in the Council
of Europe member States. Various factors are at the root of this
phenomenon, such as financial and geographical barriers, social
and economic inequalities, corruption, and certain migration and
security policies, to name just a few.
These
principles, including that of equity, require that equal access
to health care be guaranteed both in law and in practice. Unfortunately,
inequalities in access to health care are growing in the Council
of Europe member States. Various factors are at the root of this
phenomenon, such as financial and geographical barriers, social
and economic inequalities, corruption, and certain migration and
security policies, to name just a few.3. The economic crisis has had major repercussions in terms of
household income, particularly for the most vulnerable groups, thus
creating new inequalities, and has led to an increase in health
needs. Furthermore, austerity policies have targeted public health
systems in many countries and have resulted in increased user charges.
4. Consequently, while the well-off population still has relatively
easy access to available resources, some vulnerable groups face
increasing difficulties of access to the benefits provided by health
systems. These groups include people experiencing financial problems
such as the unemployed, single parent families, the elderly, as
well as Roma and migrants, particularly those in an irregular situation.
5. The purpose of this report is to identify, on the basis of
national examples, the factors that lead to inequalities in access
to health care, in order to suggest strategies for reducing those
inequalities. It is intended neither as an exhaustive analysis covering
all problems of inequality in access to care nor as a comparative report
on inequalities in access to the different types of care (primary
care, psychiatric care, antenatal care, etc.) and according to inequalities
experienced by the different vulnerable groups (migrants, persons
with disabilities, Roma, women, the elderly, prisoners, etc.), given
that this would require a much more in-depth study.
6. In this report, particular attention is paid to the impact
of the economic crisis on health systems, and in particular on the
accessibility of care, on the basis of the information gathered
during the fact-finding visit to Athens (Greece) from 11 to 13 April
2013.
2. Access to health care: a key aspect of the right to health
7. According to the United Nations Committee of Economic,
Cultural and Social Rights, access to health care is a key aspect
of the right to health. The right to health also embraces a wide
range of socio-economic factors that promote conditions in which
people can lead a healthy life, and extends to the underlying determinants
of health, such as food and nutrition, housing, access to safe and
potable water and adequate sanitation, safe and healthy working
conditions, and a healthy environment. Equal access to health care requires States to guarantee access
to health-care facilities to individuals without sufficient means,
as well as to prevent any discrimination in health-care provision.
8. The right to health is guaranteed by various international
and regional human rights instruments, as well as by many national
constitutions. The
Constitution of the World Health Organization (WHO), adopted in
1946, was the first document to proclaim that “[t]he enjoyment of
the highest attainable standard of health is one of the fundamental
rights of every human being”. Two years later, the Universal Declaration
of Human Rights stated in Article 25.1 that “[e]veryone has the
right to a standard of living adequate for the health and well-being of
himself and of his family …”. In 1966, the United Nations International
Covenant on Economic, Social and Cultural Rights enshrined the right
to health in a legally binding international instrument for the
first time. According to Article 12.1, the States Parties recognise
“the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health”.
The
Constitution of the World Health Organization (WHO), adopted in
1946, was the first document to proclaim that “[t]he enjoyment of
the highest attainable standard of health is one of the fundamental
rights of every human being”. Two years later, the Universal Declaration
of Human Rights stated in Article 25.1 that “[e]veryone has the
right to a standard of living adequate for the health and well-being of
himself and of his family …”. In 1966, the United Nations International
Covenant on Economic, Social and Cultural Rights enshrined the right
to health in a legally binding international instrument for the
first time. According to Article 12.1, the States Parties recognise
“the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health”. 9. At Council of Europe level, the revised European Social Charter
(ETS No. 163) recognises the right to protection of health (Article
11) and the right to social and medical assistance (Article 13). Protection
of the right to health as recognised by the Charter presupposes, inter alia, the establishment of
accessible and effective care facilities for the entire population.
Finally, Article 3 of the Convention for the Protection of Human Rights
and Dignity of the Human Being with regard to the Application of
Biology and Medicine (ETS No. 164) calls on the Contracting Parties
to provide “equitable access to health care of appropriate quality”.
Protection
of the right to health as recognised by the Charter presupposes, inter alia, the establishment of
accessible and effective care facilities for the entire population.
Finally, Article 3 of the Convention for the Protection of Human Rights
and Dignity of the Human Being with regard to the Application of
Biology and Medicine (ETS No. 164) calls on the Contracting Parties
to provide “equitable access to health care of appropriate quality”.3. Factors leading to inequalities in access to health care
10. Despite the diversity of methods of funding and organising
health systems in Europe, two broad trends can be identified: compulsory
sickness insurance systems funded by social insurance contributions
shared between employers and employees (for example Czech Republic,
France, Germany, Hungary, Poland, Romania) and national health systems
funded by the State on the basis of public revenues, especially
taxes (for example Denmark, Ireland, Italy, Spain, Sweden). In all
these systems, patients pay user charges, which vary in the amounts
payable. Lastly, private insurance schemes (whether voluntary or
compulsory) play
an additional role, especially with regard to medical expenses not
or only partly covered by the public health system.
play
an additional role, especially with regard to medical expenses not
or only partly covered by the public health system. 11. Equal access to health care presupposes the availability of
care to everyone, both in law and in fact. This means removing any
obstacles or barriers which might hinder certain individuals or
groups from gaining access to the benefits provided for under the
health system. These include financial barriers (cost of care),
the limited scope of benefits, geographical barriers (problems regarding
the accessibility of care over the entire territory, particularly
in rural areas), language barriers or information barriers (poor
knowledge of the health system), as well as corruption. These are
factors associated mainly with health systems.
12. Inequalities in access to health care are also the result
of other factors such as discrimination (which will not be considered
in this report), socio-economic factors
and certain migration and security policies. One, several, or all
of these factors may be at the root of inequalities in access and
it is not always easy to identify the particular factor(s) involved.
For example, the very limited use of a particular type of care in
a given region might indicate the existence of geographical obstacles
hindering access to that type of care, whereas its very limited
use in a given population group would rather tend to suggest that
its cost is too high (financial barrier).
socio-economic factors
and certain migration and security policies. One, several, or all
of these factors may be at the root of inequalities in access and
it is not always easy to identify the particular factor(s) involved.
For example, the very limited use of a particular type of care in
a given region might indicate the existence of geographical obstacles
hindering access to that type of care, whereas its very limited
use in a given population group would rather tend to suggest that
its cost is too high (financial barrier).13. Similarly, delayed recourse to care in a given group could
be an indicator that the group is unable to afford the care (financial
barrier) as well as being unaware of its right to receive the care
in question (information barrier). In certain circumstances, exceptionally
heavy use of a particular type of care (such as emergency care)
may also indicate unequal access to it, simply because its root
cause may be an impossibility to access the appropriate care at
the right time. In this context, the collection of data on the state
of health and the use of health services, with a breakdown by sex,
age, region and group, is essential in order to identify inequalities in
health and access to health care as well as the factors underlying
them.
14. Unequal access often leads to a situation of non-recourse
or delayed recourse to care, which has implications for both individual
and public health.
3.1. Factors associated with health systems
15. In its World Health Report (2010), WHO emphasises
the move to universal coverage, which it regards as an essential
means of promoting and protecting health. WHO defines universal
coverage as access for everyone to the health services they need
without suffering financial difficulties in paying for them. Today,
the provision of health systems that guarantee universal coverage,
particularly for those with the lowest incomes, remains an objective
for European countries, in view of the various factors described
below. In this connection, it should be noted that major economic
and/or political events (such as an economic crisis, a change of
regime or a war) often lead to the collapse of the existing health
system, thus having a disastrous impact on the accessibility of
care. Similarly, the concerns aroused by dwindling resources and
the crisis in health expenditure (see below) have significantly
changed the way in which health is organised, funded and administered
and have led in some countries to a rationing of health care, which
also has major implications for the accessibility of care.
WHO defines universal
coverage as access for everyone to the health services they need
without suffering financial difficulties in paying for them. Today,
the provision of health systems that guarantee universal coverage,
particularly for those with the lowest incomes, remains an objective
for European countries, in view of the various factors described
below. In this connection, it should be noted that major economic
and/or political events (such as an economic crisis, a change of
regime or a war) often lead to the collapse of the existing health
system, thus having a disastrous impact on the accessibility of
care. Similarly, the concerns aroused by dwindling resources and
the crisis in health expenditure (see below) have significantly
changed the way in which health is organised, funded and administered
and have led in some countries to a rationing of health care, which
also has major implications for the accessibility of care.3.1.1. Eligibility criteria and limited scope of benefits
16. Many health-care systems make benefiting from health
care dependent on eligibility criteria, such as lawful residence
or the possession of an employment contract. However, unemployed
people, Roma and migrants often encounter difficulties in accessing
the job market and are therefore at a disadvantage with regard to
accessing health care. In Bulgaria, for example, 46% of Roma are
reported to have no health insurance as they do not meet the eligibility
criteria. In
Spain, a new law brought into force by royal decree in April 2012
now makes access to health care more difficult for unemployed people.
This is also the case in Greece, although it should be noted that
coverage continues for a year after becoming unemployed. As a consequence,
hundreds of thousands of unemployed people and undocumented migrants
have virtually no access to health care.
In
Spain, a new law brought into force by royal decree in April 2012
now makes access to health care more difficult for unemployed people.
This is also the case in Greece, although it should be noted that
coverage continues for a year after becoming unemployed. As a consequence,
hundreds of thousands of unemployed people and undocumented migrants
have virtually no access to health care.17. The limited scope of benefits is another obstacle to access
to care. The typical example is dental care, which is excluded from
lump-sum repayments in some countries (for example Belgium, Denmark,
Greece, Portugal and Switzerland). The exclusion of certain benefits
means that patients are obliged to cover the cost themselves, and
this accordingly hinders access to care for low-income groups.
3.1.2. Financial barriers
18. As mentioned above, all health systems have charges
payable by patients, sometimes referred to as “user charges”. These
are sums which patients must pay in order to be able to make use
of the service in question (consultation, medication), the remainder
being covered by the health system. While the level of this contribution
varies from one country to another, the lack of financial protection
to make up the amounts not covered by the health-care system may
considerably limit access to care for vulnerable categories, such
as pensioners of limited means, the chronically ill etc. According
to a survey published in July 2010 by the French social research
institute Centre de recherche pour l'étude
et l'observation des conditions de vie, one French person
in seven, or around 14% of the population, is forced to restrict
spending on medical care owing to the costs involved. In Georgia,
user charges payable by patients reportedly account for 74.7% of
total health expenditure. These inequalities may lead to extremely
high health expenditure in excess of 40% of household income.
19. In this connection, it should be stressed that, according
to the European Committee of Social Rights, the right to access
to health care presupposes that the cost of care should not place
an excessive burden on individual patients. The Committee therefore
recommends the introduction of measures to alleviate the effects of
user charges in disadvantaged population groups.
3.1.3. Geographical barriers
20. Geographical disparities in terms of accessibility
of services represent another obstacle to access to care. These
disparities may be due to the lack of a health-care facility close
to the patient’s home, the lack of transport between the patient’s
home and the nearest health-care facility, and the time and cost
involved in making the journey. In this connection, there is a clear
dividing line between urban and rural areas. In the European Union,
the number of people who report problems of access to medical care
because of the distance to the nearest hospital is twice as great
in rural areas as in urban areas. In Ukraine in 2009, 30% of rural households
said they did not have access to primary health services, medical
centres, clinics and pharmacies. Poor
distribution of available doctors is another problem which should
be stressed in this context. In France, for example, there are 458
doctors per 100 000 people in urban areas, but only 122 per 100 000
in rural areas.
Poor
distribution of available doctors is another problem which should
be stressed in this context. In France, for example, there are 458
doctors per 100 000 people in urban areas, but only 122 per 100 000
in rural areas. 3.1.4. Language barriers
21. The impossibility of, or difficulty in, communicating
with medical personnel is a major obstacle to access to health care,
especially for migrants who do not have an adequate command of the
host country’s language, but also for persons suffering from sensory
disabilities. Contrary to what might be thought, this applies not
only to “recent” migrants or non-working migrant women who live
under particularly isolated conditions in the host country, but
also to elderly persons of immigrant origin and migrants suffering
from an intellectual disability.
22. Language barriers disrupt the entire process of medical consultation
from beginning to end, including the establishment of a relationship
of trust between the patient and the doctor. In addition to the
difficulties this creates for patients in giving free and informed
consent to any treatments they may be offered, the difficulty or impossibility
of understanding the patient’s problem often leads medical staff
to perform multiple tests – which are not necessarily appropriate
or essential – in order to identify the problem. In some cases,
language barriers may go so far as to cause a public danger, for
example where a patient suffering from tuberculosis does not understand
that she/he must continue her/his treatment for several months.
3.1.5. Corruption
23. Corruption in the public health sector is another
important aspect to be taken into consideration when studying inequalities
in access to health care. It takes various forms, including unofficial
payments to health professionals, in other words the payment of
bribes in order, for example, to avoid being placed on a long waiting
list (for a consultation or an operation) or, worse still, simply
to receive treatment. Whatever the purpose, and leaving aside the
other nefarious effects of corruption in general, the practice of
bribes creates an inequality in access to health care, to the detriment
of those who lack sufficient means. On this latter point, it is
interesting to note that, according to studies which have been brought
to the attention of the Group of States against Corruption (GRECO),
access to health care is one of the areas in which corruption could
have a potentially differentiated impact on men and women. GRECO
has therefore supported the inclusion of a gender perspective in
national surveys of corruption as an obstacle to equality in access
to care.
24. The Office of the United Nations High Commissioner for Human
Rights has noted that the low salaries of health professionals combined
with a lack of ethics training, a non-transparent system of financing
by the national health system and underfunded clinics create fertile
ground for bribery. While the prevalence of corruption
varies from one member State to another, the statistics for the
European Union member States are not gratifying. According to a
recent report by the European Health Care Fraud and Corruption Network,
of the thousand billion euros spent in health services in the European
Union, 56 billion euros are lost to fraud and corruption.
While the prevalence of corruption
varies from one member State to another, the statistics for the
European Union member States are not gratifying. According to a
recent report by the European Health Care Fraud and Corruption Network,
of the thousand billion euros spent in health services in the European
Union, 56 billion euros are lost to fraud and corruption. 3.1.6. Other barriers
25. Ignorance of one’s rights and of the rules by which
health systems operate is another factor making for inequalities
in access to health care. In this connection, Médecins
du Monde note that 60% of all patients who attend their
clinics do not know where to go to get vaccinations.
26. Unduly complex administrative procedures and excessive red
tape before being able to receive treatment (for example production
of valid identity documents, proof of residence, proof of insufficient
income, home visits, etc.) tend to create additional obstacles to
access to health care, especially in the case of vulnerable groups.
3.2. Socio-economic factors
27. A study carried out in developing countries shows
that access to health services depends to a significant extent on
the socio-economic characteristics of a household, especially the
mother’s education. According to the study’s authors, a policy to
provide universal education for girls could therefore contribute
to significantly improving access to health for poor people.
shows
that access to health services depends to a significant extent on
the socio-economic characteristics of a household, especially the
mother’s education. According to the study’s authors, a policy to
provide universal education for girls could therefore contribute
to significantly improving access to health for poor people.28. Socio-economic factors also play an important part in health
inequalities. Statistics on the mortality rate and state of health
of Europeans reveal substantial inequalities both between countries
and between socio-economic groups in the same country. For example,
in 2009, life expectancy at birth was 82 in Switzerland (80 for
men and 84 for women), whereas it was only 68 in Russia (62 for
men and 74 for women). Life expectancy at
birth for men was 54 in Calton, a poor area of Glasgow (Scotland),
whereas in Lenzie, only a few kilometres away, it was 82.
Life expectancy at
birth for men was 54 in Calton, a poor area of Glasgow (Scotland),
whereas in Lenzie, only a few kilometres away, it was 82. 29. This situation cannot be explained solely by inequalities
in access to health care. Such disparities are due in particular
to socio-economic factors such as income, employment, education
and living and working conditions, and their unequal distribution
among the population. According to WHO experts, disadvantaged communities
are handicapped in many different ways: “poor education, lack of
amenities, unemployment and job insecurity, poor working conditions,
and unsafe neighbourhoods, with their consequent impact on family life”
and they add that “[t]his unequal distribution is not in any sense
a ‘natural’ phenomenon but is the result of policies that prize
the interests of some over those of others – all too often of a
rich and powerful minority over the interests of a disempowered
majority”.
3.3. Migration and security policies
30. The trend in Europe towards increasingly stringent
migration and security policies aimed at deterring, in particular,
Roma and undocumented migrants is also a factor that leads to inequalities
in access to care. In this context, the repeated expulsions of Roma
in France have made it nearly impossible for some members of this group
to access health care. Similarly, the requirement for health professionals
and/or public servants to report irregular migrants discourages
many of the latter from making themselves known to the health authorities,
for fear of being reported and sent back to their countries of origin.
31. These policies also have an impact on health policies. In
Spain, for example, since 1 September 2012, undocumented migrants
have been excluded from most of the public health system, whereas the law previously provided for
all residents to have access to health care, whatever their status.
whereas the law previously provided for
all residents to have access to health care, whatever their status. 32. As the HUMA (Health for Undocumented Migrants and Asylum seekers)
network observes, “the debate concerning undocumented migrants continues
to be rooted in the fight against ‘illegal migration’, and no debate has
yet been opened, if only for public health concerns, about the need
to protect the health of these people”. The migration and security policies
in question not only put the lives of those concerned at risk and
stigmatise these individuals even more, but also constitute a real
public health problem in the case of communicable diseases, as the
inability to access care or a delay in doing so exposes the entire
population to possible infection.
The migration and security policies
in question not only put the lives of those concerned at risk and
stigmatise these individuals even more, but also constitute a real
public health problem in the case of communicable diseases, as the
inability to access care or a delay in doing so exposes the entire
population to possible infection. 4. European health systems faced with the economic crisis
33. Nowadays, longer life expectancy, due in particular
to medical advances, is accompanied by a sharp rise in chronic diseases
(cardiovascular and respiratory diseases, diabetes, cancer, etc.)
and neurodegenerative conditions (Alzheimer’s and other forms of
dementia), as well as the emergence of new diseases. Although medical
advances enable increasingly specialised treatments to be developed
in order to meet these challenges, it is still extremely costly
to fund them. As a consequence, care needs have risen dramatically
in the last few decades. In the face of this mounting financial
pressure, the viability of European health systems has been put
to the test and many States have embarked on reforms to increase
the efficiency of their health systems.
34. The situation has recently been exacerbated by the economic
crisis, which is having a dual impact on health-care systems. On
the one hand, the austerity measures adopted by governments are
leading to cutbacks in public expenditure, including on health care.
On the other, the crisis is having a significant effect on the socio-economic
determinants of health, such as access to employment or housing,
especially for vulnerable groups, which could be reflected in a
rise in care needs. This eventuality is confirmed by an article published
recently in The Lancet, which
analyses the effects of the crisis on the basis of national surveys
and statistics. In the case of the United Kingdom, the study notes
that the rise in the suicide rate between 2008 and 2010 can be linked
to rising unemployment, which resulted in 1 000 additional deaths.
In Spain, cases of mental illness increased substantially between
2006 and 2010 and it is estimated that at least half of these cases
are due to unemployment and difficulty in paying mortgages.
35. A study recently published by WHO points
out that, in order to adapt their health-care systems to the exigencies
of the crisis, States have pursued very different policies, which
may be divided into three types: policies aimed at changing the
level of contributions to fund health services, especially by making
budget cuts and increasing or introducing user charges for patients;
policies aimed at changing the range and quality of services; and
policies aimed at influencing the cost of care, especially by lowering
the price of medical goods or lowering or freezing the salaries
of health professionals, and by promoting the rational use of medicines.
In most countries, the breadth of coverage and the population covered
have not radically changed. However, several countries have
introduced or increased user charges for essential health services.
There is a risk that this will disproportionately affect access
to care for vulnerable categories such as low-income groups, the unemployed,
migrants and regular users of these services such as those suffering
from chronic diseases. The authors of the study note that, in the
long term, measures of this type might lead to an increase in health expenditure
owing to the costs arising from delayed recourse to treatment (aggravated
clinical state requiring more expensive treatment).
points
out that, in order to adapt their health-care systems to the exigencies
of the crisis, States have pursued very different policies, which
may be divided into three types: policies aimed at changing the
level of contributions to fund health services, especially by making
budget cuts and increasing or introducing user charges for patients;
policies aimed at changing the range and quality of services; and
policies aimed at influencing the cost of care, especially by lowering
the price of medical goods or lowering or freezing the salaries
of health professionals, and by promoting the rational use of medicines.
In most countries, the breadth of coverage and the population covered
have not radically changed. However, several countries have
introduced or increased user charges for essential health services.
There is a risk that this will disproportionately affect access
to care for vulnerable categories such as low-income groups, the unemployed,
migrants and regular users of these services such as those suffering
from chronic diseases. The authors of the study note that, in the
long term, measures of this type might lead to an increase in health expenditure
owing to the costs arising from delayed recourse to treatment (aggravated
clinical state requiring more expensive treatment). 36. As already pointed out above (see paragraph 32), problems
of access to care and delayed recourse to treatment could have another
consequence, not of an economic nature, but no doubt far more disastrous, namely
the public health risk associated with possible exposure of the
population to communicable diseases or the use of counterfeit medicines.
5. The impact of the
economic crisis on access to health care: the example of Greece
37. Greece is one the countries worst hit by the current
economic crisis in Europe. In exchange for “financial rescue plans”,
the government has adopted drastic austerity measures demanded by
the Troika consisting of the European Commission, the Central European
Bank and the International Monetary Fund. These measures have affected
all sectors, but especially the health sector, where significant
budget cuts have been made. There is now talk of a health, and even
humanitarian crisis affecting more and more people, principally
the unemployed, migrants, refugees, Roma, women and children.
38. The Greek public medical insurance system is based on employment.
Consequently, with some exceptions, only those who have a job and
those who have been unemployed for less than a year are entitled to
medical coverage. In a country where the unemployment rate has climbed
to 27% in the population as a whole (youth unemployment stands at
over 60%), the effect of an employment-based system is therefore
to exclude a very large proportion of the population from access
to health care. People with insurance coverage still have to pay
€5 for each visit to hospital, and charges are made for any tests
that have to be performed during the consultation.
39. The budget cuts have particularly affected public hospitals,
where some basic supplies, such as syringes, compresses, latex gloves
or suture thread, are out of stock and medical personnel are sometimes forced
to ask patients to purchase these supplies themselves. The difficulties
related to Greece’s geography (its territory includes hundreds of
islands) have grown worse with the crisis. The islands suffer in
particular from staff shortages: many small islands have no doctor
at all and others “share” a doctor with other islands. The larger
islands, for their part, suffer from a shortage of specialists.
A significant increase can be seen in the number of HIV carriers,
and cases of tuberculosis are reappearing (although they remain
isolated). Vaccines are no longer free, and children are not accepted
in schools unless they are vaccinated.
40. The situation facing migrants is growing steadily worse. With
the crisis, many have lost their jobs and fallen into an irregular
situation and, as a result, no longer have access to health care.
The problem of irregular mixed migration flows to Greece poses a
real challenge to the government. In 2012, it spent 120 million
euros on improving access to health care for irregular migrants,
whose number is currently estimated at over a million. Special centres
have been set up to cater for these migrants. At these centres,
an initial medical examination is carried out for each new arrival.
Where necessary, patients are referred to a public hospital to receive
the proper care. Access to basic care is guaranteed throughout their
stay in these centres.
41. Under current regulations, everyone has access to free emergency
care. In practice, however, this requirement is not always met.
In this connection, the situation of pregnant women who have no
medical coverage is particularly worrying. If they are admitted
to emergency services to give birth, they are subsequently required
to pay the relevant charges, which vary between 800 and 1200 euros.
Cases were mentioned of hospitals which refused to issue a birth
certificate or even to let the newborns leave the hospital until
the charges had been paid.
42. NGOs report an alarming increase in the number of people who
come to them for help, including Greek citizens, most of whom are
people suffering from chronic illnesses. Because of salary cuts
and the increased charges for medicines (25% of the total cost),
even people with medical coverage are unable to afford their medicines.
Faced with growing demand, Médecins du
Monde now issue medicines on presentation of a prescription,
whereas a prior consultation was previously required.
43. Greek citizens have set up what is effectively a parallel
health system based entirely on solidarity and voluntary work. An
example of this is the free clinic in Hellenikon, where dozens of
doctors work on a voluntary basis. Set up in 2011, the clinic caters
in particular for patients who have no medical coverage and collects medicines
which it subsequently distributes to its patients.
44. The Ministry of Health has embarked on some fundamental reforms
aimed at improving management of the health system and making it
more viable, and guaranteeing universal access to primary health
care. In this context, there are also plans to strengthen the social
security safety net in order to guarantee access to health care
for the most vulnerable groups. The plans include the introduction,
in 2013-2014, of a “health ticket” to guarantee access to care for
200 000 people (not covered by sickness insurance). This project
is funded by the European Union.
45. Lastly, xenophobic and racist acts against refugees and migrants
have increased alarmingly. Also, asylum-seekers and refugees from
certain countries who enjoy limited medical coverage by virtue of
their status say they have been ignored and/or mistreated by medical
personnel.
6. Conclusions
46. To guarantee the fundamental right to health, the
Assembly should recommend that everyone living in Europe should
be able to enjoy equal access to health care regardless of their
financial situation, their residency status or their place of residence.
The Council of Europe member States should therefore take all necessary
measures to reduce and eliminate inequalities in access to care.
To identify inequalities in health and access to health care and
the factors leading to them, States should gather reliable data
on the health status and use of health services by people living
in their territory.
47. With regard to the factors associated with the health system,
States should reduce user charges, with particular attention to
the most disadvantaged social categories, and ensure access to health-care
facilities and competent health professionals throughout their territory.
They should also strengthen free linguistic assistance in health-care
facilities at all stages of service provision (consultation, provision
of medical information, etc.). This includes translation and mediation
services for people who do not speak or understand the language,
sign language and other forms of support for persons suffering from
sensory or intellectual impairments.
48. States should also ensure the availability of information
on the health system, including vaccination and screening programmes,
especially for disadvantaged groups, and provide health education
programmes.
49. States should also tackle the socio-economic factors influencing
health, such as access to employment and housing. This is especially
important in the current context of economic crisis in Europe, which
should on no account be used as an excuse giving governments a free
hand to take retrograde measures disregarding the fundamental right
to health, to the detriment, in particular, of vulnerable groups,
who, moreover, are often hardest hit by economic crises. The crisis
should be viewed as an opportunity to rethink health systems and increase
their efficiency.
50. Lastly, health and humanitarian considerations should take
precedence over all other considerations. The Council of Europe
member States should therefore dissociate their security and immigration
policies from their health policies.