Health and the challenges of enlargement

Health and the challenges of enlargement

FORUM:

Access to Health

 

Moving east across Europe, life expectancy falls. On average men in central and eastern Europe can expect to live seven years less than their counterparts in the European Union. Women are not as disadvantaged. They can expect to live 5.5 years less than their western counterparts. Life expectancy can also be described in terms of life chances of reaching a 65th birthday. Men in the 12 enlargement countries are twice as likely to die before reaching 65 years as a man in the European Union. Women are 70% more likely to die before reaching their 65th birthday.

Explaining the gap

The three main causes of death are the same as in western Europe namely heart disease, cancer and injuries. However, the rates of childhood accidents are much higher in central and eastern Europe. Child mortality by drowning represents the greatest gap in the East – West figures.

Even in the 1980s, there was considerable diversity between countries. For example, age standardised death rates from ischaemic heart disease (male) and from external causes, injury and poisoning (both sexes) were higher in Estonia, the Czech Republic and Poland than the EU average. Since 1990, progress has been very different in different countries. For example, the Czech Republic has seen a 50% improvement in deaths from heart disease whereas in Romania rates increased until 1996 and have only now fallen. In the Baltic republics there has been a different pattern again, mirroring that seen in Russia. These differences provide important clues about why the health gap exists. They have little to do with genetics and everything to do with the social environment.

Child injury deaths in the EU and Central and Eastern Europe

Rates for both applicant countries and member states refer to 1991-95 and show injury deaths per 100,000 children aged 1 to 14 years.

 

Sweden	5.2		Austria	9.3
UK	6.1		HUNGARY	10.8
Italy	6.1		SLOVENIA	11.6
Netherlands	6.6		SLOVAKIA	11.6
Greece	7.6		CZECH REPUBLIC	12.0
Denmark	8.1		POLAND	13.4
Spain	8.1		Portugal	17.8
Finland	8.2		BULGARIA	17.9
Germany	8.3		LITHUANIA	29.2
Ireland	8.3		ROMANIA	32.1
France	9.1		ESTONIA	33.2
Belgium	9.2		LATVIA	38.4

Source: UNICEF Innocenti Report Card No.2

Identifying the causes

“The usual suspects”, namely diet, alcohol and smoking, are the main causes of the differences in health status in different countries of Europe.

Diet has improved considerably with the opening up of markets in Central and Eastern Europe, especially increasing access to a wide range of fruit and vegetables. Rapid changes for the better have taken place in Poland and the Czech Republic as a result of improved diet, but much slower improvement has t aken place in Hungary and Romania. The Central European diet is much lower in fruit and vegetables than in Western Europe. It is also somewhat higher in fat content.

Smoking is more common than in western Europe, and while rates among women have been lower, they are now increasing rapidly. In contrast to the situation with diet, this represents the downside of opening up of trade. Advertising has increased, and many new western cigarette factories have been started in Central and Eastern Europe. The smuggling of tobacco products across borders has been sanctioned and promoted by tobacco companies (www.newsunlimited.co.uk). At the same time, there has been an almost complete failure (with the notable exception of Poland) to tackle the tobacco industry. The relative risk of lung cancer among those who smoke has been shown to be higher among those consuming less fruit and vegetables.

Different types of alcohol are also more available, and more promoted, with the opening up of markets. Research in the former Soviet Union, including the Baltics, has radically changed our understanding of the health effects of alcohol. Studies in the former Soviet Union have highlighted the effects of alcohol on road and home injuries. The health effects of binge drinking are especially serious in vodka-drinking countries. Hungary, Slovenia and Romania all have high rates of cirrhosis of the liver.

Inequality and the poverty factor are also important in identifying the underlying causes of premature deaths in Central and Eastern Europe. The causes of death that are more common in eastern Europe are also more common among the poor in the west. They are heart disease, stomach cancer, tuberculosis and childhood injuries. Social class patterns mortality because the choices that poor people can make are constrained by their lack of money. In addition, economic decline is associated with greater consumption of alcohol and more people smoking. For the most part, governments in the region have not responded to this important area.

Responding to the challenge

Governments have been preoccupied with health care reform. They have failed to develop broader health policies. Some things have improved but for reasons other than government action to address health status. For example, health has benefited as a result of rapid changes in diet. This has been due to improvements in the retail sector. Another example is the emergence of civil society organisations and self-help groups.

Although major causes of premature death can only be tackled by broader health policies, health care does make an important contribution. Health care has improved in many countries though this does not include Russia. Substantial improvement in outcomes in some countries have been achieved in cancer survival, survival of low birth-weight babies and control of hypertension. For example, death rates from testicular cancer in young men have fallen. Nevertheless, growing inequalities in health are occurring in many of the countries of central and eastern Europe. The Roma population is particularly disadvantaged and is an issue for accession.

Consequences for the West

Poorer people tend to have higher rates of communicable disease, such as tuberculosis, sexually-transmitted diseases (STDs) and HIV/AIDS. Increased movement of people from east to west creates concerns about the spread of these communicable diseases. At the same time, increased movement of goods implies a growth in drug trafficking and smuggling.

Accession and health policy

The free movement of goods (e.g. pharmaceuticals, foodstuffs), services (e.g. health care providers) and people (health professionals, patients) are already affecting health and health services. The Helsinki Council of 1999 accepted applications for candidacy from six countries plus Turkey and opened negotiations w ith 12 countries (Bulgaria, Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia). It also divided the transition into two phases: single market issues, and other issues. The Copenhagen Council of 1993 defined the prerequisites of accession as follows:

• Achievement of:
  • Stability of institutions guaranteeing democracy, rule of law, human rights and protection of minorities;
  • Existence of functioning market economy and ability to cope with market forces within EU;
  • Ability to take on obligations of membership including adherence to economic and monetary union.
• Creation of:
  • Conditions for integration through adoption of European Community legislation (acquis communautaire).

The acquis communautaire is the accumulated body of European legislation since the creation of the European Community. All new member states must sign up to this in its entirety with European law taking precedence over existing national law.

What implications does this have for health policy? The priority in the transition period is the creation of the single market. The emphasis is therefore on greater freedom of movement of goods, services, capital and people. For health policy, key issues are the movement of professionals, patients and pharmaceuticals, and the need to respond to the public health agenda.

Health professionals

The free movement of health care professionals is enshrined in the Treaty of Rome and governed by the EU profession-specific directives. In theory, qualification and specialisation obtained in one member state can be registered in another. Professionals working in two countries must register in both and ensure professional indemnity to cover him or herself in both. However, in practice, administrative and bureaucratic factors, such as national requirements and discrimination, restrict this freedom of movement. Structural/macroeconomic factors and personal factors, such as high taxation or language skills, also affect free movement.

However, accession does bring with it a major threat of a “brain-drain” of health professionals from Central and Eastern Europe. The United Kingdom has plans to recruit up to 5,000 physicians, for example. Regulatory bodies (at the European Commission and throughout Europe) will need to be strengthened to deal with the increased workload. Designation of recognised specialties, nomination of competent authorities, and development of specialist registers will also be needed. A plan for general practice vocational training needs to be implemented. Finally, a review of the implications of the General System Directive for other professional groups needs to be undertaken.

Free movement of patients

Patients from another European country fall into two main categories. Temporary visitors, such as tourists, business people (E111), dialysis patients, students (E109), transport workers (E110), and unemployed people seeking work (E119). The second group comprises people who are seeking treatment for an existing condition (E112). Recent European Court rulings have greatly expanded the rights of this second group.

Accession requires a review of existing bilateral arrangements on reciprocal treatment provision and the need to establish structures and mechanisms to record patient flows. An important consideration that also needs to be addressed is the implications for health care provision and funding in border areas of countries within the European Union.

The pharmaceuticals market

Many aspects of the regulation of the pharmaceutical market are covered by subsidiarity i.e. company law at the national level. The European Medicines Evaluation Agency (EMEA) will become the responsible body for direct application for European licence. However, national licensin g followed by the mutual recognition process will continue as an alternative. Licensing in only one country will also continue.

The tightening of both regulation and manufacturing process is required during the accession process. In regulation, the key issue is transparency in decision making. It will also be important for countries in Central and Eastern Europe to create an independent licensing authority, advised by a Medicines Commission. “Good Manufacturing Practice” or GMP will need to be adhered to.

EU programme

Candidate countries will be entitled to join the new EU public health programme. It will have three strands:

• Improving information for the development of public health, e.g. learning from experience elsewhere, using the best available evidence and so on;
• Reacting rapidly to threats to health, especially where they cross borders;
• Tackling health determinants through health promotion and disease prevention.

Conclusion

Joining the European Union will have important implications for health policy, especially if you are a doctor, a nurse, a patient, or a pharmaceutical manufacturer. Some programmes will help to close the gap with the west. But it will not solve all the problems.

   

Professor Martin McKeeis a Research Director at the

European Observatory on Health Care Systems– an initiative by the WHO’s European Office, the governments of Greece, Norway and Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics, and the London School of Hygiene & Tropical Medicine.

This article was published in Issue No.59 (November/December 2001) of theEuropean Public Health UPDATE, the bi-monthly publication of the

European Public Health Alliance(EPHA).