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Health : Fifteen Who Speak (Increasingly) as One

CNRS Research Director Monika Steffen of the Centre de Recherche sur la Politique, l'Administration, la Ville et le Territoire (CERAT)1, has been conducting over the last three years a large research program on health policies in Europe. An interview.

Do the health care reforms underway across Europe have any points in common?
Monika Steffen: Certainly. Policy makers in each country are faced with identical problems and demands; costs have to be contained in order to respect the Maastricht guidelines and, more generally, in order to remain competitive with countries having less extensive social protection systems. Second, all countries need to adapt their traditional systems to new demographic realities, such as an aging population. Finally, everywhere governments are faced with strong social demands from better informed patients expecting better quality services.

How does all this translate into policy reforms?
M. S. The dynamics of reform can be divided into two periods. During the 1980's the accent was on limiting the health care budgets and, as a result, the financial contribution of patients was rising. Since the 1990's the emphasis is more on the internal working of health care systems with the aim of improving the efficacy of the systems. This requires an accurate and operational knowledge of what goes on inside the health system black box2. As a result, methods and institutions of “medical audits” are emerging in all countries.

Are these reforms having the effect of harmonising national systems?
M. S.
Toward harmonisation without any doubt. A tendency towards harmonisation results from the common goals such as equal access for all, higher quality care, and financial viability. Nonetheless these objectives must be met in national, institutional, and political contexts which all differ one from another, and therefore national differences remain. Traditionally, theory distinguishes two types of health care systems in Europe, the Bismarkian system and the Beveridgian system. They differ mainly as to the respective role of the State and labor/employers unions in managing the health care system. The ongoing reforms tend to reduce the differences between the two models3. At the same time, attempts at privatisation have been limited or have been abandoned. Health care does not constitute a market in Europe. The gap between the two models is narrowing, but differences in the way reforms are put into practice remain. Governments differ as to the degree of deference they owe to physicians, which in turn depends on the political influence doctors are able to exert or to mobilise as an organised group, a variable that fluctuates from country to country. Accordingly, some countries adopted effective reforms early on (the United Kingdom), and some have taken a much longer time in reforming their system, and then only partially (France4).

Towards what model are Eastern European countries moving?
M. S.
First of all we need to distinguish between two groups of countries: candidate countries and those on the “periphery” whose membership in the EU is not on the agenda. Candidate countries need to organize a social protection system, including comprehensive health care, similar to what exists in other Member States. The political will exists in these countries, because of a high level of social demand and pressure. The main problem is an economic situation which does not allow these countries to commit 8-10% of GDP to health. Nevertheless, when it comes to reforming the internal administration of the system and to controlling the quality of the services delivered, these countries face similar challenges to their Western neighbors, albeit in a worse context. Despite these difficulties, candidate countries have opted for the European social model, including its irreducible core, health care coverage. What the opposite of the European model would look like can be observed in most non-candidate countries; the statistics in the CIS5 for AIDS, infectious disease or accident rates are alarming, while the lack of drugs in hospitals or the absence of health services across broad rural areas illustrates the gap.


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