CONSUMER POLICY - European Parliament by yaofenjin


									             EUROPEAN PARLIAMENT
                  AND CONSUMER POLICY

                          PUBLIC HEARING

                           PUBLIC HEALTH
                          CONSUMER POLICY
                       ASPECTS OF ENLARGEMENT

                           Tuesday 11 July 2000
                              3.00 - 6.30 pm

                 BIOGRAPHICAL NOTES


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                                               PAGE OF CONTENT


BIOGRAPHICAL NOTES....................................................................................................... 3

SUMMARIES/SPEECHES ...................................................................................................... 8

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Teacher and Research Associate, IESE, Barcelona

Education. Medical Doctor, Université Louis Pasteur, Strasbourg, France (1990). MBA, IESE,
Barcelona, Spain (1993). Studies towards PhD, LSHTM, London, UK (since 1997).

Teaching Experience. Organisation and teaching in the MBA second year elective course
„Management of health systems and health institutions‟, executive education in health management:
Catalonia, Spain, countries of Central and Eastern Europe, Argentina, Peru, Ecuador (since 1994).
Teaching as visiting professor at LBS – London Business School (MBA, Service Management
Course: Management of health sector institutions) and LSHTM (MSc, Public Health and Policy:
Management of technical assistance to the health sector) (1997/98).

Consulting Experience.
 Conception and facilitation of Case Studies for the World Bank Conference: „The Challenges of
   Health Reform: Reaching the Poor”. Europe and the America Forum on Health Sector Reform,
   hold in May 2000 in Costa Rica. Project Director. (Spring 2000)

    Elaboration of studies and the resulting Staff Working Paper of the European Commission
     [SEC(1999)713] “Health and Enlargement” with the European Commission‟s Public Health Unit
     and the Phare Consensus Program: Study of the impact of enlargement on European health,
     health systems and health related activities. Proejct Director. (1998/1999).

    Extensive experience in technical assistance to the health sector reform process in Central and
     Eastern Europe (Albania, Bosnia Herzegovina, Czech Republic, Estonia, Latvia, Poland,
     Romania and Slovakia), mainly in the EC Phare program.. Consulting to health systems and
     health sector institutions in Spain, its regional autonomies and Latin America. Areas: design of
     technical assistance programs, health policy and strategy, health financing, resource allocation,
     information and control systems, quality improvement systems (since 1992).

Research Experience. European health and health systems, health and enlargement, implementation
of health sector reform, evaluation of technical assistance, project management, hospital
management: quality improvement systems, information and control systems (since 1993).

Languages. German: mother tongue. English, Spanish, French.

Publications (selection)
   'European Health Policy and the Regions', Annual Conference of the WHO Regional Health Network, Madeira, October 1999, Proceedings.
   'The influence of contextual factors on the implementation of health care reform in Central and Eastern Europe.' Internal Research Document, IESE,
    Barcelona, July 1999.
   „The Enlargement of the European Union: Challenges for Health and Health Care', Eurohealth, 4,4, Autumn 1998:18-21.
   'Critical Success Factors for Effective Technical Assistance to the Health Reform Process in the CEE Countries', Decision Science Institute, Fourth
    International Meeting, Sydney, July 1997, Proceedings.
   'Health System Reforms in Central and Eastern European Countries', IESE Magazine, Barcelona, June 1997.
   'Quality in Health Management. The European Quality Model applied to the Health Sector. Experience from Catalonia', The 1996 Quality Conference
    in Europe, The Conference Board and the European Foundation for Quality Management (EFQM), Berlin, May 1996, Proceedings.
   Several case studies, technical notes and other teaching material.

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Katalin MUCHA
Katalin Mucha is a nurse and is the President of the Hungarian Nursing Association. She is the
Hungarian representative on the Standing Committee of Nurses of the EU - the body which
represents the national nursing associations in Europe, and also represents Hungary at the World
Health Organisation (WHO) European Forum of National Nursing and Midwifery Organisations
and at the International Council of Nurses - the body which represents nursing worldwide.

Professional Background:

Expert at the Hungarian Ministry of Health - PHARE Management Unit, Member of the National
Board of Health Examinations and Director of Nursing

Mrs Mucha has lectured and prepared various articles for conferences and in professional nursing
journals in Hungary and abroad.

Mrs Mucha has been awarded by the International Council of Nurses (ICN) for achievements in
“Excellence in Nursing” “In Support of Nursing Excellence” and “Pro Sanitate”

Vilnius University
Medical doctor, paediatric surgeon

Language skills: (Mark 1 to 5 for competence)
Language                             Reading             Speaking                Writing
English                              5                   5                       5
Lithuanian(mother tongue)            5                   5                       5
Russian                              5                   5                       5
Polish                               4                   3                       2

Membership of professional bodies:
International Association on technology assessment in health care
Society of paediatric surgeons o Baltic States
Society of health care managers

Other skills (e.g. Computer literacy, etc)
Computer skills in Microsoft word, Microsoft access, Microsoft power point, Lotus notes, Microsoft
project. Experience in writing project proposals, tender dossiers. Familiar with EU PHARE
purchasing procedures

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Present position: Contract Health policy Expert PricewaterhouseCoopers EU PHARE project
Lecturer of Vilnius university social medicine centre, paediatric surgeon of Vilnius university
children‟s hospital , WHO temporary adviser.

Professional Experience Record:
Date: from (month/year) to   1984- present
Location:                    Vilnius, Lithuania
Company:                     Vilnius University children‟s hospital
Position:                    Paediatric surgeon
Description:                    Emergency paediatric surgery

Date: from (month/year) to   1985-1991
Location:                    Vilnius, Lithuania

Company:                     Vilnius city health authorities

Position:                    Consultant

Description:                    Health care organization for children monitoring in Vilnius city

Date: from (month/year) to   1994-1997
Location:                    Vilnius, Lithuania
Company:                     UNDP
Position:                    Program director-deputy director- director

Description:                  Primary health care hospital based care, university tertiary care reform projects design and management,
                                 public health care reform
                              International donors coordination
                              Project preparation including World Bank
                              Designed and implemented western-style response team training to include latest advanced life support
                                 medical techniques, personnel management techniques and response planning.

Date: from (month/year) to   1991-1994, 1997-1999
Location:                    Vilnius, Lithuania
Company:                     Ministry of Health, Republic of Lithuania
Position:                    Chief specialist of Mother and child department,- State secretary- viceminister
Description:                    Responsibility of health care reform management, health policy and strategy

Date: from (month/year) to   August 1999- september2000.
Location:                    Copenhagen
Company:                     WHO euro
Position:                    External evaluator of EUROHEALTH program
Description:                    Evaluation of the efficacy of WHO work in WHO euro office and in the .countries

Date: from (month/year) to   July 1999 – present
Location:                    Vilnius, Lithuania
Company:                     PricewaterhouseCoopers, EU PHARE project LI9704.02.01
                             "Support to the continued reform process and the development of primary health care in Lithuania"
Position:                    Health policy expert
Description:                    Assessment of current health sector in primary care, health care finance, management Identification and
                                 comparison of potential strategic options for improvement and correcting of gaps
                                Facilitation of the selection of a strategy, development of a detailed strategic model and implementation
                                Management training

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Other professional experience (selected):
UNICEF activities


Elias Mossialos, BSc, MSc, MD, PhD(Econ), MFPHM - Synoptic Curriculum Vitae

Elias Mossialos is Director of LSE Health, a research centre specialising in comparative and
international health policy, health economics and social care. He is also Brian Abel-Smith Reader in
Health Policy in the Department of Social Policy at the London School of Economics and a member
of the Academic Management Committee of the LSE European Institute. He qualified in medicine,
political science and public administration at the University of Athens, and also studied health policy
and economics at the London School of Economics. He trained in public health and is a Member of
the Faculty of Public Health Medicine (MFPHM) of the Royal College of Physicians in the UK and
one of the Research Directors of the European Observatory on Health Care Systems, a partnership of
 WHO, the World Bank, the European Investment Bank, the Governments of Norway and Spain, The
London School of Economics and the London School of Hygiene and Tropical Medicine. He has
served as an Advisor to numerous agencies including the WHO, the European Parliament, the
European Commission, the World Bank, the Ministries of Health in Brazil and Russia and health
insurance funds in Hungary and Croatia.

Dick Westendorp (60) was from 1982 until his retirement in July 1999 chairman of the Board of
directors of the "Consumentenbond", an independant organisation with more than 640.000
members (10% of the Dutch households).
He was member (a.o. vice-president) of the Executive of Consumers International and member of
the Board of Directors (and chairman) of International Testing.
He has a great experience in the (international) consumer work. He has been involved in training
activities, seminars etc. all over the world.
In the Netherlands he is member of a great number of advisory councils.
Since his retirement he is a.o. independant chairman of a regulator on the use of telephone
numbers for informationservices. Besides he has control and advisory functions at institutes in
the health care and private business.


Present Position
Director General of Consumer Protection Board of Estonia since 1995

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Member of Estonian negotiation delegation to join EU.

Previous work experience in Public Section
Ministry of Economic Affairs and Ministry of Trade. Responsible for trade and later consumer
protection matters since 1992.

Education and training
Technical University of Tallinn - bachelor degree on food industry specialty. After graduating
she has worked at the same University in Food Technology Institute as research worker.
Academic degree (Ph.D) from 1980

Different training courses on consumer protection matters in Norway and in Louvain-la -Neuve
(CDC) in Belgium.

Estonian, Russian, English, German.

Born 1 of October, 1954 in Ljubljana and graduated from the Faculty of Economics in Ljubljana
in 1978 where she obtained her university degree. During the time of her university studies (1971
- 1975) she was engaged in press and worked on a contract basis for the newspaper DELO. She
was involved in the area of sports and finances. From 1978 to 1983 she worked as a counsellor in
the Ministry of Economic Relations and Development and from the year 1983 to 1985 as a
counsellor in a commercial company SOZD KEMIJA. From 1985 she was a Research officer and
from 1986 until 1990 Head off Research Unit in the Institute of Home Economics. Her present
post since 1993 is a Director of International Consumers Research Institute.

Involvement in the field of consumer protection:
Since 1990 President of the Slovene Consumers' Association (SCA-Zveza potrošnikov
Since 1991 Chief editor of the consumer magazine VIP
1992-1996 Member of the Board of Directors of the Slovene Housing Fund
Since 1992 Chair of a Committee within the Slovene Housing Fund
Since 1993 Board Member of the Slovene Institute of Quality (SIQ)
Since 1993 Representative of the Slovene Consumers' Association in International Testing
Since 1994 Member of the American Council on Consumer Interest
Since 1994 Council Member of the Consumers International (CI)
Since 1995 Representative of SCA in European Consumer Association BEUC
Since 1997 Member of the Board of Directors of the European Research Institute Into Consumer
Affairs ERICA

Co-author of the publications:
 Comparative study of Comparative testing in UK , Sweden and Germany, 1987

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   Handbook: Consumer Policy and Consumer Organisation in Central and Eastern
   Europe, 1996
   Consumer Policy and Consumer Organisations in Central and Eastern Europe, 2000
   Guidelines for Cconsumer Policy in Central and Eastern Europe, 2000

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                  AND CONSUMER POLICY

                          PUBLIC HEARING

                           PUBLIC HEALTH
                          CONSUMER POLICY
                       ASPECTS OF ENLARGEMENT

                           Tuesday 11 July 2000
                              3.00 - 6.30 pm


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Will be distributed separately.

Katalin MUCHA
On behalf of the Standing Committee of Nurses of the European Union and the Hungarian
Nursing Association it is a great honour for me to have the opportunity to speak at this public
hearing on the health aspects of enlargement of the EU.

Nurses play a central role in the health care systems across Europe and nursing is a major force in
health care. Nurses make up the single largest occupational group in the health care systems in
all countries. Working in a wide range of settings in the community, in schools and workplaces
as well as, of course, in hospitals, nurses care for sick patients, support elderly persons, and also
have an important role in informing and educating the populations they serve in order to promote
a healthy life for all. As a result, nurses have a unique insight into the diverse factors which
influence the health and well being of the population.

The European Union has played and will, in the future, play an even more significant part in the
development of public health in Europe and nurses are a significant partner in helping to achieve
this agenda. As a nurse from one of the “first wave” of applicants, I would like to stress that it is
important that the specific needs and the situation of the candidate countries are taken into
account when developing policies and action programmes on public health.

We, the inhabitants of the Candidate Countries, are looking forward to enlargement with hope,
but, also with fear. In the last decade, since the collapse of the Berlin wall, the Central and
Eastern European countries have undergone major and rapid changes - ideological, political,
economic, technical and social. In contrast to the previous system, we are now encouraged to
take the initiative, think creatively, be flexible and be individually responsible for our lives. For
younger people there are now many new exciting opportunities but what about those who for
whatever reason find it difficult to take up these new challenges; the older generation in our
societies, those who may often find it more difficult to adapt to such radical change? Many of
the health problems in our countries are direct consequences of this upheaval. Use of legal
(tobacco and alcohol) and illicit drugs, unemployment, homelessness and social isolation
contributes to lowering the health status of the population. The changes I have outlined also
impact on the healthcare systems and thus on nurses as well.

I intend to set out the key concerns relating to public health which will need to be addressed
within the framework of the enlargment process and also to set out ways in which the EU could
support candidate countries in the transition to membership.

Human Resources:
This is a key issue in any health service as healthcare provision is a labour intensive activity and
the quality of service depends on the quality and training of staff. Health workers in Central and

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Eastern Europe are amongst the lowest paid workers of all. Major reforms in health systems
including moves from national health services to insurance based systems have created turmoil
for staff. This has lead to late and erratic payment of salaries, lack of resources and equipment.
In addition there has been a shift away from state pensions meaning that workers face an
uncertain financial future in retirement.

Such circumstances contribute to low morale and in Poland, for example, some nurses are
leaving to establish themselves as alternative therapists outside the health system. There has
also been decentralisation of power and budgets for health care without any central monitoring
in Poland which has lead to huge differences in pay and conditions for nurses within the country.
 In Estonia, nurses are paid around US $ 0.7 per hour and the rate has not increased for the last
five years; despite the fact that the cost of living is rapidly increasing. Nurses are having to work
excessively long hours due to shortages and poor remuneration. This inevitably may mean a
poorer quality of care for the patients. There is also a need to modernise the organisation of
work to allow healthcare workers, many of whom are women, to combine their family and
professional responsibilities in a flexible manner. This will be vital if we are to prevent any
further losses in qualified and experienced staff in the future. Until now, health issues have not
been seen as an important part of the enlargement process.

Free Movement:

Within existing EU countries, legislation has been in force since 1977, which guarantees the right
of free movement to nurses responsible for general care. This legislation was based on a set of
minimum standards of education for such nurses. A number of EU Member States are
encountering serious nursing shortages at present (the UK, Ireland, Denmark, Holland and
Sweden for example) and are recruiting nurses from other countries to make up the shortfall.
After enlargement, nurses from the new member countries will also have the automatic right to
live and work in other parts of the EU and there is a danger that, given the comparatively poor
working conditions at home, many will be attracted from Central and Eastern countries to take up
jobs offering better pay, working conditions and access to professional development; with serious
consequences for healthcare in the new member states.

Free movement needs to be seen to go hand in hand with developing the social dimension of the
EU in the applicant countries (working conditions, education and training provisions)

The EU needs to consider sharing good practice in recruitment in large numbers from other
countries and consider the impact on countries with limited resources for training health

Primary Health Care:

Health reforms need to focus on improving primary health care at the moment, in line with the
guidelines of the World Health Organisation. Hospital based specialist medical care is
emphasised currently in Central and Eastern European countries and there is often oversupply of
specialist doctors with shortages of nurses who may have very little independence. Despite this,
there are initiatives to improve the situation; for example, in Poland there have been efforts to set
up independent primary health care centres with doctors and nurses working together. In

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Hungary, my own country, independent home nursing groups have been established and run by
nurses with support from the EU PHARE programme and the involvement of the Hungarian
Nurses Association. These are positive examples of change and show how the EU can assist us
in the transition period.

In all countries there is a push towards health promotion. The Baltic States and Poland are doing
innovative work on women‟s health (establishing screening programmes etc…) However, nurses
often have no access to decisions on legislation, in Estonia, for example, responsibility for health
promotion rests firmly with doctors and in Romania doctors are pressing for nurses to remain
their medical assistants. This is at odds with the general trend in the current EU Member States
to improve the education and to broaden the role of
nurses so that they are seen as autonomous and well qualified professionals able to provide cost-
effective care to patients.

Health and Safety issues:

Adopting present EU legislation on health and safety will require extra resources and training.
Setting up systems for exchanging information on best practice between candidate countries and
with EU countries could be very helpful. For example the EU working time directive may have a
significant impact on nurses where long hours are routine - in Poland many nurses are working
up to 36 hours without a break with obvious consequences for their own and their patients‟


This is the key to the development of nursing and healthcare, particularly in relating to the need
to acquire new skills and work within changing healthcare environment. Legislation in this field
is also an important aspect of the acquis communautaire - the body of existing EU legislation
which candidate countries will have to adopt prior to membership of the Union.

The nurses in general care directives, introduced in 1977 which lay down minimum standards in
education content and provide a system for automatic recognition of general nursing
qualifications in each EU member state, are an important minimum standard for all countries.
The nurse education systems in Central and Eastern Europe are adapting to nurse education
based in higher education. But in Romania, for example, medical assistants continue to be trained
each year without respecting the educational standards laid down in the EU directives. There is,
therefore, a need for assistance to help us to achieve these EU standards and to ensure that nurses
regularly top up their basic skills post qualification. This will also ensure that as citizens move
around in an enlarged EU they can be confident of the quality of care that they can expect to
receive if they become ill away from home.

There is a move towards new approaches to education for nurses, particularly a competency
based approach, and it is important that the nurses in the candidate countries have access to these
EU discussions and opportunities to exchange with other countries on developments in nurse

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Representation of Nurses in the Decision Making Process:

The EU needs to assist in the development of strong autonomous professional organisations to
develop nursing and the nursing voice at national level, so that developments in health reform
reflect the realities on the ground and nurses can participate fully in EU‟s public health and
health research agenda. This will be reflected, in turn, in improvements in care and treatment for
users of health services.

I have already mentioned the rapidity of change in the Candidate countries, but let us not forget
that throughout Europe, countries are facing challenges to their health services resulting from
demographic change, technological developments and ever increasing public expectations of
health care.

Demographic changes mean that many EU countries are facing a future in which elderly people
make up a growing proportion of the total population. The requirements of an increasing number
of elderly people will have a huge impact on demand for health and social care services given
that, in general, older people suffer more from (chronic) illness and disability. The role of nurses
with older people in the community will be central in assisting them to live independently for as
long as possible. Nurses may become the main long-term support for many older people in the
future as traditional sources of support, such as the family, break down or are modified.

In health care, as in all sectors, the evolution of technology has led to the development of new
tools with potential benefits for improved quality of care and treatment. This means that that all
staff should receive, not only, technical training to use specific tools and methods, which become
rapidly outdated but, they should be educated broadly to encourage the development of
transferable skills. Skills which will enable individual nurses to learn independently throughout
their careers, in order to keep up with changes and provide the best care for their patients.

The European population has become increasingly informed about its rights and the quality of the
services they can expect, including health services. There has been a change in the relationship
between all health professionals and their patients and clients. Patients are, rightly, taking a more
active, questioning role in their own health care and treatment. This trend will require nurses
who understand the importance of communicating effectively with their patients; in order for
them to be able to explain clearly to them what they are doing and why they are doing it. Again,
a broader approach to nursing education will be required to encourage the development of such
an ethos of partnership between the patient and the nurse, rather than simply training nurses to
undertake specified and limited tasks.

For all of these reasons, it is vital to assist candidate countries to develop autonomous nurses
who are accountable for their practice and take responsibility for keeping their knowledge up to
date and who are able to make a real contribution to the health policy debate in their countries.

One of the major problems is lack of access and input to the health care reforms taking place.
For example in Estonia, nurses, unlike doctors, do not have representatives on legislative
committees drawing up new health legislation, although Estonia has now finally managed to get
a Government Chief Nurse post created in the Ministry of Social Affairs. Even then nurses
remain excluded from decision making. Romania still does not have a nurse representative at

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government level, and has no register of nurses at national level. Nurses associations and other
non-governmental organisations are not considered as partners by government. As a result, the
decision makers lack key information which affects the success of reforms undertaken. ultimately
this affects the care offered to the citizens.

Practical Support for Candidate Countries from the EU

So what kind of practical support could the EU offer candidate countries?

Involvement in decision making concerning nursing education is a key element for us - decisions
being taken now by the EU in this sphere will affect us in future. Candidate countries need to be
able to take part in this dialogue.

At this stage in the accession process, we do not need any more theoretical advice and analysis,
but, rather there is a need for practical help; including exchanges of information and health
workers. Our professionals should be assisted to go and experience working practices in EU
Member States.

Comparative information regarding our health systems and the health systems in EU countries
would give us some guidelines on which to base our activities. In this regard, I hope that the new
EU health strategy and public health action programme will offer support to candidate countries
with our specific health problems and also to encourage exchange of experience and information.

Nursing in the candidate countries needs to be developed as an autonomous profession in line
with the general trends in the EU countries. This will allow authorities to make better use of
health resources and will improve the quality of patient care. There should also be support for
development of nursing associations within the framework of the development of an active civil
society and strong NGO networks in Central and Eastern Europe.

As you can see, there are many challenges ahead for the candidate countries in improving health
care and public health in our countries. Nurses wish to play their part in this process and with the
support of the EU we want to work to ensure that the health and wellbeing of all citizens in
Europe is protected and improved.

I thank you for your attention.


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Danguole Jankauskienė EU PHARE program health policy expert, Lithuania

          I would like to make this presentation thinking not only about my own country – Lithuania –
 but I would prefer to speak about common challenges in this socio – political environment in Europe
 of all candidate countries.

        Europe today is in a great contrast and diversity: There are affluent as well as poor
 countries, 1/3 of the population live in poverty, most of the poor are women. Our future generation
 depends on them. Health and poverty are interlinked. Many countries are still struggling with the
 consequences of the social, economic and democratic transitions.

           We are facing social exclusion. There are marginalized groups, countries have migrant
 population and refugees. Especially I would like to stress aging of the population. Percent            of
 population over 65 years will continue to rise. It requires more recourse for health care. Lack of
 financial resources and disability are key problems for elderly. We are not emphasising it well in the
 future budget of health care. Demand for health services for the elderly will increase. Increase in
 demand will lead to increasing in health care costs. For example: the costs of health care for the over
 individuals over 80 years of age compared with cost for middle age groups is about 16 times as great.
  It is of critical importance as most health care is provided in the family setting. But informal system
 is weakening. Families, as cells of the society, are divorcing, children – parents relation is changing.
 It is why we need to integrate health care for elderly with social services. Organization and financing
 of long term care is an issue of growing importance. This requires new skills and new methods of
 organization of health care systems. We need to learn new methods, which western countries had

         Globalisation is a phenomenon, which is more and more obvious. Globalisation affects and
 integrates the economy, culture, technology and governance. Global markets and global technology
 can help link to individuals and to expand their choices. But globalisation is a two-edge sword. It is
 driven by market expansion and tends to outpace governance of markets. Competitive markets may
 increase efficiency, but do not guarantee equity. And this concerns us, health care specialists. Health
 of the population is becoming less and less a function of events within geographical boundaries. Free
 movement of population requires from health professionals not only language skills but also the
 assistance from the authorities to help the foreign patients in the best way and let them feel safe and
 at home. Western countries have a lot of side effects of globalisation, but CEEC countries just are
 jumping into it. So, why we in Europe need global solutions. For example, solving tobacco control
 issues. There is a need to harmonize tax policies and other legislation to deal with market forces. All
 we know, how smart tobacco companies are in attracting junior people to smoke, and without
 European directive the Governments couldn‟t do very much even having the law. The lobby is so
 strong. My Government is an example. Issue of prohibition of tobacco advertisement is been
 discussed in the Parliament again after 5 years fight.

         Talking about health challenges we have to stress increase in noncommunicable diseases,
 injuries, and violence. In particular cardiovascular diseases, depression - are major cause of death
 and Disability Adjusted Life Years (DALYs). There are indications that the trends in cardiovascular
 disease in a few countries are improving due to positive lifestyle changes. But there are big
 differences in figures for cardiovascular diseases, cancer, and mental health. What concerns us is,
 that in 1980 there were no big differences in morbidity of cardiovascular diseases in recent EU
 countries and CEEC, and now the differences in morbidity are by two times bigger in CEEC. In

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opposite, mental health rates in EU countries are bigger: 26/100 000 inhabitants and 15/100000 in
CEEC (in 1996). Those Governments, which have understood the importance of programs of
noncommunicable diseases, are successful not only solving health problems, but economy too. It is
always the question on the agenda of conversation between health specialists and politicians
economists – what is the first economy or health. The major problem for us in CEEC, as in EU too,
is alcohol consumption. It affects health of the population. Within the changing responsibilities in the
health reform process between local and central government people with those problems sometimes
lack proper help. It is also unfinished agenda of communicable diseases. Even with great successes
in spite of advances in public education, vaccine development and treatment, AIDS and resurgence
of TB are issues transcend individual countries policies and call for international action. Why the
current eight Public health programs of EU are very important. Their emphasis and importance will
have to rise and amount of them have to increase. Just here I would like to stress a need for
international donors cooperation. International organizations have to develop good partnership and
coordination of activities not leaving countries alone with donor coordination tasks, because the
counties are not able to change the roles of donor organizations. And the roles sometimes are not the
best example to follow. Coordination among EU, World Bank and other Banks also UN
organizations, especially WHO is critical to EU within the countries perspectives.

         There have been advances though in children's health. Taking into consideration, that the
rates of infant mortality are higher than EU countries, but much progress a few countries were made
in the speed of decease if these figures. In contrast to adult, the process of transition has not
increased mortality rates in children so much. But there are big disparities in health status between
countries in Europe. This is reflected in differences in life expectancy and noncommunicable
diseases with respect to socio-economic status (cardiovascular diseases, cancer, etc.). Differences in
life expectancy have rose sharply. If there was only 2,5 years difference in life expectancy among
recent EU and CEEC in 1970, this difference has increased till 6 years (in 1997 life expectancy at
birth in EU was 78 years and in CEEC – 72 years). Even more differences are in comparison the
differences in male and female life expectancy. In my country this difference is more, than 10 years.
There is rising tobacco consumption in CEE and unacceptably high prevalence of consumption
throughout Europe. Tobacco use is the single most important risk factor for cancer, which is
responsible for about a third of all cancers in Europe. Present patterns of increase in chronic disease
in Europe have major implications for organization and delivery of health services. Solutions to
control of chronic diseases requires actions from the Governments, but also from EU and outside the
health sector (e.g. legislation, advocacy, for example vis a vis tobacco control).

        Analysing health care trends, inequities are growing even in countries where the health
system provides universal access to services. Health workers are in concern, that many citizens in the
CEE have been pushed out of the health care system due to the changes in financing of health care
system and changes in social demographic groups of population. There are considerable variations
between allocations to health spending by countries. For most CEE countries the health expenditures
as percentage of GDP are below 7 % , this is in contrast to countries in Western Europe where health
expenditures as a percentage of GDP range between 7 and 10 %. Of course it is not the major health
status implication, but less GDP for health care requires much more efforts from health professionals
to provide the patients with health care services.
The countries have great pressures for health care reform. This is because of increasing spending
pressures, budget constraints, technological developments, that increase costs, expectations of
citizens, as well as aging of the population.

ENVI\OJ\416886EN.doc                            - 16 -
        The role of State is changing. Fast pace of privatisation, creation of market incentives leads
to less involvement of State in delivery of services. But health reform requires State regulation.
Increased regulatory function of the State in health care reform causes some tension between
authorities in municipalities and Government.

        Market driven innovations and a larger role for the private sector, in both the financing
the provision of health care services, which dominated throughout most of the 1990', seem now
to leave room for a new emphasis on the potential for improvement in equity and effectiveness
that can be ensured by stronger societal controls and an intense coordinating role of

Decentralization is going together with health care reform. Responsibilities of implementation of
health care reform are transferred to the local level. The central functions are turning to emphasize
more coordination between central level, responsible for policy direction also monitoring, and local
level. Skills and practice of managing of change is a key problem in the countries. Transitional
period from central administrative power transferring to new modern management of health care
system, based on market economy rules, gives challenges for policy makers. We see the problem of
increasing distance of understanding health care reform goals in central and local level authorities
and difference in knowledge, which fortunately is disappearing in time scale. But the governments
are changing. New people with new requirements in experiences and skills are coming. Here EU
support and understanding of these needs is important. It is a pity, that we have no more support for
health reform issues from EU side.

         Citizens' empowerment is increasing. The major goals of the health reform are not only to
improve the health of the population, but also to increase the participation of citizens in decision-
making process and responsibility of their health. Why it is no surprise that a question of patients‟
rights is always rising. The right to choose, right to the information and lots of other rights are one of
the priorities. This is a continuing theme in health care reform. The patients have to understand, that
recognition, that demand for services may be controlled by health promotion measures, by improved
environment, lifestyles, etc. NGO are playing more and more role. Even we see the opposite
phenomenon, when too many organisations disagree in some strategic issues and it is very difficult to
work with them. Population has to learn democracy and it takes time. Also success of health care
reform depends on emphasis on intersectoral action for health (private sector, civil society, media).
Changing Governments are the great problem not only for health care reform, but also for everyday
work of the medical staff. Changing political directions in transitional period makes a lot of damage
for sustainability of health care reform. Health sector reform in rare cases is as top priority for the

        The main goal of health reform is shift to Primary Health Care. We feel the lack of
understanding new philosophy of PHC and team‟s work approach. It is very difficult to change
mentality of thinking and it takes decades to implement PHC. It is also difficult for the people to
recognize the importance of integration of a variety of services at the local level and provision of
efficient services as first line of care. Coordination of health promotion, environmental activities are
turning more to the local level. Engagement of citizens and communities in the needs assessment and
in the planning and evaluation of services is very important.

        Health systems are facing economic constraints that impact on their ability to keep pace
with rising health care costs. Accession countries face significant challenges to cope with health care

ENVI\OJ\416886EN.doc                             - 17 -
demands since they have to put emphasis on cost containment and fiscal policies to curb deficits.
Human resources at the heart of health care reforms. Costs for health care personnel are rising fast
in Europe. So, why we need to find solutions of using less expensive health care workers in some
functions of health care. And not only, because they are cheaper, but because they could be more
professional also. Spending for personnel has followed the general pattern of public spending for
health. Deployment mix of human resources varies widely. For example: the nurse to doctor ratio is
3 to 1 in the UK, but 1 to 1 in Portugal and Spain, the highest difference in ratio is in Nordic
countries – 1 to 4-6. Professional education and recruitment policies are a most urgent need. The
efforts of EU to harmonize curriculum of training is very needful aspect. We are working hard on
promotion of multidisciplinary health care teams, which are new approach and where the special
attention is given to key new roles of nurses and medical practitioners. We have to learn new skills,
in prevention, health promotion, management of health services, modern public health.

        Once again focusing on responsibilities of governments I would like to stress not only budget
constrains, but also responsibility to correct inequity in access to health and health care. Access for
the poor and vulnerable will be always the major issue for all governments. At the recent time it is
very difficult, talking about the budget, to prove to politicians, that health is a basic need and a
primary good, that enables people to be productive and contribute to society. But we are trying to do
our best to ensure, that health and health care policies are driven by values. In these circumstances
governments need to take action on the broader socio-economic determinants of health. Of special
significance are reduction of poverty and education (especially of young women and children).
Financing and allocation of resources have to maximize the health impact. Of course, it has to be
going with the special attention to ethical issues, involved in the new biotechnologies and genetics.
We have to care application of new knowledge and technologies based on scientific evidence and
cost effectiveness considerations: demonstrable contribution to health gains.

       In the end I would like to stress two major issues in this health and enlargement
process: we will be always in health reform process, so to share experiences and skills,
based on evidence, between the countries is very important. We need cooperation between
donor organisations and the countries. The second issue is human recourses development,
as a centre for all health care reform process. Only with proper human recourses it is
possible to manage the change.


Some points that will be included in the presentation:
- most work in the region has concentrated on legal harmonisation
- there is still a lack of understanding in most of the region on the roll of civil society and the
  consultation process
- there is a lack of training both in government departments and in the judiciary
- the consumer protection departments (if present) have often very limited power
- there is no longer a regional Phare CICPP programm with consumer issues left in the hands of
  the local Phare programms. Other priorities than consumer protection will take precedence
- DG Sanco made a commitment at a consumer assembly for candidate countries last year in

ENVI\OJ\416886EN.doc                            - 18 -
  Brussels that training on a regional basis will happen. That was his answer on a strong voice
  throughout that assembly on the need for continued training. Until now he didn't fullfill his
- NGO's suffer from a cronic lack of funding

- continued training of governmental officials, NGO's and judiciary
- training for NGO's how to research and formulate policy, how to promote and advocate that,
   how to work with the media
- specific promotion of priorities relevant to EU as well (food, financial services, public
   utilities, consumer education etc.)
- finding ways and solutions to ensure a more constant financial base fore the NGO's as
   selfsufficiency through magazine production is not a viable option in most of the countries
- consumer education is vitally important in changing cultures in countries and promoting
   democratic principles
- educate many of the NGO's to apply democratic principles and leadership
- support to increased networking with EU country organisations
- as not much money is available it should be spent well involving independant consumer

Consumer protection in Estonia - summary of the presentation
The Consumer Protection Board of Estonia

The basis for developing consumer protection system in Estonia was created with adoption of the
Consumer Protection Act (CPA) in 15 December 1993. The CPA entered into force from the 1st
January 1994.

The Estonian CPA determines consumer rights in relations between the consumer and the seller in
purchase and use of goods and services as well as the obligations of the seller and responsibility for
violation of legislation.

The basic rights of consumers are stated in CPA § 4 and based in UN consumer protection

The Estonian consumer policy is to great extent based on prevention, which consists of consumer
information, education and market surveillance. It takes into account also informal and fair handling
of complaints or formal means of consumer redress.

The emphasis is on close co-operation between various parties, public and voluntary consumer
bodies, also business plays role in improving of consumers' position in the market.

In May 1994 a specific institution - the Consumer Protection Board (CPB) under jurisdiction of the
Ministry of Economic Affairs was established for implementation of the Consumer Protection Act

ENVI\OJ\416886EN.doc                           - 19 -
The CPB was founded in May 1994. Scope of activity and efficiency has been increased steadily
since the establishing. The three most important functions of the Board are:
    - to supervise the consumer market
    - to settle consumer complaints
    - to inform and advice consumers.

The CPB has a staff of 57 in 2000. The CPB has regional offices in 14 counties all over Estonia.
In each office is 1-2 specialists.

The CPB constitutes an inexpensive alternative to the civil courts and the decisions of the Board
serve as guidelines for trade enterprises. The CPB supervises the consumer market of goods and
services. The Board is entitled to impose fines and prescriptive orders in case of the violation of
the CPA and other regulations. Together with other state and local government institutions the
Board also monitors the following fields: product safety, misleading advertising, consumer
contracts, public services, product-labeling etc.

As Estonia is one of the candidate countries of the EU accession, the Estonian Government has
drawn up the National Program for the Acquis Adoption (NPAA). According to the NPAA Estonia
will adopt and implement the consumer protection Acquis in a given time. The harmonization
process of the consumer protection acquis is going on satisfactory.

The Board is developing strong working relations with both the local government institutions and the
independent sector, and organizes joint training of staff of the Board and representatives of consumer
organizations. The Board and the Estonian Consumers Union work together in supervising trade
and services at the local level, and in exchanging information about goods on the market in order to
make consumer choice easier and more effective.

The CPB has a role of coordinator between the different supervisory authorities in order to exchange
information regularly.

The CPB is according to Product Safety Act the national contact point concerning rapid exchange
information on dangerous goods between other countries. The CPB has already participated actively
in PHARE TRAPEX project.

Besides the CPB have contacts with different business organizations for exchanging information and
promoting the role of consumer protection.

The consumer information and education is one of the most important tasks of the CPB

      A shortcut to advice is the free telephone consulting service, operating working daily.
       Experts of the CPB provide advice and information about consumer rights, warranties,
       required labeling, and other safety and marking requirements.
      Media relations and press contact is another way of providing information to consumers.
      The Board publishes information leaflets in order to teach consumers to be critical and
       active and to give them practical tips to make their choices in everyday life.
      The website was opened in the end of 1997.
      Among afore-mentioned activities the information system TarKa has become an

ENVI\OJ\416886EN.doc                           - 20 -
       important tool of consumer information in Estonia. Since there are no special consumer
       magazines in Estonia TarKa is the only regular and up-dated source of consumer

The consumer protection is a developing area in Estonia and in order to fulfil requirements coming
from the acquis communitaire and EU consumer protection policy the CPB strengthens its
institution, e.g. carries out market surveillance, advises and educates consumers in efficient.

Results of the Consumer Protection Boards' consulting and market control activities in 1997-1999

                                 1997         1998         1999
Telephone consulting             3996         6580         7621
Received complaints              3841         3027         2481
Controlled enterprises           3504         3506         3508
No of fined enterprises          1595         1306         1219
Amount of determined             1114         1194       1,6 (mill)
fines (thousand EEK)



If we would judge Consumer protection and Consumer policy in Slovenia only from the
perspective of formal adoption of legislation and the established institutional structure, the
picture would be very good. Slovenia adopted the Consumer protection act in 1998, amendments
to the Act are in Parliament as well as draft Consumer Credit law, and even a National Consumer
Protection programme a five year Action Plan has recently been adopted by the Parliament.
In spite of very sophisticated institutional and legal framework there are however some serious
problems, which need to be solved quickly if consumer policy is to be effective

The specifics of situation in the development of Consumer protection and Consumer Policy
activities in Slovenia are as follows: independent national non-government consumer
organisation ZPS was established already in 1990. It was modelled after Western consumer
organisations with paying members, a test-based magazine VIP and was involved in consumer
policy-making and campaign. Under the PHARE Democracy Programme and with support of
the Slovene government and in partnership with Consumers International and German umbrella
consumer organisation AgV, ZPS developed a comprehensive consumer advice network
supported by computerised information service. By the summer 1996 ZPS- Slovene Consumer
Association was a well established, strong and influential non-government consumer
organisation, involved in all main activities on the national level and very active internationally
(a Council member of Consumers International and first candidate country member of the
European consumer organisation BEUC.)

ENVI\OJ\416886EN.doc                           - 21 -
 Since autumn 1996 when Slovenia established government Consumer protection Office the
 policy of » active partnership and involvement of NGO in creating consumer policy changed.
 The government decided that ZPS influence in consumer policy has to be diminished as non-
 government organisation was regarded being »too strong«..

 To summarise main problems:
  A misunderstanding of the role and tasks of an independent consumer movement and
    government role in supporting its development resulted in different kinds of pressure against
    ZPS, including encouragement and financial support for small, local and government
    dependent consumer groups.
  A lack of understanding of the complexity of creating and implementing consumer policy,
    which reflected the very poor co-ordination of different aspects of consumer policy between
    different Ministries and government agencies and also with other stakeholders.
  Very slow and delayed court procedures which result in ineffectiveness of law enforcement,
    sometimes even in violation of human rights. In one consumer case, still under way, there has
    sill been no court decision after almost nine years!
  Non-existence of out of court procedures and different ADR (alternative dispute resolution)
  Lack of consumer education on all levels which reflects a high level of functional illiteracy

 Training for all stakeholders including government officials is needed.
 Support from the European Commission and of the European Parliament is needed to ensure the
 development of the strong independent consumer movement During the whole process of
 approximation to EU too much emphasis was put on the development of the legal framework
 and development needs of an independent movement have been neglected. If this process would
 depend on the governments of candidate countries we might never have strong and independent
 civil society which is essential in modern and democratic market economy.

 Breda Kutin
 President of ZPS-Slovene Consumer Association
 And Director of International Consumer Research Institute

 ENVI\OJ\416886EN.doc                         - 22 -

           European Parliament Public Hearing on Health and EU Enlargement

                                    Elias Mossialos

                                      LSE Health

                       Health care in EU pre-accession countries

                                     11 July 2000


ENVI\OJ\416886EN.doc       - 23 -
                                             Analytical Framework

                                                   Pooling and allocating
                           Raising resources             resources                 Purchasing
                          Compulsory vs.             Fragmented vs.          Explicit rationing
                           voluntary                   integrated revenue       (positive negative
                                                       channels                 list) vs. implicit
                          Prepaid vs. point-of-
                           service                    Size of purchasing

                          Organizational form
institutional             Organizational incentives
                          Vertical and Horizontal Linkages
Impact on                        Health                 Equity/financial            Efficiency
performance                                               protection

ENVI\OJ\416886EN.doc                - 24 -
Characteristics of Health Insurance Contribution Revenues
              introduce        Salaried
                   d      Employer:employee       Self-employed               Nonactive population
Albania           1995      Public: 3.4%         7% of statutory         Central budget
                               (1.7:1.7)         minimum wage
                            Private: 3–5%
Azerbaijan                                           No payroll tax
Croatia           1993           18%             18% of declared         18% of gross pension and other
                                (18:0)           income                  benefits plus central budget

Czech             1993          13.5%            13.5% of 35% of net     Central budget transfer 13.5% of
Republic                        (9:3.5)          pretax income           80% of statutory minimum wage

Estonia           1992           13%             13% of declared         Central budget transfer
                                (13:0)           income
Georgia           1995            4%             4% income tax           Central budget, but amount
                                 (3:1)                                   unspecified

Hungary           1990           14%             14% of declared         Central budget. Per capita
                                (11:3)           income but at least the amount of transfer is unspecified
                         plus hypothecated tax   minimum. Wage
                            of US$170 per        plus hypothecated tax
                           employed person       of US$170 per person

ENVI\OJ\416886EN.doc           - 25 -
Kazakhstan           1996                   3%           3% of declared income Per capita oblast contribution for
                                           (3:0)                               nonworking
Kyrgyzstan           1997                   2%           2% of declared income Oblast contribution of
                                           (2:0)                               undetermined level
Latvia               1998            28.4% of personal   28.4% of personal     General budget transfer
                                        income tax       income tax
Moldova                                                      No payroll tax
Poland               1999                  7.5%          7.5% of declared      7.5% of gross benefits
Romania              1999                  14%           7% of declared income 7% income tax based on gross
                                           (7:7)                               benefits
Russian              1993                  3.6%          3.6% of declared      Central budget. Per capita
Federation                                (3.6:0)        income                amount of transfer is unspecified.

Slovakia             1994                 13.7%          13.7% of declared      Central budget. Per capita
                                         (10:3.7)        income                 amount of transfer specified as
                                                                                the contribution rate applied to
                                                                                73% of the statutory minimum
Slovenia             1993                13.25%          13.25% of declared     Central budget.
Note refers to tax rates for 1999.

ENVI\OJ\416886EN.doc                      - 26 -
Trends in GDP and Health Expenditure
                       Per capita % Change                                                             Real health
                         GDP       in real         Per capita health expenditure        Total health     spending
                        (ppp $)     GDP                        (ppp $)                 expenditure as   (public) as
                                                                                        percentage of percentage of
                                              Total      Public Private Private/total       GDP       1990 spending
                         1997    1997–90       1997       1997       1997        (%)   1990    1997        1997
Croatia                  4,780    –18%        481.1       402.2      78.9       16.4%  10.5      8.4        68.5
Czech Republic          10,500     –9%        758.3       695.3      62.9        8.3%   5.4      7.2       115.8
Estonia                  5,240    –21%        241.2       209.1      32.1       13.3%   1.9      5.7       186.8
Hungary                  7,190     –6%        510.9       417.4      93.5       18.3%   5.7      7.1        95.7
Slovakia                 7,900     –2%        617.6       498.4     119.2       19.3%   5.4      7.8       113.3
Slovenia                11,800      4%        897.0       802.8      94.2       10.5%   5.6      7.6       149.2
Average Group A          7,902     –9%        584.3       504.2      80.1       14.4%   5.7      7.3       121.6
Albania                  2,120    –11%         58.0        44.5      13.5       23.3%   4.4      3.3        46.5
Kazakhstan               3,560    –40%        123.7        83.5      40.2       32.5%   3.3      4.1        57.9
Latvia                   3,930    –45%        195.4       151.2      44.2       22.6%   2.5      4.5        77.8
Poland                   6,520     27%        413.9       315.4      98.5       23.8%   4.6      6.5       132.1
Romania                  4,300    –13%         78.5        54.9      23.5       30.0%   2.7      4.2        93.5
Russian Federation       4,370    –40%        228.2       175.5      52.7       23.1%   2.3      5.2       121.9
Average Group B          4,133    –20%        182.9       137.5      45.4       25.9%   3.3      4.6        88.3
Azerbaijan               1,720    –57%         64.5        11.9      52.5       81.5%   2.6      7.4        21.8
Georgia                  1,960    –68%         34.6        4.3       30.3       87.5%   3.2      4.6        28.9
Kyrgyz Republic          2,250    –43%        168.9        67.1     101.9       60.3%   4.2      7.4        39.7
Moldova                  1,500    –63%        174.5        94.6      79.9       45.8%   4.0     11.3        93.5
Average Group C          1,858    –58%        110.6        63.1      62.0       60.2%   3.5      7.7        46.0
                                     Note: Average are unweighted means for the group.

ENVI\OJ\416886EN.doc                 - 27 -
                                      Aggregate Health Status Indicators
                         Male life expectancy        Female life expectancy      Infant mortality rate
                       1990      1993      1997     1990      1993      1997   1990      1993      1997
Croatia                 69        69        68       76        77        77     11        10         9
Czech Republic          68        69        71       76        76        78     11         9         6
Estonia                 65        62        64       75        74        76     12        16        10
Hungary                 65        65        66       74        74        75     15        13        10
Slovakia                67        68                 76        77        77     12        11
Slovenia                69        69        71       77        77        79     8          7         5
Average Group A         67        67        68       76        76        77     12        11         8
Albania                 69        69        69       75        74        75     28        33        26
Kazakhstan              64        62        60       73        72        70     26        28        24
Latvia                  64        62        64       75        74        75     14        16        15
Poland                  67        67        69       76        76        77     19        16        10
Romania                 67        66        65       73        73        73     27        23        22
Russian Federation      64        59        61       74        72        73     17        20        17
Average Group B         66        64        65       74        74        74     22        23        19
Azerbaijan              67        65        67       75        74        75     23        28        20
Georgia                 69         ..       69       76         ..       77     16        18        17
Kyrgyz R.               64        63        63       73        71        71     30        33        28
Moldova                 65        64        63       72        71        70     19        22        20
Average Group C         66        64        66       74        72        73     22        25        21

ENVI\OJ\416886EN.doc             - 28 -
Source: WHO HFA database.

ENVI\OJ\416886EN.doc        - 29 -
Beds, Physicians, and Admissions
                                                                          Hospital               Outpatient
                   Hospital beds     %         Physicians      %      admission rates    %     consultations     %
                      per 1,000    change      per100,000    change       per 100     change     per person    change
                   1990     1997             1990     1997             1990     1997           1990    1997
Croatia             738      601   –18.6%     212      226    6.6%     15.4     14.9   –2.9%   8.24     6.08   –26.2%
Czech Republic     1,092     877   –19.7%     271      311   14.8%     18.1     20.2   12.0%   13.9     15.1     8.6%
Estonia            1,157     740   –36.0%     349      310   –11.2%    18.4     18.3   –0.4%    7.9       7    –11.4%
Hungary             984      831   –15.5%     317      349   10.1%     21.8     23.7    8.9%   11.7      18     53.8%
Slovakia            895      833    –6.9%     298      302    1.3%     16.4     19.9   21.2%   13.6     11.7   –14.0%
Slovenia            604      567    –6.1%     205      224    9.3%     15.7     16.2    3.0%    6.5      6.8     4.6%
Average Group A 912          742   –18.6%     275      287    4.2%     17.6     18.9   7.1%    10.3     10.8    4.6%
Albania             403      305   –24.3%     137      130   –5.1%      8.9      7.7  –13.7%    3.3     1.66   –49.7%
Kazakhstan         1,367     845   –38.2%     398      330   –17.1%    23.6     15.1 –36.0%     8.3      5.5   –33.7%
Latvia             1,404     966   –31.2%     411      292   –29.0%    22.5     21.7   –3.5%    8.1      4.5   –44.4%
Poland              660      622    –5.8%     214      235    9.8%     10.6     11.1    4.3%    6.0      5.2   –13.3%
Romania             892      738   –17.3%     180      179   –0.6%     20.1     20.9    4.0%    8.3       8     –3.1%
Russian Federation 1,306 1,140     –12.7%     407      417    2.5%     22.8     20.6   –9.5%    9.5      8.1   –14.7%
Average Group B 1,005        769   –23.5%     291      264   –9.4%     18.1     16.2 –10.5%     7.2      5.5   –24.2%
Azerbaijan         1,010     961    –4.9%     392      383   –2.3%     14.1      5.8  –59.1%    9.1       6    –34.1%
Georgia             980      454   –53.7%     493      402   –18.5%    13.7      4.3  –68.2%     8       1.3   –83.8%
Kyrgyz Republic 1,198        832   –30.5%     337      306   –9.2%     23.9     17.5 –26.9%     6.3      4.9   –22.2%
Moldova            1,315 1,126     –14.3%     355      347   –2.3%     23.5     18.7 –20.3%     8.5      8.1    –4.7%
Average, Group 1,126         843   –25.1%     394      360   –8.8%     18.8     11.6 –38.4%     8.0      5.1   –36.4%
 Source: WHO HFA database

ENVI\OJ\416886EN.doc                - 30 -
Composition of health revenues

                                                                                                                 Group A: predominantly social
                                                                                                                 insurance financed
                                             0.9 SL
% of health revenues from soical insurance

                                                                                                                 Group B: predominantly general tax
                                                        CZ                                                       financed
                                             0.8 SK
                                                                                                                 Group C: predominantly out-of-
                                                                   ES                                            pocket financed
                                                              HU         CR
                                                                         Group A


                                             0.3                                               RU        Group B
                                             0.2                   Group C
                                                                                                      AL     ROM
                                             0.1        GE                                          KAZ
                                                                    AZ                 KY           MO                   PO     LAT
                                                   0%        10%        20%    30%      40%      50%       60%       70%       80%       90%          100%
                                                                                 % of health revenues from general tax
ENVI\OJ\416886EN.doc                                                          - 31 -
 Changing the source of financing for the health sector has significant implications for equity,
  with a risk of deterioration in financial protection when policy-makers allow out-of-pocket
  expenditure to grow in an uncontrolled manner as a major source of revenue for the health

 There is little evidence that changing the source of financing for the health sector has any direct
  impact on either health or quality of the service delivery system although health-seeking
  behavior may be negatively influenced by out-of-pocket user fees.

   The introduction of social health insurance is an effective way to mobilize additional revenues
    for the health sector, but has been consistently associated with greater not less politicization of
    health care financing and no obvious improvement in expenditure control, administrative
    efficiency, or strategic purchasing (allocative efficiency).

ENVI\OJ\416886EN.doc            - 32 -

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