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European Union enlargement and health

European Union enlargement and health. Martin McKee European Observatory on Health Systems and Policies London School of Hygiene & Tropical Medicine. A divided Europe? What does the future hold for an expanded European Union?. http://www.politicalstrikes.com/store.html. Nostradamus.

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European Union enlargement and health

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  1. European Union enlargement and health Martin McKee European Observatory on Health Systems and Policies London School of Hygiene & Tropical Medicine

  2. A divided Europe?What does the future hold for an expanded European Union?

  3. http://www.politicalstrikes.com/store.html Nostradamus Prophesy

  4. Jules Verne Leonardo da Vinci Vision

  5. Or is it more complicated?

  6. What we can be certain of … • The EU25 will be very different from the EU15 • The future direction of Europe has been redirected by the election results in Spain • Withdrawal of Spanish opposition to EU voting rules undermined Polish position, making new arrangements possible • Otherwise, the future is pretty uncertain, but at least we can start with what we know now

  7. <= 45000 <= 20000 <= 9250 <= 3000 <= 745 No data Gross National Product, US$/per capita (2001) EU-15: 21,537 (2001) Central, South East Europe & Baltics: 3318 (2001) Source: HFA database

  8. Economic trends in CEE candidate countries and EU EU Slovenia Source: HFA database

  9. GNI per capita, EU Member States & Candidate Countries (2001) Source: World Development Report 2003

  10. gap: 10 years Male life expectancy in selected candidate countries & the EU EU Czech Republic Hungary Romania Latvia Source: HFA database

  11. Ratio of death rates in different age bands between CEE and the EU

  12. ‘Old’ problems and new threats • High levels of non-communicable diseases and injury & poisoning • Cardiovascular mortality <65 in CC about 2-times EU-average • Pockets of extraordinarily high death rates from lung cancer (Hungarian men) or suicide (Lithuanian men) • Traditionally high levels of smoking in CEE • 29% of all deaths among men aged 35-69 in EU attributable to smoking compared to 37% in acceding countries (2000); women to follow • Re-emergence of infectious diseases • e.g. syphilis and tuberculosis; rising burden of MDR TB (especially Baltic states)

  13. Source: European Centre for the Epidemiological Monitoring of AIDS.

  14. Health and wealth: United Kingdom GDP per capita Life expectancy at birth (years) Log GDP per capita Life expectancy Source : Floud & Harris, p116,1997

  15. So what does the future hold? • There is still a large health gap • It is closing slowly • (Life expectancy will converge about 2030 on current trends) • It could close more quickly • Some policies enacted now will have effects almost at once, others will take a long time

  16. Reforming health care in the CEE candidate countries

  17. From Semashko . . . • Principle: universal access to free health care • Centralized, tax-based model • Line-item budgeting • Emphasis on supply & specialized care • . . . . . . to Bismarck • Shift to decentralized, contract-based social health insurance model • Performance-related purchasing • Reduction of excess hospital capacity • Strengthening primary care • Evidence-based medicine • . . .

  18. <= 12 <= 10 <= 8 <= 6 <= 4 <= 2 EU-15: 8.9 (2001) No data Central, South East Europe & Baltics: 5.8 (2001) Total health expenditure as % of GDP Source: HFA database

  19. Per capita expenditure on health, EU MS & CC (2001) Source: World Health Report 2003/HFA database 2004

  20. Challenges • Weak macroeconomic context • Informal payments as significant proportion of health care financing (between 21% in Bulgaria and 60% in Slovakia) • Lack of capacity (technical & managerial skills for purchasing) • Institutional impediments • Weak public health function

  21. Single European market: The four freedoms Free movement of • Goods • medical technology, pharmaceuticals • Persons • Patients, health professionals • Services • Some providers of health care • Capital

  22. Adaptation to requirements of the single European market Goods • Pharmaceutical standards (GMP, GCP, authorization procedures etc) • Greater access to international market vs. pricing of pharmaceuticals • Intellectual property law: Supplementary Protection certificates, Bolar provisions, parallel trade Free movement of patients: opportunity or risk? • Attraction of patients by providing cheaper services • Incentive to improve quality of services • Financial consequences from costs incurred from treatment in current Member States

  23. Adaptation to requirements of the single European market – cont’d Free movement of professionals • Update legislation on professions incl. training programmes • Polish nurses: new career opportunities & qualification improvement • No ‘dramatic’ increase in migration expected • “Those who want to go have gone already” • Looming shortages of physicians in western Europe • Scope to recruit from eastern Europe • Potential ‘brain drain’ • Questions of quality, language, equity

  24. Beyond the EU25/ 27/28/29 Article 49 Treaty on European Union • Any European state may apply to become a member of the European Union • Prospective candidates must meet the criteria for membership (Copenhagen criteria) • Democracy • The rule of law • Human rights • Respect for minorities • Functioning market economy • Capacity to cope with competitive pressures • Ability to take on the obligations of membership (i.e. to apply effectively the EU’s rules and policies)

  25. The new abroad: the wider Europe • Beyond the new borders: South-East Europe • Stability Pact (1997): strengthen peace, respect for human rights & democracy, post-conflict restoration, economic growth • Stabilisation and Accession Process (1999): prospect of gradual integration with European structures • New neighbours: Belarus, Moldova, Russia, Ukraine • Economic contraction, breakdown of social security systems • Widening inequities increase incentives for migration • Widening health gap: life expectancy among lowest in Europe; rapidly rising burden of infectious disease • Weak surveillance and response system within EU, candidate countries & neighbouring countries

  26. Free movement of infectious agents Tuberculosis incidence per 100,000 Russia Ukraine Belarus EU The new abroad Source: HFA database

  27. <= 75 <= 70 <= 65 <= 60 <= 55 No data Disability-adjusted life expectancy, men EU-15: 71.7 (2002) Russia, Ukraine, Moldova: 58.6 - 59.8 (2002) Source: HFA database

  28. Need for ‘Healthy Neighbourhood’ strategy? • Strengthening health financing & delivery systems in neighbouring countries • EU-TACIS, IFIs, bilateral funding • Investing in public health infrastructure, information and response links across countries • Collaboration among EU, accession and new neighbour countries with financial assistance & technical leadership from EU, bilateral/international donors & technical agencies (WHO) • Initiate collaboration with MENA countries who will form the southern fringe of the EU neighborhood and which face similar problems

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