London 2001 Conference Abstracts: L. Briziarelli et al.

Prof. Lamberto Briziarelli*, Dr. Masanotti Giuseppe**

Documentation without Information

*Director The Experimental Centre of Health Education, Department of Hygiene, University of Perugia.
**Collaborator The Experimental Centre of Health Education, Department of Hygiene, University of Perugia.
Contact: L. Briziarelli

The documentation and information policies in Public Health and Health Promotion throw out Europe, even with some differences, are insufficient for who is called to work and for who demands- payees (the population).

In the last decade documentation policies have had some attention, in fact, today there are numerous databases full of data of all kind. If we analyse these database we see that:

  • Most are incomplete (mostly on the purpose of global Health Promotion);
  • The data collected often do not have any use for who is called to program health services, and
  • These database are reserved only for experts and a limited part of the population.

Most of the data collected have no sense when it comes to Public Health or more specifically to health promotion, because they give only a peace of a much bigger picture. This is clear if we realise that the data contained in most of the database have been collected using methods and instruments of traditional epidemiology. Who is called to operate in Public health needs to link the illness with the possible determinants and traditional epidemiology is not able to give this.

Even if with all the limits that these database present, rarely these data are transformed in information for the population, that payees and that makes the demand especially in the field of health. Most of the information in circulation today is functional for who, in that moment, wants a certain message to pass to the population. In a situation like this in which the data collected is insufficient, only limited information is given to the population and only in “special” occasions makes it impossible for who operates in public health to program on correct bases.

Today there are some international organisations (WHO and E.C.) initiatives that propose information systems for example: Health Observatory, Verona Challenge, Health Impact Assessment (HIA), Euro database and so on� Especially the HIA strategy can give, to who operates in Public Health, the information necessary to program health services independently by the environment in which we are called to work in today.

What is necessary to point out is that all the new systems base or need to base on a good documentation and information system, so that all the data collected can be fully given and comprehensive for the population. It’s necessary that every person, in a liberal environment, have access to the same information.

London 2001 Conference Abstracts: Ch. Sevilla et al.

Christine Sevilla*, François Eisinger**, Jean-Paul Moatti*

Do gene patents linit the diffusion of genetic testing? The case of DNA tests for breast cancer susceptibility

* INSERM U379, Marseille, France
** E9939, Marseille, France

Introduction

Hereditary Breast/Ovarian Cancers (HBOC) are presently known to represent 5 to 10% of all breast/ovarian cancers and 84% of these hereditary forms are estimated to be due to deleterious mutations of the BRCA1/2 genes. The research based private firm, Myriad Genetics Inc., which has initially identified these two genes, and which has launched in 1996 the world�s first clinical test based on direct analysis of the DNA sequence of a gene, has obtained a recognition of its property rights by the US Patent & Trademark Office (USPTO). Consequently, all US physicians seeking genetic testing for mutations in BRCA1/2 to determine risk of breast cancer must send their patients’ samples to this private patent holder or to its licensees Costs charged to the patient or to her health care insurance are currently 2,400$ for diagnosis of BRCA1/2 deleterious mutations in the index case, and 395$ for testing of each subsequent person in the family. Myriad Genetics Inc. has claimed the extension of its patent rights to the member states of the European Union in order to introduce a similar procedure for breast cancer genetic screening in the health care system of these countries. One practical consequence would be that the diagnosis strategy currently used by Myriad Genetics Laboratories, the complete analysis of both genes (BRACAnalysis�,) by Direct DNA Sequencing (DS), would become the only available technical standard for breast cancer genetic screening. Alternative strategies using simpler techniques to scan the entire gene and to detect variants, in order to limit the region of the gene that will necessitate further characterization by DS, have however been experimented, on a routine basis, by various research and hospital laboratories world-wide.

Methods We performed a cost-effectiveness comparison of 20 technically available alternative strategies for BRCA1 mutation research to DS of the entire gene. The cost evaluation was based on a detailed observation of the different stages of each strategy in three French laboratories, and is presented in a theoretical population of 10,000 with a 15% probability of deleterious mutation for BRCA1, corresponding to the index case of an individual breast cancer patient with two antecedents of breast cancer cases in the family history.

Results Five strategies, using prescreening techniques, were found to be less expensive and more cost/effective than DS of the entire gene.

Conclusions Patents on human genetic materials allow private and academic research institutions to recover research and development costs. They also allow these organisations to become profitable by marketing exclusive rights to genetic testing. Economic theory however point out that the monopoly position that a patent guarantees to its private holder sometimes slows down the diffusion of innovations and of the associated gains in efficiency at the collective level. Our study shows that this negative impact is the case for BRCA1 diagnosis. The application of patent laws to the case of genes should – at minimum – limit the monopoly power of the patent holder who initially identified a gene.

London 2001 Conference Abstracts: E. Zebiene

Egle Zebiene

Patient satisfaction with health care services in changing socio-economic environment

Vilnius University
Centre of General Practitioners
Egle Zebiene

Patient satisfaction as an indicator of quality of health care services, is now being introduced into the health care system in Lithuania. Health care providers become more interested in the consumer�s opinion, considering patient satisfaction as an indicator of quality of services provided and an indicator of weaknesses in a service.

Patient satisfaction is known to be dependent on various other factors: outcome of care, health status, socio-demographic characteristics of patient, characteristics of health care system itself, meeting patient expectations and others. Several studies (D. Jankauskiene et al. (1998), survey of Vilnius Regional Governmental Sickness fund (2000), Kaunas University of Medicine project �Equity in health and health care in Lithuania. A situation analysis� (1998)), performed during last years in Lithuania, support the opinion that at least some aspects of consumer satisfaction may originate in factors outside of the health care system. Some findings of these studies will be presented. As some of these indicators are changing along with changes in the socio-economic environment, their influence on the patient satisfaction can be considered as a factor causing certain limitations on the validity of consumer�s satisfaction.

The research data indicate that satisfaction rates can change when the standard of comparison changes even though the object of evaluation (health care services) remains the same. Health care reform based on the ideology of improving health care delivery has an influence on public expectations. Development of the private sector in the Lithuanian health care system also changes patients� perceptions of �better services�, increasing competition between health care providers.

Recognising the importance of patient satisfaction and its influence on further compliance, health care outcomes and utilisation of health care services is necessary. Improving health care services requires an understanding of the importance of both patients� satisfaction and it�s limitations. Knowing the nature of satisfaction, its consequences and patient preferences for health care, we can more effectively use the limited health care resources, trying to reduce the gap between consumers� requirements and possibilities of health care system.

London 2001 Conference Abstracts: H. Beiras et Manuel Martín

Hixinio Beiras*, Manuel Martín**

Understanding, explaining, organising and occasionally succeeding: recent experiences promoting opposition to neoliberal counter reform in Spain

*Cardiologist in Vigo, president of Galician Regional NHS Defence Association (AGDSP, member of Federación de Asociaciones para la Defensa de la Sanidad Pública, FADSP)

**Specialist in Family and Community medicine in Marín, Pontevedra, Secretary of FADSP (Federation of Associations for NHS Defence).

Contact: Hixinio Beiras

In spite of the appreciable overall results, and the cost/benefit relationship in the Spanish NHS, the conservative government has devoted itself to its dismantling and privatisation, following the European 1980�s conservative approach focused on the privatisation of public services, increase of copayments, rationing publicly financed benefits, and increasing the role of private health insurance. Following these trends, the conservative government is applying important modifications to the Spanish NHS:

The introduction of the market through the finance/provision split with the intention of transforming NHS into a large number of smaller enterprises known as �Fundaciones� in the case of hospitals, similar to UK�s Hospital Trusts.

An increase in outsourcing to private enterprises some or all public health services, even awarding public companies the hospital care of some local communities, a policy inspired also by the UK�s Private Finance Initiative (PFI).

The limitation of healthcare services remains a menace only held back by the opposition of public opinion and pensioners.

The reinforcement of private health insurance, mainly through economic support to MUFACE (private mutualities for some public servants), and a 36% tax reduction for companies who privately insure their workers.

These reforms began in Galicia in 1995 before being extended to the rest of the country. Against this policy, the FADSP promoted the creation of unitary organisations of NHS supporters altogether with political parties, trade unions, professional associations and civic, neighbour, consumer and patient organisations. These Platforms for NHS defence (PNHSD) led growing actions against privatisation in Galicia and promoted the People�s Legislation Initiative campaign in 1998-99.

The success of PNHSD in the creation of a professional and social opposition, simultaneously with the extension of neoliberal policies, extended them across the country.

Further conflicts with health authorities have taken place, some of which ended with success of PNHSD. The most relevant experiences being the important demonstrations in the Madrid against the conversion of a hospital into a Fundación, the social opposition altogether with religious charity associations to the demolition of the old Santiago General Hospital and in demand of its conversion into a long term care institution. Also, the mobilisation of Pontevedra, the local and surrounding municipalities �some governed by the party in power- in demand of a new public hospital. Finally, the research led by the Vigo PNHSD promoted by the municipal authorities to investigate local health care resources and needs as a starting point to settle down demands before the regional health authorities in Primary Care, Hospital reforms, new social health services and mental health facilities, a change as it overcomes simple opposition with the proposal of practical outcomes.

At a national level, PNHSD�s have addressed the public through the media, making Health Policy a matter of public interest, generating opposition to neoliberal counter reforms, making the Ministry of Health abandon their principal policy of converting hospitals into Fundaciones.

Main steps have been understanding complex conservative policies, creation of PNHSD�s, and the introduction of simple but in this field new communication and propaganda methods.

London 2001 Conference Abstracts: G. Barro et al.

Giovanni Barro, Antonello Briguori, Mara Giglioni, Rita Manfroni, Maurizio Mori, Osvaldo Palumbo, Carlo Romagnoli, Elisabetta Rossi, Stefania Piacentini

Micro and Macro-privatisation are obscuring the sky of the italian National Health System

Equi.Jus Association, Perugia
Regional Health Service of Umbria

A national health service (SSN) was applied in Italy in 1978 with the law 833. The British NHS was its model.

It is not only a curiosity to observe that the law 833 was endorsed just a few weeks after the Alma Ata Conference, when the strategy of WHO, pushing for the priority of primary health care within a public health service, was flourishing.

This coincidence of dates reflects two separate itineraries followed in autonomy but with reciprocal influences. Indeed the law 833 was the conclusion of almost a ten years period of struggles for health, promoted jointly by the Trade Unions, the most important democratic parties, the most advanced scientists, even in the academic settings, the womens� movements and the strongest Unions of doctors (hospital doctors and GPs). Such a large movement drew its nourishment from the WHO�s activity and documents against the current concept of medicine as an ensemble of practices pivoted on highly specialised care, and its organisation as the triumph of the hospital. (At a few weeks from 7th April, devoted this year to mental health, it is not to be forgotten that 1978 is also the year of the Italian law which abolished mental hospitals, a law strongly fostered by Franco Basaglia).

Notwithstanding such a smart �birth certificate�, the SSN did not grow up so smartly for many reasons, among which a major role must be assigned to the end of the political coalition that had brought the law into effect, a coalition pivoted on the so called national solidarity and ended after the assassination of the premier Aldo Moro by terrorists.

After the breakdown of the national solidarity, the conservative parties became more and more influencial, playing an always stronger hegemony on those social and political sectors who, having refused the reform in 1978, were now trying to frustate it either (a lobbystic minority) through an open opposition, or (and mainly) bridling it in the web of a centrally-run policy and underfinancing the expenditures. Again, it is not a mere curiosity to observe that during the period under consideration many health ministers were drawn by the liberal party, the sole democratic party to vote against the reform in 1978.

After 1978 the Law 833 has been reformed many times, with the consequence (maybe desired) to prevent its full enforcement. Major changes to the Law 833 were introduced in 1992 and 1999.

The first one is the law n. 502 which aimed at rationing the health system and giving it more efficiency. Both such targets were inspired by the reform adopted in the UK by Margaret Thatcher: we can cite as an example the establishment of trusts for running USL and hospitals, the appointment of managers as general and sole directors of such trusts, the creation of a quasi-market for the trade off of the medical procedures, even when delivered in a public framework, and other such measures. None of them obtained more efficiency, the only result being to strengthen instead of weaken hospitals versus primary health care and territorial services. Nor has the objective of a control over the expenditure�s trend been attained, which continued to expand notwithstanding the large number of measures undertaken in order to reduce the costs of the service at a local level.

Beside that, the Law 502 resulted in a huge quantity of severe contradictions, first of all the multiplication of medical acts, not always based on health�s needs, and viceversa the loss of effectiveness in the preventive and prevention�s domain.

In 1996 a new government was appointed, based upon a left-center coalition, with Mr. Prodi as premier and Mrs. Rosy Bindi as health minister. A new reform was then planned to cope with the more dramatic consequences of the law 502, which came into effect in 1999.

At the end of the day the period from 1978 through 1999 can be divided into three phases. In the first one (lasting until 1992) we had practically no health policy because our system was paralysed from economic and financial measures and by the related under-dimensioning of expenditures.

The second phase (until 1996) coincided with the arrival in Italy of the long wave of American neoliberism: many attempts of health policy were carried out, but their sign was opposite to the welfarian principles of the 1978 reform.

The third phase, still lasting, is characterised by the attempt to reset the system and its welfarian principles through the adoption of measures aimed at rectifying the most severe bias of the previous policies and at recovering many of the basic principles which had been lost along the way.

As a final statement it can be sinthetically affirmed that in comparison with other western european countries our health system could cross the neoliberist wave of the Nineties and the related reaganian policy saving enough of its welfarian characteristics, except for some limited, even if consistent, losses of universality and solidarity (the same unfortunately cannot be said for equity).

We must therefore complain that some measures adopted in 1999 after the demands of the doctors contracted to the SSN, and the measures recently adopted by some regions ruled by right-center majorities, have darkened the horizon.

For a better understanding of this point, it must be recalled that the doctors contracted to the SSN are allowed, since 1978, to practice medicine publicly as well as privately, in the second case for payment. Such a liberal profession can be practiced both inside the public structure and within private clinics and hospitals: this faculty, not accompanied by strategies assuring the priority of the doctors� duties in favour of the public service, provoked a veritable concurrence against the pubblic service, stemming the paradox that doctors are allowed, by their employers, to become their competitors. The reform adopted in the early 1999 has not abolished the right for doctors to legally work privately, but has obliged them to chose just one form of liberal profession, intramoenia or extramoebia, which means inside or outside the public hospitals. In order to make an option which is not so good in terms of mere earnings desirable, new incentives have been introduced in favour of those opting for intramoenial activity.

Unfortunately the application of this law has been affected by a pause. The terms for applying the new regulations have been considerably diluted, the fulfillment of the option delayed and the incentives quite amplified by some hospital administrations. The new minister of health (Prof. Umberto Veronesi, a well known oncologist from Milan), justified such measures assessing that the public hospitals are not yet ready to lodge the liberal profession intramoenia. Whatever the real reason, it is a matter of fact that as of few months the atmosphere inside the public hospitals is worsening and even darker clouds are pending.

Waiting lists are considerably lengthening, and the citizens are often forced to pay out of pocket if they want to be cured in a timely manner. Nowadays a cospicuous part of the hospital�s activity is practiced for payment and not free of charge as requested by a public health system worthy of this name. In Perugia, which is all but the worst place in Italy for equity and fairness, many departments, especially in the surgical areas, operate free of charge only for emergencies and oncology, the remaining requests being delayed even for many months, or alternatively offered for payment when a timely service is necessary, including the case of some preventive procedures (i.e. mammographies and cervical examinations).

But another severe consequence is the creation of caregiving areas directly managed by doctors for their liberal profession with the creation of clinics only nominally public, but in fact private, where to select the patients who can pay out of pocket and to absorb a huge quantity of professional, technological and therapeutic resources that should be equally distributed among all people: a consequence even more dangerous because its effects are likely to become more lasting.

Such a tendency, that can be defined a “microprivatisation”, must be taken into consideration in parallel with a hidden process of “macroprivatisation”. Indeed, many fear that our hospitals will be transformed from public trusts, as they are now, to corporate holdings, owned by both public and private stakeholders, with the creation of healthcare areas reserved to the well-off, destroying the equalitarian profile of the SSN.

Elements of this trend are already noticeable in Lombardia, a Northern region administrated by a centre-right majority and bridgehead for a very large devolution destined to disintegrate the country�s unity, the central state being empowered only for a very limited span of topics. The health system that Lombardia wants to build in its territory and then to transfer all over the country is indeed based upon a complete parity between public and private providers, a strategy inspired to the Thatcher split between providers and purchasers, but much more flexible as far as the control on the performances� quality and quantity and on the expenditures is concerned.

After that or because of that, the expenditure for hospital and specialistic care is growing more quickly in Lombardia than in the whole country. For instance, the per capita cost has grown 25% in Lombardia and 19% in Emilia (a left-ruled region where the reform has always been correctly enforced). The main role for this trend is played by hospitals: in the last year Emilia reduced its admission rate 5% versus 3% of Lombardia.

The regional government of Lombardia is all but worried by this result, because its actual scope is far more bursting than a �simple� rationalisation. Lombardia is the largest region for population, and the one where Berlusconi and Bossi are installed. It actually wants to trigger a process of public health system dismantling and healthcare privatising and marketing, no matter if the quality of the service will worsen and expenditures increase.

The final point envisaged from the supporters of this policy is to abandon the welfarian system based on universalism, and to replace it with a �Bismarck model�, not to say a USA system. The issue of this perspective is partly consigned to the result of the next general elections, when the country will decide the destiny of the Welfare state. The neo-liberal strategies, up to now substantially rejected, have been included in the electoral agenda of the centre-right coalition. Its victory would mean the rejection of a fifty year history of social security, including 22 years of a welfarian health care system.

London 2001 Conference Abstracts: M. Johansson et al

Mauri Johansson & Timo Partanen

Trade Unions in workplace safety- and health promotion. With focus on cooperation between workers and academics in promoting health

Public Health Partner, Denmark
Finnish Institute of Occupational Health

Mauri Johansson, MD, Denmark

Since the middle of the nineteenth century, workers have organized in unions and parties to strengthen their efforts toward improvement of health and safety at work, job conditions, working hours, wages, job contracts, and safety. During history alliances have, from time to time, been established between workers, their unions and academically trained persons, working in solidarity with the workers and on their premises.

During the last decades there are in the Nordic countries some interesting examples of this type of co-operation between workers and their organizations on the one hand and scientists, practitioners of medical, social, hygienic, and technical occupational health on the other. These coalitions have occasionally been instrumental in improvements in regulation and legislation pertaining workers’ health. They also have been active for a surprisingly long period of time, in spite of ideological changes in the societies in the mean time.

In early 1970s, adverse health effects of organic solvents that were regularly used by construction painters were virtually unknown or alt least unrecognized. In the vivid years following 1968, when joint activities between workers and academics evolved all over Europe and elsewhere, a local painters� union in Aarhus, Denmark, contacted a group of medical students, asking for help to find out about severe central nervous symptoms among their members. Using interviews, short questionnaires and finding relevant scientific documentation it was shown that exposure to organic solvents could explain both acute and chronic symptoms, described by the painters. This led to a joint report , demanding that the working conditions had to be changed and the toxic substances eliminated. The co-operation resulted in a new type of organizations (“Co-operation Worker – Academics” (SAA) in Aarhus and “Action Group Worker Academics” (AAA) in Copenhagen), which still exist. They have produced more than 80 nontechnical reports, pamphlets and other material covering a broad range of industrial and other areas in working life. Most of them were initiated by single workers or shop-stewards, who with help from their local unions followed the problems up with active students and academics. The publications had a wide distribution among workers and were used in training sessions for safety representatives and had positive influence on working conditions throughout the country. AAA has also published a newsletter for distribution among active union representatives. The painter reports were followed by systematic research at university levels, confirming the findings , , . Threshold Limit Values were reduced, and the painting industry was forced to develop and apply water-based paints. Chronic illnesses among painters and others exposed to solvents became compensated as occupational diseases. The number of new cases of chronic solvent syndrome is considerably reduced during the 90’ies. Strong counteractions were taken by the oil industry, hiring scholars to deem the research as false . The public presentation of the oil industry report in 1984 was greeted by red union banners at the University auditorium to mark the protests.

These reports had a considerable impact during 1972 -1975 in Denmark. In a State Committee set up to propose revisions of the 1954 Worker Protection Act, seven of the reports were appreciated by the way they exposed the problems . The committee proposed the main elements to a new Working Environment Law, passed 1975 and enforced since 1977. Workers� influence on their working environment and on occupational health and safety in general was strongly secured. This law in many respects served as inspiration for the European Union Framework Directive as of 1989/391. Also the Danish National Confederation of Trade Unions (LO) was forced to accelerate its working environment programs and demanded influence on university research .

A similar worker-academic coalition (“The Health Front” – Terveysrintama) has been active in Finland since early 1970s. In fact, is has been communicating steadily over the years and occasionally joined forces with the Danish organizations, some times attending each others meetings. So, a report, prepared in Denmark by SAA, covering the questions of psychic working environment, was used as a model for an alike Finnish publication in 1978. The Finnish organization is an NGO, and has published a 8-to-16-page newsletter four times a year, prepared and distributed pamphlets, booklets, and books, and organized various campaigns and training sessions. One of the books presented the laws and formal regulations in a language understandable for ordinary workers. In particular, a set of strict threshold limit values for workplace chemicals and other hazardous exposures , and a draft for a law on occupational health services (OHS) were prepared. Both were printed and distributed among trade unions and unionists, particularly safety representatives, and are likely to have influenced legislation and regulation of workplace chemical exposures and OHS in the country. Annual conferences were held during a long range of years with dozens of participants – both workers and academics, posing statements and resolutions for public debate.

In Sweden, delivery truck drivers employed by a brewery had for years had serious ergonomic problems and accident risks in unloading and delivering cases of beer and mineral water down the steps to basement-placed bars and restaurants. A safety representative and a shop steward contacted the local University Department of Occupational Medicine. The problems were carefully examined, and proposals for a solution were made. After a systematic campaigning, binding regulations were enforced, with a maximum of 5 steps accepted, otherwise no delivery. Mini-elevators were drafted for easier delivery.

On European level a cooperation between workers, their local and national unions and academics has existed since the late 80’ies, collecting hundreds of activists every second year for policy planning. Permanent working groups e.g. on OHS are working between the bigger meetings. A very successful e-mail network assists continuously workers and unions with qualified answers to new hazard problems. This network has i.a. been strongly fighting for a total asbestos ban globally. Contacts can be taken on e-mail: editor@hazards.org

What represents research in the above examples might today be called participatory or action research, the research problems being defined by those at risk, and academics providing support with their experience in literature search, systematic documentation, report writing, etc., and the workers contributing with their practical experience and knowledge of what kinds of solutions would be applicable. It must be stressed, that the joint activities between workers and academics during the first years were characterized by some scepticism and the debates were brisk, until differences in the background cultures were mutually understood and accepted. The examples may be considered narrative, since the causal relations between the events were not confirmed in the strict sense.

In conclusion it can be said, that this type of cooperation has been extremely useful and influential on working environment questions. Also broader topics of cultural nature have beet taken up (what do children in schools learn about workers working and living conditions? How can the history of workers struggle for better conditions be presented etc.). The beginning of the co-work was hard both for academics and workers, but as time vent by, it helped mutually.

I can only recommend you to do all your best to establish alike structures to improve the working and living conditions for the working class and others striving under the burdens of the global neoliberalistic experiments.

London 2001 Conference Abstracts: M. Bayle et al (2)

Marciano S. Bayle, Carlos Ponte, Manuel Martin, Hixinio Beiras and Felix Payo

Social Movements against the privatization policy of the National Health Service in Spain

Federacion de Asociaciones para la Defensa de la Salud Publica, Spain

During the last years several social movements of general people have been produced, inside and outside of the health area, against the initiatives of the Government addressed to the privatization of the public health services. The purpose of this communication is to describe and analyse one of the peculiar structural forms that they have been developed: “The Platforms in defence of the Public Health”, which are playing an important role against the neoliberal measures and with the purpose of defending and improving the Public Health System.

1. What are the Platforms?.

The Platforms are considered as unitary organizations that arise in front of specific health or social problems, as the need of a new hospital or a particular sanitary or medical care service, the improper working of some health service, etc. And also in front of more general problems as governmental political decisions that affect to the whole population. Therefore, its working area is variable. It can be a neighbourhood, a city, a region or all the state.

Its composition is variable: worker unions (CCOO, UGT), or health workers by themselves (SATSE, SAE), Political Parties on the left spectrum (PSOE, IU, Nationalist Parties), Neighbours and Costumer Associations, City hall representatives, Professional Organizations (FADSP, SEMFYC).

Currently, the following platforms are operating:

  • In State level with head office in Madrid.
  • In several Autonomous Regions (CC.AA): Galicia, Asturias, Andalucia, Madrid, Murcia.
  • In several cities: Córdoba, Cádiz, Lugo, León, Valladolid, Burgos, Salamanca, A Coruña, Orense, Valencia, Ciudad Real. Zaragoza.
  • In some health areas and neighbourhoods.

2. Activities of the Platforms:

  • Discussion, analysis and alternative of the health/social problems object of the platform.
  • Diffusion of brochures, information leaflets, public acts, intervention in the media, popular celebrations, demonstrations, legislative initiatives.
  • The most outstanding movement:

Medtec (Vigo,1996) against the privatization of a service of hemodynamic and heart surgery.
Protests against a law that decrease the public financiation of drugs prescriptions (1998).
Against the hospitals conversion in Foundations (Trusts): Getáfe and Alcalá (1988), Arriondas (2000).
Claming for the construction of new hospitals: Burgos (1999), Oviedo (2001), Pontevedra (2001).

3. Balance of the Platforms:

The result has been globally positive. In the case of the Foundations, the movement was essential to stop the Government policy. Also they were successful in more specific problems, for example: the maintenance of an old hospital in Santiago and to reconvert in a social clinic…

The Platforms, however, they have some problems:

  • * Most of them are of informal character. Only a few of them had an statute or legal personality.
  • They use to work in a irregular way. The members joint together only in face to specific problems and without regularity.
  • They are influenced in a strong way by the political position of the different organizations that integrate them and by the relationships between them.
  • They need an organization, this is the role of our FADSP, to perform the meetings, to propose objectives and to look for agreement and concurrence against the political differences between the organizations that integrate them.

4. Current objectives of the Platforms:

At this time, in the FADSP , the following topics in the Platforms
are outlined

  • To make an active follow-up of the decentralization process of the Health Policy from the State to the Autonomous Regions (CC.AA) and Nationalities. This process have to be made with criteria of equity and economic sufficiency, otherwise, it is sure that it will cause an important problem for the immediate future of the public health service. From the FADSP and the state Platform they have been made already proposals in this regard.
  • To obtain sufficiency sanitary financing. Our proposal is that the GDP must be increased in 1 point.
  • Rejection of the copayment. The Health Ministry already has raised this idea, but the presence of the generalized refusal, it was delayed.

London 2001 Conference Abstracts: D. Gannik

Dorte Gannik

Is General Practice trapped?
Reflections on health care, liberalisation and research priorities

Central Research Unit for General Practice, Panum Institute, Copenhagen

Dorte Gannik, Assoc.Professor, DscSoc

For a while, reforms with a liberal tendency have been discussed with regard to health care in Denmark. Today, health care is largely a public responsibility. 81% of health care costs are financed through personal income taxes. Primary health care consists of general practitioners, practicing specialists, practicing dentists, physiotherapists, nurses etc. Services are available for all, however the general practitioner functions as a “gate-keeper” with regard to hospitals and specialised medical treatment. He/she is paid by regional authorities in a mixed capitation and fee-for-service system. The patient chooses a GP and remains on his/her “list” for a minimum period.

This system is not yet subject to major reforms. However, liberalisation is sneaking in by way of minor administrative changes and individual behavior changes. The development is part of a global liberalisation trend, supported by new economic theory and a postulated pressure of demand.

In this paper I shall discuss first the question of which forces are behind the pressure of demand. Health economists recognise that suppliers have a heavy influence on health care demand by means of informational and organisational de facto monopolies. The explosion of biomedical research, and in turn, the accompanying ultra-specialisation, makes the whole area incalculable and its development obscure.
Given this scenario, suppliers must rely extensively on estimates and judgments in their decision processes, and commercial agents, e.g. pharmaceutical firms, have ample room for choosing and promoting suitable research evidence.

Being the gate-keeper, general practice is obliged to take part in this development. General practice must have a working overview of advances and inventions in a broad medical field. But general practice also holds the inherent qualities of continuity, wholeness and a personal doctor-patient relationship. These qualities may be the very essence of general practice, since general practice works to sort out and coordinate services so that they suit any single patient. Though many commissions and working groups have paid lip-service to these qualities, GP’s today are only partly dedicated to them. They have lain folded into traditional structures of primary health care, handed over by history – the “list” system, the free GP choice, solo praxis and the gate-keeper role.

These GP “core” qualities stand in opposition to liberalisation, and are now threatened by it. The second question I shall discuss in my paper is thus how general practice will face this challenge. We do know something about the merits of the traditional qualities of general practice. They seem to make patients more content, they contribute to shared decisionmaking in the consultation, and they limit economic costs through more coordinated services. However we do not know nearly enough, as this research is scanty, untrendy, non-profitable and tends to be overshadowed in the media. My conclusion would be, that to preserve their trade and to contribute to public health, general practitioners must unite to call for changed public research priorities.

London 2001 Conference Abstracts: M. Bayle et al.

Marciano S. Bayle, Carlos Ponte, Manuel Martin, Hixinio Beiras and Felix Payo

The privatization policy of the National Health Service in Spain

Federacion de Asociaciones para la Defensa de la Salud Publica, Spain

Spain is endowed of a powerful National Health Service with free and universal coverage, with a high degree of equity as the most relevant aspect, and health expenses that are found in 5,8% with respect to the GDP (Gross domestic product) (1,3% the private health). Through the last ten years, in Spain several initiatives clearly addressed to the deregulation and privatization of the parts of their public health services have been developped.
The analysis of these initiatives is the object of the present communication.

The first warning on a new direction of the health policy came from the hand of a parliamentary commission, created in 1991 with the purpose to analyse the economics problems of the Spanish National Health Service with the support of all the parliamentary groups. The conclusions, known as the ” Abril Report” were favourable, between others, to the following points: to the division of the financing and the purchase of the health service, to promote the private management of the public health services, to increase the contracting capacity with the private medicine (particularly the high-tech) and to the extension of the copayment of drugs prescriptions to the retired workers, that already exists for the active workers. It is important to notice that in that year the Socialistic Party was in the Government and that previously it had played a positive role in the development and consolidation of the National Health System.

In spite of the recommendations of the “Abril Report” were not put in effect, it is true that it was an important ideological reference towards a mixed sanitary model, which was significant in the further development of the events. Thus, in the 1993, in the context of a strong restriction of public expenditure, some drugs prescriptions were eliminated from the public financing . (Real Decreto of selective financing of the drugs prescriptions).

After 1995, when the Popular Party obtain the Government, the trend towards the internal market and a mixed model is stressed. The hegemony of the right, in the state and in several Autonomous Regions ( Comumidades Autónomas, CC.AA), permits to be approved the recommendations of a Parliamentary Subcommittee for the Consolidation and Improvement of the National Health Service (1996) giving legal coverage to private management of the public health services and to the insurance.

Political interventions in a neoliberal perspective:

1. To privatize the insurance:

  • Law of reform of the Taxes. Permit that the companies contract private health insurances with workers, with tax allowances and other fiscal advantages.
  • Greater state subsidies to the private medical services of given collective of workers (public officials, journalists, judges and military professional).

2. To privatize the financing:

  • Cutting in financing of drugs prescriptions (a new restrictive decreto of selective financing), proposals of copayment (recent statements of the Health Ministry) and limitation of the health services.

3. To privatize management of the public sector.
The new hospitals are endowed of their own legal personality and with administrative structures of private character (the foundations). Let is take one example like the hospital of Alzira, in Valencia, which has transferred all the specialized assistance to a private company.

Global valuation.

In the last years it has been stressed the trends to the mercantilization and privatization of the health public system. The political opposition on the left political spectrum and several forms of social opposition have made possible, in most cases, that these legislative reforms may have had a limited practical effects. In the last months, the Government seems to give up this initiatives and its health policy has been focused on the devolutions process to the 17 Autonomous Regions (Comunidades Autónomas, CC.AA.) These devolutions have to be made with criteria of equity and economic sufficiency, otherwise, it is sure that they will cause an important problem for the immediate future of the public health service.

London 2001 Conference Abstracts: A. Benos et al.

Alexis Benos*, Stathis Giannakopoulos**, Theodore Zdoukos***,

The ongoing health services reforms by the greek social-democratic governement: a fast way backwards

*Assistant Prof In Social Medicine,
**General Practitioner, Research Fellow,
***General Practitioner, Secretary of the Union of Physicians working in the NHS
Laboratory of Hygiene & Social Medicine, Medical Dept, Aristotle University of Thessaloniki, Greece

Contact: A. Benos

The Greek National Health System was founded in 1983, by the freshly elected Socialist government. During the eighteen years that followed, minor-scale reforms were attempted but never completed. Immediately after April´s 2000 elections the socialist government announced a major reform of the Greek National Health System.
The main characteristics of the health care system are:

  • The complete lack of organized Primary Health Care, especially in urban areas.
  • Chronic underfunding of the National Health System, mainly from the Public Insurance Funds, and the lowest per capita public expenses for health in E.U.
  • The constantly increasing corruption in the public sector.
  • The unrestrained development of the private sector supported by public funds.
  • Bureaucratic, medical-centered services, mainly located in big urban centers, developed without reasonable design or unified quality criteria.
  • Satisfactory access to the National Health System for all people, at least for urgent health problems.

Though it is a paradox, the same conclusions are included in the report that accompanies the new National Health System�s Reform Act, which proposes answers in not such a «socialistic» direction:

Introduction of the institution of the «personal doctor», a kind of «gate-keeper» based on a capitation system, while there is a dramatically low number of properly trained Primary care workers (GP�s, community nurses, health visitors etc.).

Introduction of an internal market based on the purchaser � provider split. Funds� management is granted to an autonomous, privatized �Fund Allocation Organization�. This organization will manage a closed budget, buying services from public as well as private sector, with main consideration on money saving, regardless the quality of services, the state denying any guaranty for covering the real health care needs of the population.

Creation of a new, bureaucratic corpse of managers in the public hospitals, with increased authorities, focused on profit making and money saving, running the hospitals like private enterprises rather than public institutions.
Privatization of crucial sectors of the hospitals (constructions, catering, cleaning).

Strengthening of the strategic role of the private sector, in favor of the big Health Trusts and against individual private doctors and small firms, with generous funding from public expenses. Expansion of this role to medical education.
A hypocritical effort to control corruption by legalizing it! (Offering private services into the hospitals and creating two uneven categories of patients, depending on their financial capabilities).

Lack of evidence based planning according to the local health care needs.

Last, but most important, equal free access to the system is denied to all non-insured citizens (long-term unemployed, immigrants), estimated to be approximately 10% of total population.

In conclusion, the reform carried out by the Greek social democratic government is an integrated, radical reform, based on the same neo-liberal European trends and rhetoric. These policies, enhancing in a cynical way the reemergence of the �inverse care law�, are imposed with only marginal reactions. The necessity of the emergence of a new social movement defending health as a social right is further discussed.