Impressions from the Eleventh European Health Forum Gastein

Bad Hofgastein 06 October 2008This year's European Health Forum Gastein (EHFG) showed a new record in the number of participants. With 620 participants from 45 countries, the 11th edition of the most important health policy event in the European Union has exceeded even the peak figure at the anniversary event last year. The EHFG 2008 took place from 1 to 4 October in Bad Hofgastein. This year, as well, a large number of prominent European health policy representatives were scheduled to attend, in particular European Union (EU) Health Commissioner Androulla Vassiliou along with several ministers, secretaries of state and leading representatives from the World Health Organization (WHO). The host country of Austria was represented by Health Minister Andrea Kdolsky and Salzburg Governor Gabriele Burgstaller.

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With its extraordinary conception over the last decade the EHFG is a permanent fixture on the European health policy calendar. Unlike most other congresses in this field, the European Health Forum provides a broad-based platform for every group indispensable to a functioning health care systems, that is, public health officials, health policymakers, scientists, physicians, health care managers and, last but not least, patient advocates and NGOs.

"I'm proud we have also been able to continue the momentum of the 10-year anniversary in the 11th EHFG", EHFG President Günther Leiner stated. "As a complement to the numerous special events, the concept of a comprehensive platform for meeting and discussion between various interest groups has been a complete success. The EHFG thus lives up to its ultimate goal that here the guiding principles of future European health policy are discussed on a broad basis from every different perspective."

The key theme of this year's EHFG was "Values and Health - From Vision to Reality". The most modern health care systems and the next years' upcoming reforms were explained from ethical perspectives. Günther Leiner formulated the crucial requirement for success of the necessary reforms: "In health policy and health care services ethical decisions must be constantly made. What will the available funds be used for? Who is eligible for what services? Do patients suffering from the consequences of an unhealthy lifestyle have the same claims as patients affected by fateful illnesses? Questions such as these have to be asked again and again, even if modern medicine remains humane and society remains willing to bear the enormous costs of the health care industry."

Health care system needs binding set of accepted principles

Modern health care systems are increasingly confronted with controversial ethical issues. Scientific progress and the aging of the population in industrialised nations play a particular role in this regard: scientific progress is creating an increasing number of medical options, while the aging of the population has led to a considerable rise in the demand for medical services. "Values in Medicine - From Vision to Reality" was therefore the key theme of the 11th European Health Forum Gastein (EHFG).

"Medicine can do more than ever, we need more medical services than ever, and therefore the question of how to pay for it is more urgent than ever", EHFG President Günther Leiner stated at the opening plenary session of the European Health Forum Gastein. "This alone raises ethical and moral questions for which there are no simple answers and which frequently plunge those employed in the health care industry into major moral conflict."

Thus it is necessary for society in general and health care policy in particular to embrace these issues. This is a task which is at least as important and urgent as medical research. Günther Leiner stated: "Medical advance without generally accepted ethical values and norms will not improve our lives, but lead to social conflict and inequality instead."

Austrian Health Minister Andrea Kdolsky pointed out that it is necessary for the health policy debate to go beyond the current issues of the day: "For years the value of health has had a prominent position in the discussions, whether in policy making, in the media or in public discourse. At the forefront are issues concerning the ability to finance the continually increasing range of services as well as new technologies which are to some extent related to ethical questions as well as fears. The consequences for health policy resulting from the progressive aging of society raise questions about the organisation of future health policy. In an era in which short-term solutions must be found for many specific factors it is necessary to orient our view toward a longer-term perspective and the system in its entirety."

"One of the most important challenges in Austrian as well as European and international health policy is the promotion of health and prevention. For this reason I am looking forward to the first forum today, which is devoted entirely to preventive thinking. For me the aim is to develop a national overall strategy for prevention."

State Secretary Dr. Klaus Theo Schröder of the German Ministry of Health pointed out in his opening speech on the subject of values and health: "The values of universality, quality, general access and solidarity play a central role in the health policy of the European Union. The practical implementation of these values will be best achieved by developed health care systems of the individual member states. Only with the bundled strength of all 27 countries in the EU will we achieve the reality of best possible care."

European Health Forum Award goes to Irish-Northern Irish project on caring for patients with kidney disease

The "European Health Forum Award" for 2008 goes to the Irish-Northern Irish CEWT Renal Project, a cross-border co-operation between the Republic of Ireland and Northern Ireland for improvement of the care of kidney patients in rural areas at the border of both sections of the island. The co-operation encompasses cross-border use of medical facilities - for example dialysis stations - as well as the establishment of common quality standards and patients' freedom to choose medical services, such as taking advantage of operations in the respective other country."

"The jury of experts decided in favour of this project because specific options for improving health care were developed in economically disadvantaged border regions and are being put to extraordinarily effective use", stated jury chairman Günther Leiner. "This is no longer about a good idea, but a model of co-operation which is being very systematically pursued."

The prize was awarded after the plenary session of the European Health Forum Gastein (EHFG) 2008. Austrian Health Minister Kdolsky pointed out that the prize is important particularly for a small country like Austria: "In a small country such as Austria virtually no region is far from a border, thus cross-border initiatives provide good opportunities for us to become more efficient and better."

Cross-border health care is one of the keywords of 21st century health policy. "The European Health Forum Award being presented this year for the second time reflects this as well. I congratulate the winners of the award on their exemplary project, which will make a substantial contribution to the improvement of health care in the border regions."

Another seven outstanding projects involving all 27 EU states ended up as finalists. These initiatives are an important foundation for the exchange of best practice examples. Here is an overview of the eight finalists'projects:

  • CAWT - Kidney Diseases, Ireland, Great Britain: Cross-border co-operation for the improvement of quality in nephrological care. With kidney disease this health policy initiative is involved in an area that requires the continual availment of health care services (dialysis). Co-operation between health and social service organisations are the focus of this project.
  • "Healthregio" - Regional network for the improvement of the health care system, Austria, Slovakia, Czech Republic, Hungary: "Healthregio" is the first major co-operation in the health care sector in Central Europe. Its primary concern consists of eliminating the differences between the "old" and "new" EU states. The countries involved are Austria, Slovakia, the Czech Republic and Hungary. As these are countries with very different health care systems until now, the challenge lies in raising the quality of health care to the level of the best country in the respective area of health care. This initiative is to improve especially the quality of health care in border regions.
  • Mental health for Southeastern Europe, Albania, Bosnia & Herzegovina, Bulgaria, Macedonia, Croatia, Montenegro, the Republic of Moldova, Romania, Serbia: All of these countries have been faced with an increase in mental illness since 1990. The goal is to raise the norms and standards in mental health services in these countries to those of other EU countries. The project also focuses on improved national legislation in the area of mental health including the protection of human rights.
  • Improved recognition of alcohol abuse in the clinical environment using web-based programmes and biomarkers, Austria and Germany: The main focus of this initiative lies in the clinical sphere, as alcohol consumption causes complications in stationary treatments and operations and has a strong negative impact on the success of operations. In the scope of the project a questionnaire was developed concerning improved recognition of the excessive alcohol consumption of patients undergoing an operation. The use of biomarkers to recognise alcohol abuse is to be supported as well.
  • EuroHEAT - Improvement of reaction to extreme weather events and heat waves in the area of public health, France, Germany, Hungary, Italy, Portugal, Great Britain, Spain, Macedonia, Croatia: This project prepares the involved countries for the health-related consequences of climate change. The European countries involved used the results of the EuroHEAT project to introduce a national heat health action plan. There are also joint training programmes for specialists in the relevant areas of expertise.
  • European Heart Health Charta, EU member states and Switzerland: This project is devoted to one of the most frequent clinical patterns in the EU, cardiovascular disease. In the EU more than two million people die from it, with 45 percent of the fatalities among women and 38 percent among men in Europe. 28 countries have officially adopted and introduced the Charta. The aim of the Charta is the improvement of public awareness about cardiovascular disease and its risk factors based on the provision of support programmes for public servants, health organisations and lobbies.
  • European Immunisation Week, EU member states and others: European Immunisation Week takes place on a yearly basis. PR and targeted communication is to raise awareness of the significance of immunisations. 33 European countries participated in the European Immunisation Week in 2008. The focal points were vaccinations against diphtheria, hepatitis B, measles, mumps and rubella as well as polio.
  • HELENA - Improvement of the Nutritional Habits of Youths, Austria, Germany, Greece, Belgium, France, Hungary, Italy, Sweden and Spain: With the cross-sectional study Helena an important scientific basis was established for measures to improve nutritional behaviour from ages 13 to 16. The aim is to create an environment in which positive health-related behaviour and a healthy lifestyle are promoted.

Network of European medicine authorities to strengthen position with respect to pharmaceutical industry

The network of European medicine authorities intends to improve its position with respect to pharmaceutical companies in the future with increased international co-operation. The network was established at several meetings between competent authorities from the 27 EU countries between January and April 2008 during the Slovenian presidency; at another meeting in December during French presidency the priority for the coming years will be determined.

"This network of national authorities, who are responsible for the added value assessment of medications and determination of prices and decision on access to public funds, is of course a deliberate signal to the pharmaceutical industry that it is not dealing with 27 small and medium-sized countries, but that we intend to bundle our strengths more substantially in the future", stated Stanislav Primozic of the Slovenian Agency for Medicinal Products and Medical Devices (JAZMP), the driving force behind the network's establishment. Additional options were mentioned in a wide forum of experts at the European Health Forum Gastein.

As the most important goals of the co-operation Stanislav Primozic mentioned:

  • The best possible availability of medications: in some member countries new medications are still put on the market considerably later than in other countries.
  • A better position in negotiations with pharmaceutical companies concerning the prices of medications through coordination of talks, exchange of information, etc.
  • More efficient process for assessing the use of new medications: the costly process leads to considerable bureaucratic expense for authorities and is also an essential cost factor for new medications.

How rapidly and to what extent the co-operation of EU pharmaceutical authorities will become effective depends on the commitment of the member states as well as the EU Commission. "We have established a network based solely on volunteerism and which is not to become a central office, but to support the authorities of the member states instead", stated Stanislav Primozic. "The intensity with which the work is continuing under the current presidency is highly encouraging."

International co-operation indispensable in the battle against "rare diseases"

More intensive international co-operation can make a decisive contribution to an increase in quality and efficiency in the battle against rare diseases. This was the conclusion of Ségolène Aymé, director of the French National Plan for Rare Diseases, at the 11th European Health Forum Gastein (EHFG).

"As long as countries fail to co-operate intensively and in a structured fashion, the work in the field of rare diseases simply cannot be carried out efficiently", according to Ségolène Aymé. "It is the nature of rare diseases that the case numbers are too small to establish laboratories, educational institutions and an adequately large pool of experts in every single country to work cost-efficiently and ensure the best possible quality of treatment." Yet the treatment can and should remain organised at the local level. "Efficiency certainly does not mean patients have to fly back and forth across the continent."

In addition to the international network, Ségolène Aymé, who with the French National Plan directs the world's most comprehensive programme for the treatment of rare diseases, demands primarily a systematisation of activities: "There are very ambitious activities in an entire range of EU countries, yet they are not incorporated into an overall programme comparable to the French initiative."

Thus, the French initiative for rare diseases is now a highly regarded model for other countries within the EU. Important cornerstones of the more than 100 million euro programme are:

  • A network of 132 national competence centres for various rare diseases
  • Comprehensive online patient information at the website www.orpha.net - now available in five languages
  • Innovative pricing for medicines for rare diseases ("orphan drugs")
  • Rare diseases are standard components of doctors' university training

"Patient satisfaction has risen in the last four years since the start of the programme", stated Ségolène Aymé. "In the coming years we will also analyse the influence of the national plan on the aetiopathology of disease and the fatality rates of the patients."

Young Forum Gastein: Network for junior managers in EU health policy

With the "Young Forum Gastein" project the European Commission and the European Health Forum Gastein (EHFG) has initiated the development of a network of junior managers in the area of health policy and health administration as well as of young political scientists. One scientist and an administrative or policy expert from each EU member country receive an invitation to the EHFG.

With 45 participants in the inaugural year 2007 and 60 participants in 2008, from the start Young Forum Gastein has proven to be a resounding success. Thus a Europe-wide network of junior managers is being developed, which will make a significant contribution to the intensification of co-operation in the health sector between the EU member states in the coming years. The importance of the project is also underscored by the meeting between Young Forum Gastein participants and EU Health Commissioner Androulla Vassiliou at the EHFG.

"This initiative, now in its second year, brings young researchers and young officials to the conference for them to gain valuable insight and exposure to the key players in the sphere of health policy in Europe. Young people are a core concern of mine and I am particularly keen to hear their views in the important issues we have been discussing here in Gastein", Androulla Vassiliou stated.

The significance of the contacts made through Young Forum Gastein is highly appreciated by the participants as well. "My personal experience within the German presidency is that the success of many European initiatives depends very much on the personal commitment and confidence between the decision-makers involved", Young Forum participant Björn Kümmel of the German Ministry of Health explained. Networking at an early stage is essential for this and until now has been lacking among young policymakers. The chances for young health policymakers in Europe to exchange their ideas have been quite limited because the main European health events are often attended only by senior colleagues. In this regard Young Gastein Forum offers a unique opportunity for young policymakers from all member states."

Growing acceptance for advisory councils on ethics

Advisory councils on the ethics of medical and scientific developments are becoming increasingly important in European countries. Advisory councils were frequently viewed as potential opponents to progress by industry and officials just a few years ago, but today this relationship is becoming increasingly collaborative. That was the tenor of the panel discussions at the European Health Forum Gastein 2008.

"Naturally we are unable to implement even close to 100 percent of our ideas", stated Professor Albert Weale, chairman of the Nuffield Council on Bioethics, the United Kingdom-based bio-ethics advisory group. "But our voice is being heard and often we see that policy decisions in the United Kingdom on issues related to biology and medicine coincide with the Council's advice." For example, in one of its earliest reports the Council made a number of recommendations to improve the implementation of genetic screening programmes in the United Kingdom, which have since come to fruition.

According to Professor Weale, the scientific and ethics competence of advisory councils is crucial in order for them to have influence. "Formal regulations requiring the inclusion of ethics councils in decision-making processes can be a good approach, but to be effective they must ultimately be convincing. This can only succeed if the personalities represented on the councils enjoy the necessary expertise." Broad competence in the natural sciences, physicians, ethics specialists, sociologists and legal specialists are indispensable for this.

Professor Weale is encouraged that industry and the authorities now view ethics councils as a potential partner rather than an "unavoidable evil". "No ethics council intends to hamper or impede scientific and technological progress. But we want to ensure any such progress has been considered carefully in terms of its social and ethical implications. This is in fact essential for ensuring that research and innovation do not encounter public resistance, and in this regard we believe that ethical review can be a driver, rather than a hinderer, of scientific advance."

General practitioners must be more firmly incorporated into measures for the promotion of a healthy lifestyle

General practitioners play a key role in every effort to implement a healthier lifestyle in the population. The physician's expertise provides him or her with the opportunity to have a different and frequently far more effective impact on patients than others and to influence their behaviour. This was the conclusion of the experts at the European Health Forum Gastein (EHFG).

"Unfortunately, this key role often exists only in theory", Reiner Brettenthaler, vice president of the European Union of General Practitioners, stated with regret. "In practice there is often simply too little time to conduct in-depth discussions about the risks and consequences of their lifestyle with patients." This problem can only be solved by a reduction in the number of patients per physician and by adequate compensation for the time spent in patient dialogues.

Reiner Brettenthaler also demanded an increase in the range of educational and further training options for physicians on the subject of smoking, alcohol and bad nutritional habits. Special psychotherapeutic training for therapeutic dialogue is particularly important. "The battle against addictive behaviour is an enormous challenge, thus practical training also facilitates substantially higher success rates."

Patient safety: health care systems must learn more quickly from mistakes

Patient safety has become a key issue in improving the effectiveness and quality of modern health care systems. For instance, this year alone nearly 400,000 deaths will occur in Europe as a result of venous thrombo-embolism (VTE), a condition that encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE). Among patients who survive, VTE is associated with significant long-term complications that not only have a dramatic impact on their ability to function, but are also associated with a tremendous cost burden. Statistics indicate that more patients die from VTE than from AIDS, breast cancer, prostate cancer, and road traffic accidents combined.

"This is an absolutely unacceptable level as there are risk assessments and treatments that can be used for prevention as many of these deaths are avoidable", stated Jo Groves, Chief Executive Officer of the London-based International Alliance of Patients' Organizations (IAPO), at the European Health Forum Gastein.

At a workshop addressing patient safety with a focus on VTE, Ms. Groves said that European health systems must learn more quickly from health care incidents. "Medical treatment is a high risk endeavour but what is important is that there are systems in place to prevent error, and in the event of an error the system picks up on it before it can cause harm to a patient. All errors should then be analysed and addressed so that the system learns and recurrence is avoided."

However, Ms. Groves saw some opportunities to sustainably improve the situation:

  • Education and training for doctors and medical staff: communication skills and training in how to create a co-operative relationship between the patient and doctor will lead to safer health care
  • Open disclosure procedure: this shifts the focus from blame and defensiveness to one of open disclosure, learning and health care improvement
  • Capturing the patient experience and learning from it. Empowering patients and families to be involved in the improvement process, thereby acknowledging that taking the perspective of patients and families into account is a useful validation tool for the implementation of guidelines, processes and protocols.
  • Formal incorporation of patients' organisations in health policy making.

"It is the first priority of patients to contribute to a safe, quality health care system", stated Ms. Groves. "Empowering patients does not make life more difficult for doctors and other medical personnel, but helps to improve patient safety."

Tackling cancer in the EU: Why is innovation necessary?

Leading experts from patient organisations, the professional community, the pharmaceutical industry and key members of the European Parliament have called upon the EU to recognise the importance of innovation in the fight against cancer. At a workshop sponsored by Novartis entitled "Tackling Cancer: The Role of Innovation", an expert panel examined the challenges to supplying innovation, how this area needs support and prioritisation from all key stakeholders within the EU and the impact that innovation can have on dramatically improving the everyday life for cancer patients.

The panel of experts consisted of senior MEPs Georgs Andrejevs and Alojz Peterle, Richard Sullivan of the European Cancer Research Managers Foundation, Julio Celis from the European CanCer Organisation ECCO, Roger Wilson of Sarcoma UK and Guido Guidi of Novartis Oncology. Engaging in the debate, the workshop audience discussed how innovation can be encouraged and developed in the EU.

"Cancer research and innovation are fundamental elements in the fight against the burden of this disease and the improvement of life for millions of patients in Europe. Europeans have witnessed substantial progress in the fight against cancer in the past 20 years through the development of new and innovative therapies. As a result, patients with cancer that would have killed them in a very short period of time are now able to have a substantially improved quality of life and their life expectancy extended, and in some cases these diseases have even become curable", stated Dr. Guido Guidi, Head of Region Europe, Novartis Oncology speaking at the event.

"This is why the EU needs to take a leading role in creating incentives for innovation, stopping the brain drain to the United States and ensuring that we continue to develop treatments which will save the life of millions of people. To put it simply: we must continue to innovate so we can help patients escape their death sentence", he continued.

Indeed, the participants recognised that despite great progress cancer remains the second largest killer in Europe, and what is particularly worrying is that Europeans do not have the same chance of surviving across member states: inequalities in the EU result in great differences in outcomes concerning survival rates - for example, the five-year survival of all cancer patients varies from 25 to 50 percent.

In this respect, many of the participants agreed that the EU has a key responsibility in ensuring that the positive effects of innovation are accessible across all member states and that the aim of EU action is to encourage the development of informational exchange, improve best practice sharing and ultimately ensure that standards of research, prevention, care and treatment are raised across the whole of the EU.

Better value for money with value-based pricing for medicines

Value-based pricing models for new medicines are beneficial for both the pharmaceutical and biotech industry and the patient health systems on the other hand. This is the conclusion of an expert panel on biotechnology medicines at the European Health Forum Gastein.

"We have a crystal-clear approach to pricing for new medicines", stated Andreas Engström, an expert from the Dental and Pharmaceutical Benefits Agency (TLV) in Sweden, responsible for reviewing reimbursement applications. "We are prepared to pay for the benefits a new medicine brings patients, but we do not pay a single cent extra of the taxpayers' money if there is no clear evidence that a new drug is an improvement for patients."

The TLV assesses the effect on patients in terms of quality-adjusted years of life as well as all cost effects that can be expected related to a new drug. "This assessment is the basis for rational and transparent pricing", stated Andreas Engström. "The industry is rewarded for the benefits of a new drug, and we avoid excessive pricing as we have a clear view of all potential advantages and disadvantages."

Generally this pricing model is well accepted in the biotech industry, for which the justification of the frequently high costs of newly developed medicines has become a major burden. "Clear pricing rules are perfectly fair and enable us to develop sound business cases for new drugs", stated Thomas Bols of the biotech company Amgen. "We support developing the best value based evidence to ensure access of innovative biotech medicines for the patients who need them."

After a few years of experience with value-based pricing models in several countries like the United Kingdom or Sweden, it turns out that this reimbursement scheme is in many respects more efficient than traditional systems focused entirely on cost comparisons. It incorporates improvement in the quality of life of patients as well as cost effects outside the area of health care - for example economic effects due to reduced sick leave - and it turns out that the costs are lower in the medium and long term: this is underscored by the fact that the increase in costs for pharmaceuticals in Sweden, where value-related pricing is carried out most systematically, is well below the European average.

The health care system has to approach men and not sit back and watch them die

The lower life expectancy of men compared to that of women is only to a very limited extent a result of genetic determination. The main reasons for this are an unhealthy lifestyle and the fact that men make use of health care services too little and too late. "This is the bad news", stated Ian Banks, spokesman from the British Medical Association for men's health issues and president of the European Men's Health Forum, which was featuring a "Men's Health" panel at the European Health Forum Gastein. "The good news is: We can change this."

Ian Banks demanded a radical change in the attitude of health professionals and health systems towards men's obvious disregard of health issues. "As long as we sit around and wait for them it makes no sense to lament about men's neglect of their health needs and inadequate use of our great health system. If men do not come to us, we have to go to them."

Potential battlegrounds in the fight for better men's health are workplaces and sports grounds. When men are addressed with health issues in their working environment, where it becomes obvious that better health is linked with greater success and higher professional standing, they are more open to advice and changes in lifestyle. Information campaigns at football or rugby stadiums have also proven to be quite successful, according to Ian Banks.

"It doesn't matter what someone may think about it. The only thing that matters is that it works." Ian Banks also regretted the fact that there is too little political backing for men's health issues: "There were already two EU reports on women's health but we are still waiting for the first one on men's health."

There is little doubt about the urgency of the issue. A striking fact is that low social status affects the health situation of men far more than that of women. For instance, in socially deprived areas of Great Britain the life expectancy of men is as low as 54 years of age, whereas in other areas men's life expectancy is up to 80 years. "There are no similar differences between women with low or high social status", Ian Banks stated. "Furthermore, we know the health of women and men is often inextricably linked. Whoever wants to seriously tackle the problem of inequalities in health has to deal with men's health issues."

Young people in the focus of the new EU health offensive

Young people are in the focus of the EU's new health action plan presented by EU Health Commissioner Androulla Vassiliou. At the European Health Forum Gastein, she stressed that the pre-eminent goal of her "Europe for Patients" campaign is to raise awareness of health issues among young people: "Young people are our greatest asset. Their health is crucial for their ability to live successful and productive lives. Currently, however, the health of young people deteriorates all too often due to preventable factors."

Commissioner Vassiliou pointed out that health prevention and health measures focussing on young people are far more effective than any other preventive measures: "People have to protect their health as long as they are healthy. Therefore we have to involve young people by tackling the health issues that obviously affect them. To be successful, it is important not to take isolated action in the field of health policy, but to create synergies with other areas, namely education, employment and the media."

A key part of the Europe for Patients strategy is a campaign against smoking targeting young people over the next two years. 35 million euro will be invested for this purpose. Additionally, the European Commission will actively approach Member States to explore opportunities for collaboration in a wider campaign addressing nutrition, physical activity and alcohol abuse, as well. "Young Europeans live their lives more internationally than the older generations. Therefore it is crucial to combine national and European activities to be sustainably successful."

Pan-European co-operation is also the idea of the "Young Forum Gastein", which involves young policymakers and scientists from all the EU member states. "Health policy addressing young people must incorporate the points of view of young people. Therefore I am keen to hear their views concerning the crucial issues we must tackle in the years to come."

"Iron Curtain" separates a sick and healthy Europe

With respect to health care a united Europe even within the European Union can hardly be spoken of. The differences in the quality of health care systems and the health of the population between the old and new member states are enormous.

"Is there an Iron Curtain between a sick and healthy Europe today?" asked Alojz Peterle, member of the "MEPs Against Cancer" initiative and speaker on the subject of "Health and Justice" at the European Health Forum Gastein. The former Slovenian minister president addressed one of the most urgent issues in EU health policy.

The example of infant mortality makes particularly clear how dramatic the differences in the status of health care are. "The likelihood that a child in Romania will die in its first year of life is six times as high as it is in Sweden", stated Alojz Peterle, quoting an especially shocking statistic. "And in terms of the mortality rates for cancer patients the differences are so great that in terms of health care we can virtually talk of an Iron Curtain through Europe."

"The EU Commission must treat problems of inequality between the various Member States on par with the differences between social and demographic groups", Alojz Peterle demanded.

The EU Commission is thoroughly aware of the problem. "One primary reason for the enormous differences, however, is the variety of economic situations", stated Andrzej Rys, head of the Directorate of Public Health in the Directorate General for Health and Consumer Affairs (DG Sanco). "Measures to reduce economic differences, particularly the use of structural funds, will automatically lead to decisive improvements in the area of health care as well. The programmes to reduce health-related differences between social groups will help eliminate the differences between the member states."

However, Andrzej Rys warned of expecting that in the area of health care the new Member States will quickly reach the level of the "old" EU states: "Key indicators such as life expectancy and healthy phases in life are not only influenced by the present, but ultimately reflect the positive and negative influences during the entire lifespan. With targeted measures a few things can be achieved in the short term, but the complete elimination of differences is undoubtedly a long-term project."

Social determinants for the improvement of health status

In most parts of the world the key to improving people's health is not in the area of health care, but in economic and social policy. This is the most important conclusion of the WHO Commission on Social Determinants of Health in a report it recently presented. Based on several thousand individual studies, Commission Chairman Prof. Sir Michael Marmot discussed the report issued with leading European health experts at the European Health Forum Gastein.

"Medical care can lead to an improved course of disease and a higher life expectancy, but it is primarily the social and economic conditions which make people sick in the first place", Sir Michael Marmot stated. "For this reason improvements in these areas are disproportionately more important for the health of the overall population. This fact must be reflected in health policy."

This is not only true of developing countries, Sir Michael Marmot pointed out. In rich industrialised nations, as well, social differences are the main reason for inequalities in the health status of the population. "We aren't talking about a third world issue here, but a problem we can see at our doorstep on a day-to-day basis - if we want to see it", Sir Michael Marmot stated. This is not just a matter of material poverty, but of other social factors such as social isolation, unemployment, the lack of self-esteem and family relations.

The fact that these environmental conditions cannot be changed in the short term is reflected in the title of the report presented recently by the World Health Organisation (WHO). To the WHO and its member states "Closing the Gap in a Generation" recommends a multi-disciplinary approach in which health targets are incorporated into every area of policy including education, environmental policy, equal opportunity issues and budget policy. "We have to face these social inequality-related problems, even if there will not be any simple or rapid solutions", Sir Michael Marmot stated. "But only a fair world can be a healthy world."

Strengthening health systems: measuring pays out

At the European Health Forum Gastein, WHO representatives and experts discussed ways to implement the "Tallinn Charter", which was adopted at the recent WHO Ministerial conference in the Estonian capital in June 2008. In this Charter both national governments and international institutions express their commitment to invest in the health of their respective populations. They also acknowledged the beneficial effect for economic development. The Charter provides guidance and a strategic framework for strengthening health systems throughout Europe.

"There is no doubt that health is influencing wealth", stated Josep Figueras, Director of the European Observatory on Health Systems and Policies. "What we need are better evaluation and measuring systems for better assessing the effects of policies on the values and goals we have set for our health systems." For instance, a close monitoring of the effect of out-of-pocket-payments on different income groups offers the possibility to refine protection mechanisms to ensure accessibility to care for all. Too often reforms are still more based on feelings than on evidence.

"Efficient measuring tools are a prerequisite for good health policies and they have to be in place before measures are even implemented", stated Josep Figueras. Examples show that also lower income countries in the Eastern part of the European region can set up effective measuring systems for steering and strengthening their health policy. Investing in performance measurement pays out in outcomes.

Still strong potential for better efficiency and quality through eHealth

There is still a large potential for cost-savings and an improvement in quality through wider use of information and telecommunications technology (eHealth) in the health sector. This was the conclusion of a panel of experts at the 11th European Health Forum Gastein. The issue of innovation in co-ordinated care was a top priority at this congress.

"The eHealth Action Plan has sparked significant progress and the process of implementation of eHealth applications in the member states has become considerably quicker", stated Flora Giorgio of the DG Information Society and Media in the European Commission. "These applications already play a key role in the enhancement of quality and efficiency in health care, and there is potential for further improvement." A few examples are the use of eHealth records to enhance the quality of care, e-prescription services and automatic alerts in the event non-compatible drugs are prescribed.

However, this is only a comparatively small portion of the opportunities, according to Flora Giorgio. EU co-funded research in the area of eHealth will continue to provide innovative solutions to meet the challenges health care systems are facing. With the following new initiatives, the EU Commission is aiming for new impulses in the implementation of eHealth in the EU member states:

  • The recently adopted "Commission Recommendation on Cross-Border Interoperability of Electronic Health Records Systems"
  • The planned "Commission Communication on Telemedicine for the Benefit of Patients, Healthcare Systems and Society"
  • The projects co-funded under the Competitiveness and Innovative Programme
  • The European Patients' Smart Open Service project, aimed at testing and validating interoperability of electronic health records and ePrescription solutions
  • The CALLIOPE thematic network, aimed at building consensus and providing technical support for the implementation of interoperable eHealth solutions across Europe

The campaign in the area of eHealth also opens up opportunities for European companies. Paul Rübig, MEP, president of the international SME lobby SME Global and co-founder of the task force SME Health, demanded in particular the increased incorporation of SMEs in the development and implementation of eHealth applications: "There are countless European SMEs doing outstanding work in this area, some of which offer considerably more innovative solutions than the big IT companies." SMEs can establish themselves in niche areas and play an excellent role here on a European and global level.

The Czech Republic and Sweden present health priorities in the coming EU presidencies

The next two countries presiding over the EU Presidency, the Czech Republic - first half year of 2009 - and Sweden - second half year of 2009 - presented the priorities of their presidencies in the area of health care at the European Health Forum Gastein.

Five common key themes have been defined in co-operation with France who currently holds the EU Presidency:

  • Promoting a EU for patients
  • Improving health security at European level
  • Ensure safe and efficient pharmaceuticals
  • Addressing disease prevention and health promotion
  • Promoting actions for a healthy, active and dignified ageing

In the range of themes concerning healthy active and dignified ageing, the Czech Republic will focus on financial sustainability while Sweden will highlight the dignity aspects of elderly care, promoting closer co-operation between the health and social policy areas. Another focal point of the two presidential periods is the antimicrobial form of resistance, which are becoming an increasingly big problem not only in hospitals. The Swedish presidency will devote itself to the problem that there are hardly any new antibiotics in development which can replace older strains, against which massive resistance has developed. The possibilities should be evaluated concerning how research for new antibiotics can be accelerated.

The implementation of eHealth uses for improving patient safety and quality of care is also a common theme that will be on the agenda during both the Swedish and Czech Republic presidencies. Another issue of the Swedish presidency will be the follow up on the EU alcohol strategy. A conference will be held that will look at progress made in implementing the strategy with the view to explore possible room for improvement. The conference might highlight topics such as young women and fatal alcohol syndrome, children in families with alcohol problems and the identification of "drivers" contributing to alcohol related harm.

Experts demand systematic implementation of ethical principles in the health care industry

The theme of the 11th edition of the European Health Forum Gastein was "Values and Health - from Vision to Reality". The conclusion of the expert panels, in which more than 600 leading representatives from the areas of health policy, health administration, medicine, science, industry and NGOs took part, was the following: there is unanimous agreement concerning the ethical principles around which the health care industry must be oriented - and in practice these principles are not or are inadequately implemented.

At the closing plenary session of the EHFG the attending high-profile representatives from international health policy - EU Health Commissioner Androulla Vassiliou, WHO deputy regional director for Europe Nata Menabde and several European health ministers - were confronted with the demand for orientation based on five fundamental principles which were defined by the experts who met in Gastein

  • General access to health care services
  • Availability of high-quality health care
  • Equality and the elimination of differences based on social status
  • Solidarity
  • Financial sustainability

For the issues addressed at the EHFG 2008 criteria were also defined on the basis of which it should be evaluated whether the demand for a value-oriented health care system is also reflected in the practice of health care systems:

  • Transparency of political decision-making and social debate
  • Clear areas of competency in the scope of health policy and administration
  • Fair reconciliation of patient rights and public interest
  • Just solutions for minorities, for example in the area of rare disease
  • Access to cross-border health services
  • Use of information and telecommunication technology in order to improve access to health services
  • Qualification measures for those employed in the health care industry

"It is wonderful that experts from so many different interest groups were able to agree on a set of common principles and objectives", stated EHFG President Günther Leiner. "But having common principles is not the important thing; we actually have to live by them as well." The application of ethical principles is indispensible to the health care industry, which in its essence cannot be bound primarily to material objectives.

This objective can only be attained if all the groups involved in the health care industry make a contribution. Günther Leiner concluded: "Ethical principles cannot be decreed, they have to become an overall concern. We need leadership at many levels so our health care system not only functions, but lives up to our social visions of humanity and justice."

The date for next year's European Health Forum Gastein has already been scheduled: the 12th EHFG will take place in the Gastein Valley again from 30 September to 3 October 2009.


Leslie Versweyveld

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