Health Policy
Fifth Conference of Health Ministers: "Equity and Patients' Rights in the context of health reforms"
7-8 November 1996, Warsaw, Poland
The 5th Conference of Health Ministers, held in Warsaw, Poland on 7-8 November 1996 had as its theme "Equity and Patients' Rights in the context of health reforms". It was a major event gathering 44 European countries to discuss one of the most crucial challenges facing governments today : ensuring equity and patients' rights at a time of economic constraints.
CONTENTS
Report by the Secretary General - "Social challenge to health : equity and patients rights in the context of health reforms"
Appendix I : Final text - A changing Europe
Appendix II: List of participants
Report by the Secretary General 
"Social challenge to health : equity and patients rights in the context of health reforms"
The Secretary General, in presenting his report to the Committee of Ministers, wishes to express his gratitude to Prof. Ryszard Jacek Zochowski, Minister of Health, for hosting this Conference in Warsaw.
He also wishes to thank the Polish authorities for their excellent welcome and perfect organisation of the meeting. This was the 5th Conference of European Ministers of Health organised within the framework of the Council of Europe and it is noted with great satisfaction that many member States were represented at Ministerial level.
The Parliamentary Assembly of the Council of Europe sent a delegation to the Conference. The Congress of Local and Regional Authorities of Europe, the World Health Organisation (WHO-European Region) and the OECD were also represented.
The Conference was opened by Mr R. Guthrie, Director of Social and Economic Affairs, on behalf of the Secretary General, who welcomed all participants to the Conference.
The Polish Minister of Health then addressed the participants, followed by speeches by the representative of the Parliamentary Assembly of the Congress of Local and Regional Authorities and of the World Health Organisation. A message by the Prime Minister of Poland was read out.
On the proposal of Mr Kari Paulsrud, Secretary of State of Norway, the Polish Minister of Health was elected Chairman.
Mrs Erica Terpstra, State Secretary of Health of the Netherlands and Mr Manolis Christofides, Minister of Health of Cyprus, were elected Vice-Chairpersons.
The subject of the Conference was "Social Challenge to Health : Equity and Patients' Rights in the context of Health Reforms". It was introduced by the Polish Minister as Chairman who opened the floor for discussion.
The theme of the Conference was in line with the concept of the right to health enshrined in the European Social Charter and with the right to equitable access to health care guaranteed in the Convention on Human Rights and Biomedicine, 1996.
The main purpose of the Conference was to permit discussion at the highest political level of the major political, social and technical changes which are raising major concerns.
Foremost amongst these concerns are :
the economic constraints in the face of increasing demands, particularly as a result of demographic change;
social exclusion resulting from health status;
weak user participation.
The Ministers discussed these concerns and particularly ways and means of facing up to the social challenges arising from the changes.
The Ministers felt that the solution lay in a tripartite social deal between patients, providers and payers, with the commitment of all sectors and the participation of all the protagonists to achieve equitable distribution.
The Final Text adopted at the end of the debate stresses the need for action on a number of important issues, particularly :
citizens and patients' participation in the conception, building-up, reforming and functioning of a health system;
an equitable access to health care services by balancing the right to health care and financial constraints and addressing the needs of the most disadvantaged groups of the population;
a reassessment of the importance of health status for the social wellbeing of the population.
The Ministers agreed that these issues required action at the level of the individual, at the level of health care delivery and at a governmental level.
The attention of the Committee of Ministers is drawn particularly to the recommendation that health issues should be put high on the political agenda of member States. Health was an indispensable prerequisite of social wellbeing and was the best possible investment for the future.
The attention of the Committee of Ministers is also drawn to the proposal that the Council of Europe consider building up a network for an exchange of information between member States on :
patients' rights and patient participation;
the role of lay persons in promoting health in their own environment;
the exclusion of certain groups of patients, in particular the chronically-ill and people with disabilities from society;
the involvement of the scientific community in a setting effecting treatment and procedures.
At the end of the Conference the Minister of Health of Greece invited the Health Ministers of the Council of Europe of member States to hold their sixth Conference in Greece.
The challenge
Europe is undergoing major political, social and technological changes which call old solutions into question, reveal fresh potential and raise new challenges for the future.
The main challenge facing Europeans remains to ensure harmonious and prosperous development within each member State and within the European continent as a whole.
The good health of a population is a pre-requisite to the social wellbeing and economic functioning of a nation. Health promotion and health care are important social goods, raising fundamental questions about social obligations and goals and the protection of human rights as essential for promoting health.
An important aspect of the European challenge is how to develop health care systems based on values enshrined in the European Convention on Human Rights and the European Social Charter. Present ongoing reforms in health care are mostly motivated by escalating health costs and increasing demands of the population. The question is how reforms of health care systems should ensure equitable access to health care which is both adequate and of optimal quality.
Concerns
Change carries multiple risks and constraints and can raise major concerns including :
the widening gap between the demand side, stimulated by raised expectations of the public and a changing demography, and the possibilities of the supply side, limited by economic constraints;
predominance of budgetary constraints at the national level in many countries, leading to serious cuts in health expenditure despite the relative priority of health care as compared with other social goods, thus counteracting the necessary development and implementation of a sound public health policy;
withdrawal of state and collective responsibility for health promoting environments, health and social security, leaving too much to market forces and allowing for a growing health divide, in particular between employees and those who are not part of the work force;
in some countries the tendency towards an increasingly influential role for budgetary authorities (Ministers of Finance) leading to a vanishing leadership role for the Ministers of Health, which can sometimes contribute to their divided loyalty between the public and the governments;
the higher cost of health care resulting from demographic change, the new epidemiological profile and more sophisticated technologies; this may exacerbate the inequality in access to care within each country, in particular affecting groups of the population which are disadvantaged (marginalised groups), and between countries, even further aggravated by inadequate resources and their inefficient use;
an increase in the number of dependents (elderly and disabled persons) who need more complex and very specific care and consume more resources as a consequence of increased life expectancy from improved care and better living conditions;
more fragmented and possibly depersonalised patient care caused by the omnipresence of increasingly sophisticated medical technology, which could replace human contact;
the phenomenon of social exclusion on health status grounds, because health has become an important asset in a market environment and a prerequisite for social integration; the chronically ill in particular risk a vicious circle of unemployment, exclusion and poverty;
emerging threats to the confidentiality of personal data, particularly of the most vulnerable individuals as a by-product of the development and quickening pace of medical information systems, influenced by the development of information highways and health cost containment policies;
a change in the respective roles, responsibilities and entitlements between patients, providers and payers, the latter playing a dominant role;
the fragmentation and relative weakness of the users' voice, lacking institutional possibilities to put health on the political agenda, to mobilize the public or to attract the attention of the media.
The reply - a new social deal on health : consensus building
To face up to these challenges it is necessary to focus on the most appropriate method for ensuring good conditions for health and for proper health care for everyone, how to counter unreasonable differences in socio-economic positions as a result of one's health status on the one hand and how to counter discriminatory access to health care on the basis of socio-economic positions on the other.
A new social deal on health and society is needed, with the commitment not only by the health sector, but of all other sectors involved, with the empowerment of individuals to look after their health and the participation of all the protagonists in order to achieve equitable distribution of scarce resources, thereby eliminating exclusion. Limited funds should be used in the most effective way.
An added value for the health of Europeans
There are several dimensions to the possible impact of the new social pact :
ethical: establishing a framework of values, fostering a more transparent setting of priorities;
social: guaranteeing equity in access for all to quality health care;
legal: defining patients' rights and obligations as well as the role and responsibility of the State;
economic: restoring the balance between supply and demand, between cost and benefit and between individual expectations and the services that can be provided; developing financial accountability of all the protagonists;
psychological: increasing the feeling among citizens and families that health is also their concern and their responsibility, by alerting them to healthy lifestyle choices;
civic: renewing citizens' interest and increasing their confidence in democratic procedures;
political: making health a political issue and a subject of political commitment;
preventive: ensuring optimal healthy living and working environments;
deontological: redefining priorities of the health professionals in line with new economic accountability and ethical responsibility.
An effective means for carrying out profound reforms
Increased health and social safety should prevent social disintegration and political instability, especially in countries which face economic austerity or carry the burden of a transition period. It could also enhance a social and political acceptance of hardships of the on-going reforms.
A new social deal should therefore ensure that equity and patients' rights issues become an integral part of health care systems and address a number of important issues at the patients' level, at the level of health care delivery as well as at the governmental level: a tripartite social deal between patients, providers and payers.
For this purpose, governments should strengthen the institutions and instruments of political and social dialogue between these partners to give them equal opportunities to mobilize public opinion, and to promote social entrepreneurship.
European citizens need to reach democratically a new consensus around a set of common values. The participatory process of negotiating the deal would renew interest and increase confidence in democratic procedures, building a sense of ownership and responsibility.
This process of social negotiation and consultation geared to the specific characteristics of each State and existing procedures could become a continuous process for the periodical auditing of the deal.
A consensus to act : three pillars
The deal would address explicitly a number of important issues :
Citizens' and patient' participation
Goal : to promote a democratic participation in the conception, building-up, reforming and functioning of a health system
Citizens and patients should be actively involved in the process of deciding how health care and health promotion actions are to be organised and controlled. Appropriate health care implies shared rights and shared responsibilities. Trust in the health professional - patient relationship contributes to an individual's health and to speedy recovery; respect of the rights of the patients by the health professionals increases the commitment and responsibility of the patient. The more people are aware of their autonomy, of their right to decide and make choices, the greater is a need for patients' participation in improving quality and appropriateness of care.
Action :
At an individual level :
* promote active involvement in health matters, dialogue between professional corporate organisations and patients' organisations, balancing rights and responsibilities.
At an institutional level ( health care delivery ) :
* actively involve the patient in the health care process by providing appropriate information and by presenting alternative treatment methods;
* secure respect of rights of the patient ; accountability and transparency; effective complaint procedures;
* fostering patient participation in setting standards of quality of care.
At a governmental level :
* promote the democratic participation of the patient in developing health policy through legislation, funding and other appropriate instruments;
* promote training and education programmes of health care professionals which encompass the perspective and the role of the patient.
Equitable access to health care services
Goal : to achieve solidarity by balancing the right to health care and financial constraints, ensuring basic coverage from the perspective of a health care policy, equal access to health care and equal treatment of all patients and addressing the needs of the most disadvantaged groups of the population
Equity has to be an integral part of health systems in European democracies, as it is indispensable in making rational and fair choices about health policy and health aspects of other policies.
The Government has a responsibility to ensure a healthy social and economic environment, provide the structures and mechanisms to prevent illness and promote health and guarantee equal access to affordable health care, with special regard to the more vulnerable groups of the population. It must seek to monitor and eliminate the socio-economic inequalities arising from the health status of the individual and the unreasonable differences in access to care which may arise from the deterioration of socio-economic situations.
Action :
At an individual level :
* increase patient awareness on their rights and possible role in reducing inappropriate recourse to health services, (including medicalisation and overconsumption), as they are counterproductive to the health of the individual, to solidarity and to equitable access;
At an institutional level ( health care delivery ) :
* organise the participation of health personnel in promoting health and improving health care delivery;
* introduce standards of appropriate care through consensus on practice guidelines and protocols, in order to promote medically appropriate and financially responsible health care delivery based on solidarity ;
* develop instruments to optimise cost-containment and cost-effectiveness through monitoring-instruments, through accountability and by applying evidence-based medicine;
* treat every patient in a non-discriminatory way.
At a governmental level :
* develop policies based on the approach to health care as a social good rather than as a private commodity;
* define essential health needs and guarantee a package of health care on the basis of health policy requirements;
* ensure that equity and social justice takes priority over narrow-minded definition of cost containment;
* develop an equity monitoring system, introducing an equity audit as a systematic activity in all health related activities;
* balance as best as possible priority setting for health against budgetary restrictions;
* ensure equal status for patients in the health care and social protection system;
* develop instruments to ensure that health-care delivery is adapted to the needs of the patient thus avoiding unjustified overutilisation;
* reconsider redistribution of health services according to need;
* adapt health care structures in order to achieve flexibility and diversity of health care services, thus stimulating autonomy of the patient as well as cost-effectiveness and allowing for the facilities to be geared towards the needs of the patient instead of the interest of the health care provider;
* develop if necessary health information systems which permit the achievement of certain strategies.
A better health status for the social well-being of the population
Objectif : to re-evaluate the importance of the health policy field in the present economic environment and strengthen the position of health care vis-à-vis other policy fields.
This objective must be pursued at several different levels by :
redefining, where necessary, the role of governmental authorities, including that of other ministers, whose decisions have an impact on health, in order to create healthy environments and to improve the health of citizens;
redefining the role of ministers of health, strengthening their position and their coordinating role at the governmental level in order to let them better respond to the expectations of the society;
increasing consciousness of the contribution made by investment in health promoting environments and public health policies towards the success of the social and economic policies;
encouraging people in their different roles as citizens, users, consumers, clients and patients to be the agents of their own health, both in organising their living conditions and in establishing their relations with the medical profession and the institutions responsible for health. This is all the more true for the chronically ill and dependent persons, who have to be given new opportunities to help themselves;
empowering individuals means applying a subsidiarity principle with respect to health: as much State intervention as necessary, but only when the individual responsibility and autonomy has been defined and agreed.
Action :
At an individual level :
* encourage, through active discussions, reassessment of values of health for the individual and society;
* increase awareness of citizens' and patients' responsibilities and choices towards individual health and promote healthy life styles.
At an institutional level ( health care delivery ) :
* prevent as far as possible obstacles to social functioning stemming from the health status of the individual; santé;
* acknowledge the role of primary health care and other health professionals as vehicles for change and as health agents of their clients;
* increase consumer satisfaction by increasing freedom of choice where affordable;
* increase providers' satisfaction by offering them professional freedom where appropriate.
At a governmental level :
* develop an assessment system of the health impact of other policies, based on a systematic "health audit" as complementary to the financial audit and cost accounting of the health policies;
* take appropriate action in order to prevent that the economic consequences of adverse health effects of other policies are shifted to the health sector;
* develop policies which reduce inequalities in health matters among the population;
* promote prevention;
* introduce innovative preventive, curative, and care programmes including an integrated approach to care services, including the psycho-social perspective;
* take appropriate actions in other fields of the society in order to make health and health promotion of the population a dominant determinant in all legislative and decision making activities in all fields of society;
* encourage, where necessary, the involvement of local and regional authorities and institutions in the promotion of a healthy environment and of a health system of quality.
At all levels :
* promote, facilitate and support active involvement of Non-Governmental Organisations as protectors of the patients' rights, promoters of equity and as embodiment of the idea of a civic society;
* encourage creating an European-wide network of national Non-Governmental Organisations;
* encourage the involvement of the media in prevention and health promotion;
* encourage the exchange of information in priority setting among member States.
This exercise should create a permanent forum, where the three pillars of the Council of Europe's ideals would be put into practice: democracy, rule of law and respect for human rights.
In particular, the Council of Europe should consider building up a network for an exchange of information between member States on
patients' rights and patient participation;
the role of lay persons in promoting health in their own environment;
the exclusion of certain groups of patients, in particular the chronically-ill, and people with disabilities from society;
the involvement of the scientific community in a setting effecting treatment and procedures.
The Council of Europe ideals of human rights and ethics-oriented policy should influence and change the practice of politically governed policies.
Health is not merely a product of a health care service. It requires people to take more individual responsibility. It also requires greater control over policy development in all the domains which may influence health determinants (lifestyle, economic, social, education, transport, labour, housing etc). Health issues should be put high on the political agenda of each member state and become a vehicle for common European action. A better social and political marketing for health should serve this purpose. This would be difficult without establishing clear leadership for health development.
The Council of Europe as an organ of cooperation between sovereign States brings them together to provide a forum for raising their health standards in democratic structures. This forum could also be used to open a permanent political dialogue among health ministers on essential questions facing health care policies. There is a need to develop new strategies and structures for rapid and efficient international and interregional cooperation in health care. The Council of Europe long-term, intergenerational accountability should be reflected in its future work programme, targeting on priority aspects and patient participation.
International organisations active in the field of health should work closer together and seek synergism in their quest for a coherent European health agenda.
In this way a "health crisis" could be turned into a "healthy crisis" - one which mobilizes, generates innovative solutions applicable to the challenges of today and opens new venues for tomorrow. Furthermore, the social justice, human rights and ethical dimensions of health care could help us to understand that an investment in health is an investment into people, the biggest asset society can have. This is the best possible investment for the future.
Health has become an indispensable prerequisite of individual and social well-being, like peace being a prerequisite for well-being of the nations of Europe. Health is an indicator of the general success of socio-economic policies, a predominant factor in a civilisation's progress.
Investing into health means investing in human capital, investing in a future for democracy, in a future Europe.
Appendix II: List of participants
Albania
Andorra
Mr Josep GOICOECHEA, Minister of Health
Mr Josep BURGUES, Director of Health, Ministry of Health
Austria
Dr Elfriede FRITZ, Director, Federal Ministry of Health and Consumer Protection
Belgium
M. Guy GOYVAERTS, Conseiller du ministre de la santé publique
M. J. DAMS, Adjoint au Directeur de la Santé
Bulgaria
Mrs Diana MITZOVA, Expert at the International Dept., Council of Europe Division
Dr Tseko VODENITCHAROV, Medical University
Cyprus
Mr Manolis CHRISTOFIDES, Minister of Health
Czech Republic
Mr Miroslav MACEK, Secretary General, Ministry of Health
Mrs Alexandra KRALOVA, Senior Official
Mrs Hana PIPKOVA, First Secretary of the Embassy
Denmark
Mr Steen LOIBORG, Head of Division
Mrs Elise QUAADE, Head of section, Senior Official
Finland
Mrs Terttu HUTTU-JUNTUNEN, Minister of Social Affairs and Health
Mrs Helena MIKKONEN, Ministry of Health
Mr Jarkko ESKOLA, Ministry of Social Affairs
Dr Olli SIMONEN, Government Counsellor, Senior Official
Ms Marja Liisa PARTANEN, Senior Counsellor,
Mr Ralf EKEBOM, Ministry of Social Affairs
Mrs Marjatta LILJESTROM, Interpreter
France
S.E.M. Daniel CONTENAY, Ambassadeur de France en Pologne
M. André ERNST, Chargé de mission, Ministère de la Santé publique
M. Xavier COYER, Secteur des Affaires européennes
M. Patrick MONOD GAYRAUD, Conseiller Social auprès de l'Ambassade de France
Germany
Mrs Maria-Magdalena SCHLEEGER, Conseiller de l'Ambassade
Greece
Mr Constantinos GITONAS, Minister of Health and Welfare
Prof. Constantina POLITIS, Consultant to the Minister
Mr. Yannis IFANDOPOULOS, Professor of Health Economics
Hungary
Dr Mihaly KOKENY, Secrétaire d'Etat parlementaire
Mme Katalin SARKANY, Directeur adjoint, Relations internationales
Mme Hanna PAVA, Directeur adjoint, Affaires juridiques
Dr Szofia HAVAS, Conseiller, Politique de Santé
Dr Jozsef KOVACS, Professeur assistant (Université de Semmelweis)
Iceland
Mr David GUNARSSON, Secretary General, Ministry of Health and Social Security
Mr Gudridur THORSTEINDOTTIR, Director of Legal and International Affairs
Italy
Dr Marta DI GENNARO, Director of Health, Ministry of Health
Dr Stefano MORICONI, Medical Officer
Latvia
Lithuania
Dr Leonas KACINSKAS, Vice-Minister of Health
Dr Robertas PETKEVICIUS, International Affairs
Moldova
Netherlands
Mrs Erica TERPSTRA, State Secretary of Health
Prof. Henriette ROSCAM ABBING, Legal Adviser to the Ministry of Health
Mr H.H.P. MEIJER, Directorate of Public Health
Norway
Mrs Kari PAULSRUD, Secretary of State
Mrs Hilde Caroline SUNDREHAGEN, Director General, Ministry of Health and Social Affairs
Ms Grete GJERTSEN, Senior Adviser, Ministry of Health
Dr Per WIUM, Senior Adviser, Norwegian Board of Health
Poland
Prof. Ryszard Jacek ZOCHOWSKI, Minister of Health
Mr Krzysztof KUSZEWSKI, Deputy Minister of Health
Mr Janusz OPOLSKI, Ministry of Health
Mr Janusz HALIK, Centre of Organisation and Economy in Health Care
Prof. Wieslaw JAKUBOWSKI, Head of Department of Science and International Affairs
Portugal
Mrs Maria de BELEM ROSEIRA HENRIQUES DE PINA, Ministre de la Santé
Mr Luis FILIPE DE CARVALHO MAGAO, Directeur général
Mr Vasco PINTO REIS, Conseiller du département de la Santé
Mr Victor MELICIAS,
Mrs Paula Pinto da FONSECA
Romania
Prof Dr. Ion Ioan COSTICA, Secretary of State
Dr Victor OLSAVSZKY, Head of International relations
Mr Mircea BEURAN, Senior Official
Russian Federation
Prof Tatiana DMITRIEVA, Minister of Health
Mr Anatoli PAVLOV, Deputy Chief international relations
Mr O.V. MALIUGIN, Head of Department, Academy for Postgraduate Medical Education
Slovenia
Mr Bozidar VOLJC, Minister of Health
Mrs Silvija ONUSIC, Ministry of Health
Slovakia
Mr Lubomir JAVORSKY, Minister of Health
Mr Jan GAJDOS, Director, Health Section
Mrs Irena MAJEROVA, Director, Department for Press
Mr Jan KLESKEN, Ministry of Health
Mr Alexander KASJANOV, Interpreter
Spain
Mr Arturo PEREZ, Deputy Director General, International Relations
Sweden
Mr Björn REUTERSTRAND, Director General for Legal Affairs, Ministry of Health
Mrs Kerstin BENDZ, Deputy Director
Ms Monica ALBERTSSON, Deputy Director
Mrs Lena JONSSON, Deputy Director
Mr Lennart RINDER, Head of Division, National Board of Health and Welfare
Switzerland
Mme Alice SCHERRER, Ministry of Health, Canton of Appenzell
Dr Stephanie ZOBRIST, Federal Office of Public Health
Mr Gianfranco DOMENIGHETTI, Health Section, Canton de Ticino
Mr Olivier GUILLOD, Institut de droit de la santé, Neuchâtel
"The Former Yugoslav Republic of Macedonia"
Mr Ilir LJUMA, Deputy Minister of Health
Turkey
Dr Yildirim AKTUNA, Minister of Health
M Oguz SAHIN, Director of European Affairs
M Selcuk METINER, Head of Dept. of Curative Services
M Cihangir ÖZCAN, General Director of Curative Services
M Nihan KONURALP, private Secretary of the Minister
M Leyla KARAHAN HIZ, Press Counsellor
Ukraine
United Kingdom
Baroness CUMBERLEGE, Under-Secretary of State
Mrs Heather ROGERS, Secretary
Mr Tony KINGHAM, International relations
European Community
Mr Dieter BIRKENMAIER, Second Secretary, Delegation Warsaw
Holy See
Mrg Jan CHRAPEK, Evêque auxiliaire de Torun
Professeur Krzysztof SZCZYGIEL, Académie de Cracovie
R.P. François-Dominique CHARLES, Représentant du Saint-Siège auprès du Conseil de l'Europe
World Health Organisation (Europe)
Dr J.E. ASVALL, Regional Director
Dr Mikko VIENONEN, Regional Adviser for health services management
Dr Anna RITSATAKIS, Regional Adviser for countries health policies
OECD
Mr Manfred HUBER, Directorate for Education, Labour and Social Affairs
Parliamentary Assembly
Mr Denis JACQUAT, Président de la Sous-Commission Santé
Mr Alexander MALACHOWSKI, Membre de l'Assemblée parlementaire
Congress of Local and Regional Authorities
M. Alexander SLAFKOVSKY, Membre du Conseil municipal, Liptovsky Mikulas,
Slovakia
Council of Europe Secretariat
Directorate of Social and Economic Affairs
M. Robin GUTHRIE, Director
M. Henry SCICLUNA, Head of Division
M. Piotr MIERZEWSKI, Administrative Officer
Press relations
M. Wolfgang RÖSSLE, Adjoint au Chef de Division
Mme Cathy BURTON, Attachée de Presse
Mme Virginia PIVIDORI, Attachée de Presse
Interpreters
M. Robert SZYMANSKI
Mme Teresa-Magdalena POTOCZNA
M. Didier JUNGLING