Council of Europe

• Council of Europe
• Democracy
• Health Policy

Introductory paper on the adaptation of health care services to the demand for health care and health care services of people in marginal situations

By Professor Jean-Daniel Rainhorn

The objective of this paper is to introduce the discussion of the working group. It presents some of the questions, which are usually addressed when examining the consequences of poverty on health and discussing the relevance of various strategies. It is based on the author’s experience.

Background:

During the last twenty years, two historical factors have dramatically changed household living conditions in Europe. In the majority of EU and other western countries, the economic crisis started by mid-70s has led to an important increase in unemployment and social inequalities with a measurable impact on the health of the most vulnerable part of the population. In the ex-socialist countries, the collapse of the centrally planned economy system during the 80s has left a large majority of the population without the ability to cover their basic needs. It is today roughly considered that Europe¹ has more than 200 to 250 millions people living under the level of poverty (about 15% of the population in the EU countries and, according to various estimations, 40 to 80% of the population in the majority of the countries of central and eastern Europe). In addition, some estimations consider that an additional 50 to 100 millions group is living just above the level of poverty with the permanent risk to loose their jobs and to enter into poverty. One could therefore consider that 30 to 40% of the population living on the European continent does not currently have the means to cover their basic needs². This phenomena affects particularly two groups of the population: (i) a large share of young people between 16 and 30 - especially males - who are facing a high rate of unemployment and a regular increase of their mortality rate, and (ii) a large proportion of the elderly who do not get sufficient pension especially in the ex-socialist countries. During the past ten years the media have focussed on exclusion, the most visible aspect of the growing poverty in Europe but which affects probably less than few millions people. Although these situations are unacceptable, the image of homelessness should not hide a more important phenomena -poverty and precarity - which is daily affecting hundreds millions of Europeans at permanent risk of becoming excluded.

When examining the health status of a population, it is necessary to remember that there are different concepts related to “health”. On one hand, “health” can be understood as the absence of disease as defined by medicine throughout history. On the other hand, “health” can be conceived as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity”³ or even in a more dynamic perspective as “the capacity for each human being to identify and achieve his/her ambitions, satisfy his/her needs and be able to adapt to his/her environment”⁴, the absence of disease being only one aspect. All these concepts have different implications when defining action for improving health. If poverty and social inequalities are considered as the key factors for the deterioration of the health status, experience shows that the last definition is more operational than the other ones when formulating and implementing strategies geared to limit their effects on health. Therefore, indicators to be used should not be limited to classic health indicators but should also measure various social factors, which have a direct or indirect influence on health status.

The development of new social inequalities, the increase in the number of people at risk of poverty and exclusion, and the reduction of equitable access to health care are already affecting the health status of a significant share of the population in Europe. Although the situation is significantly different between Western countries and those of Central and Eastern Europe, there is a common concern related to changes in health inequalities as they represent today a serious threat for the future health status of the most vulnerable part of the European population and particularly the youth. In the Western countries, the difference in health status between the underprivileged and privileged groups is regularly growing as it has now been proven in many countries^{5 6}. In Central and Eastern Europe, life expectancy at birth declined during the 80s and the 90s with a recent stabilisation in the majority of the countries. It is now well documented that violence, accidents and suicide are more and more the major causes of morbidity and mortality of the young males (they represent more than 50% of the potential years of life lost in Russian Federation⁷), this being accompanied by a regular increase of drug abuse, alcoholism, smoking and HIV/STD. In conclusion, after a century of regular improvement of health status in Europe, a new situation has developed during the last twenty years: some categories of the population are now facing a stagnation and even in certain cases a decline in their health status. This is happening in a global context characterised by a diminution of the role of the State, which in the past played the major role in developing relevant strategies for better health. The risk to see the situation worsening is high and should not be underestimated.
Terminology and essential concepts:

When examining the question of poverty and health, experience shows that there are often misunderstandings in the use of certain words and concepts. Due to the different geographical origins of the members of the working group and the difficulties linked to using a language, which is not the mother tongue of the majority of them, it seems that some definitions and concepts need to be clarified.
1. The question of “the concerned population” :

q Exclusion: In the legal sense, there are not many excluded people in Europe. Officially, only individuals who are illegally resident in a country cannot benefit from the social protection. But during the last ten years the situation has dramatically changed and the definition of “exclusion” has been extended to⁸ :

� The people “without”: persons living in a country without official documents, without permanent housing, without being recorded at the right social sector office, etc.

� Vulnerable groups such as: drug abusers, prisoners, sex workers, teenagers having left their families, etc.

� The “non-categorised”: some people are not registered in any social category, e.g. some young unemployed people, some groups of migrant people (tziganes), refugees, etc.

� The definition is now covering a larger proportion of the population, i.e. the persons who are at risk of exclusion because they are living in a very fragile socio-economic, domestic or housing situation.

These situations are difficult to identify and categorise because these people are often reluctant to approach the social sectors which, in turn, are usually not prepared to take marginal situations into consideration. However, experience shows that their number should not be underestimated.

q Poverty: Poverty is an economic definition. Various approaches for measuring poverty have been proposed. Some are based on the concept of relative poverty (e.g. income lower than 50% of the median of each country incomes or of the average income of EU countries); others are based on the concept of absolute poverty. According to these definitions it is considered that 57 millions persons were living in poor households in EU countries in 1996. Among them 13 millions are children under 16. In many EU countries this population is well identified, as it is the one often taken in charge by the social sector. Quantitative estimations are more difficult in the ex-socialist countries.

q “Pr�carit�” (Precarity): This term derived from the French language is not yet well known in English-speaking countries. The best definition now endorsed by the European Commission in its official documents⁹ was given in 1987 in an official report to the French Government¹⁰. Precarity is defined as: “… the absence of one or several securities which normally allow individuals and their family to assume their basic responsibilities and to benefit of their rights. To live in such insecure environment, which is more or less serious, could lead to serious consequences. When this insecurity affects several aspects of the life, when it becomes permanent, when it prevents individuals to recover their autonomy and responsibilities at short term, it could lead to great poverty”. Today in each European country, millions and millions people are living with the permanent risk of loosing their jobs and their house and are exposing their family to poverty even if they do not officially belong to the group defined as poor. There is a growing concern about this category of the population, which cannot be easily identified but should benefit from strong social policy for preventing them to become poor.

2. The question of “specific pathology” :

It is a common idea that poverty is responsible of specific pathology. But on the contrary of what public opinion is usually thinking, there are no or very few specific pathologies due to poverty. This has been well documented since the Black Report¹¹ in UK, it has shown that for all the causes of mortality and for each category of age, there is a regular social gradient but no specific diseases in the underprivileged categories of the population. In other words the underprivileged groups of the society have more chance to die from common causes of death than the most privileged groups. More recent studies have shown that the gap has regularly widened during the last twenty years and that some categories of people have 3 to 4 times more chance to die before 65 than others¹². This increase of the health gap between the most deprived and the most privileged is now a major concern for the western society.

3. The question of the different types of health systems

There are several types of organisation of health systems in Europe. Due to specific historical development of the social sector each EU country has a particular health system which normally covers the needs of a large share of the population. In these countries, only few people have no legal access to the basic health care services. But in many of these countries some fees have to be paid by patients. This represents an obstacle to an equitable access to health care services. In the ex-socialist countries, everybody has normally access to health care services. But due to the lack of resources, the low level of income of the health professionals and the shortage of pharmaceuticals, fees are also frequently paid to providers. A significant share of the population cannot pay these fees and is therefore excluded from the services. Health systems are usually described taking into consideration the level of intervention of the State in the organisation and the financing. Broadly there are four types of health systems:

q The Semashko system: This system is the model, which was implemented in every socialist country. Health facilities were owned by the State and health professionals were paid by the State. Services were normally free of charge but patients were asked to pay a lump sum for some services such as pharmaceuticals. The Semashko system provided a universal access to health care and therefore no one was excluded. But after the collapse of the socialist regimes, the shortage of financial resources led to a higher contribution of patients who are now obliged to pay direct fees to providers. Today, in some of these countries, the cost of health services is so high – especially pharmaceuticals - that a majority of the population cannot afford these costs and is de facto excluded from the services. The national health expenditure of these countries is generally low (2-3% of the GNP).

q The Beveridge system: This system was first implemented in Great Britain just after World War II. It is a tax-funded system with a large regulation and control of the services by the State with a mix of private market and public services. Although the system is theoretically based on the concept of universality, it has been demonstrated that important inequalities in health persist among the different “social classes” of the population. With some differences, this system was implemented in UK, Ireland, Nordic countries and more recently in Southern Europe including Spain, Italy and Portugal. Although criticised by patients as bureaucratic and not user-friendly, the Beveridge system is recognised as the most cost-effective one. The national health expenditure of these countries is at an average of 6 to 8% of the GNP.

q The Bismarckian system: Initially implemented in Germany, the Bismarckian system was developed after World War II in other EU countries as France, Belgium, Netherlands and Denmark. The system is based on a compulsory health insurance system controlled by the State with additional coverage provided by profit or non-profit private health insurance companies. The health services are a mix of private market and public sector. GPs, medical specialists, pharmacists and dentists are in majority private providers when hospitals are in majority public ones. Although based on the concept of universality, these systems are not covering the entire population. Therefore some groups – especially the unemployed young adults - are more or less excluded from the health services. Recent measures have been taken in some of these countries for ensuring a universal coverage. But the issue of access for illegal immigrants who represent an important population in countries like France and Germany is still not solved. In countries with a Bismarckian health system, the national health expenditure is high (8-10% of the GNP).

q The market-oriented system: Switzerland is the unique European country whose health system is similar to the American one. The contribution of the State is reduced to the coverage of the most underprivileged groups of the population with the majority insured with private insurance companies. Due to the fact that Switzerland has the highest GNP per capita of the world there is only very few excluded persons. But the cost of private insurance is high and more and more people cannot afford it. The example of USA shows that this type of market-oriented health system is the most inequitable one in term of access to health services and the most expensive one (10-13% of the GNP).

Despite the regular growth of its cost in the majority of the countries, the health system plays a modest role in improving health status of the population. It is now largely acknowledged that regular income – even if modest - social protection, housing and education play a bigger role in protecting health status. To ensure an equitable access to health services is certainly necessary in any country but largely insufficient if the objective is to limit the effect of poverty on health.

4. The question of inequalities among European countries :

According to their wealth (GNP per capita), countries of Europe could be divided in three categories: the low income countries with an annual GNP less than 3.000 US$ per capita (all are ex-socialist countries), the middle income countries which are both from Southern and Central Europe and the high income countries which are located in the Northern and the Western part of Europe. When working on policy for limiting the effect of poverty on health, the financial capacity of the countries should be taken into consideration and specific strategies should be adapted to the economic level of each country.

Table 1: GNP per capita of countries of Europe and proportion of people living on less than 1 US$ a day (Source: World Development Report 1997, The World Bank).

Key issues:

In a period of huge socio-economic changes in the world, with among other consequences an increase of social inequalities, some key issues should be addressed when working on the effects of poverty on health. A general trend is to consider that only the worst situations should be taken into consideration and to propose specific measures for these marginal people. Another perspective is to consider that poverty affects or could affect hundreds millions people through Europe and that the key question is to ensure equal access to health and social systems to everybody. Some of these issues are presented below for discussion.

1. Who are they?

This issue is in any country the most political one. Is the target population limited to the formal excluded persons and the ones in great poverty? In that case, measures will be essentially curative and will not concern more than few millions people in Europe. Experience shows that in EU countries, NGOs are often the key actors. Is the target population represented by the ones living under the level of poverty? In that case health and social systems are key institutions and the issue is to ensure an equitable access for everybody. Finally, if the choice is to take into consideration the people living in a precarious situation even if their income could be higher than the level of poverty, a special effort should be made to develop specific prevention measures for limiting the risk of falling into poverty. Such a policy is obviously beyond the capacity of the health sector and should be based on Ottawa principles. When working on the effects of poverty on health, it is proposed that the working group take this broader view.

2. The risk of stigmatisation

Very often scientists, politicians and journalists have a tendency to simplify the problems in order to present complex issues in a simple way to public opinion. In the field of poverty and precarity such an attitude represents an enormous danger of stigmatisation. Excluded people and poor are not a social class. They are people who - for various reasons – are living in a deprived situation at a particular moment of their life. The majority of these people in EU countries were not poor twenty years ago, they often leave poverty when they find jobs even if they could fall back to poverty when they loose their jobs. Only a variable proportion of the people identified as living under the level of poverty is permanently living in such conditions. The risk of proposing to identify precisely these people and to set up specific measures to improve their health situation can lead in health facilities to a stigmatisation of these populations who are already psychologically weak. It is proposed that the working group endorse the concept of non-stigmatisation of this category of population.

3. Specialised facilities versus equal access

The debate about the non-stigmatisation concept is also valid for the strategies, which recommend setting up specific facilities for the excluded people. Today in many countries NGO's have implemented specific clinics for solving a short-term problem. But States working with long term perspective should not create specific health systems for the deprived categories of the population. They should create the conditions for an equal access for everybody. It is therefore proposed that the working group endorses this concept and makes policy-makers aware of the problems linked with the creation of specific facilities.

4. The difficulty to propose common measures with different levels of wealth and four types of health systems

Beyond general principles, which can be put forward as introductory recommendations and strongly supported by the working group, it will be difficult to recommend common measures throughout Europe. Due to the enormous gap between the richest and the poorest countries of Europe, the working group should work on recommendations, which would clearly take into consideration the specificity of each country or groups of similar countries.

Proposed organisation of the work:

It is suggested that the discussions among members of the working group follow a logical approach. This approach, which takes into consideration previous experience, will be the following for the two first meetings:

1. To agree on terminology and concepts: It is suggested that this discussion takes place during the first meeting and that final consensus be reached during the second meeting after the review of the relevant literature.

2. To discuss key issues: It is also suggested that this discussion takes place during the first meeting and that final consensus be reached during the second meeting after the review of the relevant literature.

3. To read relevant literature: According to the needs assessed during the first meeting a set of key documents and articles will be provided to members of the working group. They will then come to the second meeting sharing the same level of information.

4. To set up a common approach: The second meeting should lead to a common view of the major issues among the working group. The group will then formulate draft recommendations.