Health policy and risks of pandemics

Last update: 30 11 2009

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Background

The expenditures of the Visegrad countries on health care are considerably lower than EU (15), which can be attributed to a weaker economy. These countries also lag behind the western EU in terms of life expectancy. All four countries inherited soviet model of 100 % publicly covered healthcare systems, with many inefficiencies whose inalienable part was corruption.

The reforms of the healthcare systems in Visegrad countries focused mainly on limiting redundant seeking of healthcare by introducing fees (Slovakia and Czech Republic), increased effectiveness of healthcare providers by privatizing of healthcare insurance and increased the security of healthcare by establishing new authorities for control.

In this year annually published ranking of healthcare systems in Europe from the patients’ perspective made by Health Consumer Powerhouse, V4 countries were ranked among 33 European countries as follows:

17. Czech Republic

20. Hungary 

26. Poland

28. Slovak Republic

CZECH REPUBLIC

The Czech healthcare system face many difficulties and inefficiencies such as wasting of medicines (large volume of drugs sold by pharmacies and paid for by insurance companies but are then unused), long waiting periods for specific surgeries (e.g. interjections of the orthopedic prosthesis), unequal availability and quality of medical help depending on regions, or the lack of paramedical personnel caused by relatively low level of remuneration.

Also, most of the people are not motivated to take care of their own health and tend to underestimate preventive measures and healthy lifestyle. Another thorny issue is a high rate of work absenteeism. According to the study published in February 2009 by Mercer, the UK consultancy, Czechs are the third biggest absentees in the EU (while on average, Europeans take 7,4 sick days a year, Czech stay at home for 11 days a year).

On the other hand, some segments of the medical care in Czech Republic are of first quality such as treatment of oncological illnesses or cardiovascular disorders. But in spite of that, and in relation to low awareness of preventive behavior, the vascular and circulatory diseases are still the most frequent cause of death in Czech Republic.

Most of these problems were meant to be solved with the recently launched reform of the healthcare system introduced by the center-right government.

Czech health service is based on the system of public insurance. In compliance with the Czech constitution, the basic health service is meant to be „free and universally available“.

However, with a view to introduce incentives in the healthcare system that would change the behaviour of patients and limit their wasteful behaviour, the centre-right government introduced, as of 1 January 2008, symbolic „regulatory charges“. Charges range from 1, 15 EUR for seeing a doctor or for one item on a prescription to 3,46 EUR for using emergency service.

As a kind of a measure that should prevent seriously ill people to pay too much for the medical expenses, law also introduced a limit of 190 EUR on patient's expenses per year (regulatory charges and surcharges for some medicines are counting towards this limit). When the limit is crossed, the insurance companies are obliged to return their client excessive money.

But the reform was halted already after the first phase characterized by regulatory charges which turned out to be extremely unpopular with the voters. Opposition social democrats even made cancelling of charges the flagship of their campaign ahead of regional elections in fall 2008. As they did not succeed to cancel regulatory charges in the national Parliament, they tried to get around the law and cancel them, de facto, at the regional level by paying them from regional budgets instead of patients themselves.

However, every region took a different strategy and, from the national point of view, the result is very messy. For example, some regions simply cancelled levying charges while others, in fear that such behaviour might be seen as unlawful, keep patients charging but send them their money back later on. Also, some regions cancelled charges for medicines at the premises that are administered by the region, but as they did not involve private pharmacies, they face a potential legal action for discriminatory practices from the European Commission.

The Czech Republic had until recently a very opaque system of setting the prices of medicines, in which the maximum producer prices, margins of pharmacies and distributors, scope of coverage from the public insurance, and patient's supplementary payments were decided by the special commission subordinated to the minister for health. The transparency of the decision making was very poor and it was unclear what interests individual members of the commission (composed of doctors, insurance companies, ministry officials, and others) defended. This has changed with a reform as there is now a single independent agency that is responsible for all the price regulation and its decision can be challenged at the court in case of any doubts.

Currently, the most serious threat, as well as for other countries, is the impending pandemic wave of the Mexican flu. As of October 2009, there were 351 infected patients and one death announced. Most of the sick people are kept in quarantine at their homes and no serious complications have arisen yet. Czech authorities have developed the „pandemic plan“ and count on the incoming vaccine which should be ready for administration within six months, according to the information by World Health Organisation.

HUNGARY

The situation of Hungary’s health care is showing a weakening trend, compared to other European countries. The 2009 Euro Health Consumer Index ranked the country’s health care system on the 20^th place on the list of 33 countries. This is a setback, since last year Hungary was ranked 14^th. According to the Health Consumer Powerhouse, although Hungary has demonstrated progress in some areas (e.g. the information of the patients), the results of a health care reform are yet to be seen.

Nonetheless, Hungary is one of the first European countries releasing a vaccine against the H1N1 influenza virus. The European Medicines Agency has only authorised three types of influenza vaccines used in Europe (Focetria, Pandemrix, Celvapan). Although the Hungarian vaccine called ‘Fluval P’ is not among them, the Hungarian National Institute of Pharmacy did authorize the release of the vaccine in the end of September 2009. In fact, the vaccine passed the World Health Organization’s laboratory tests.

Still, public, political, even professional opinion is divided concerning H1N1. In spite of the Hungarian Ministry of Health’s arguments, people are uncertain about the safety of the new vaccine. Several doctors are only willing to provide their patients with the vaccine if they undertake the vaccination’s possible side effects at their own risk. Although – from the doctors’ point of view – this is only a precaution, it can also increase the panic among the patients.

The virus has infected politics as well. Government and political opposition unanimously state that the new vaccine is appropriate for stopping the pandemic. On the other hand, the opposition accuses the socialist government of handling the situation inadequately. According to the opposition, the government has been indecisive and secretive, especially in the question of the vaccine’s distribution.

Moreover, the H1N1 flu is a popular topic in the media. Minister of Health Tamás Székely approached the court of justice, accusing some members of the media (Internet and press) of deliberately spreading false information concerning the issue thus causing dilemma in the public and jeopardizing the avoidance of the pandemic. Nevertheless, the minister’s denunciation has been rejected by the local Prosecutor’s Office.

POLAND

The four strategic goals of health policy in Poland are: increasing health safety of the society, improvement of the functioning of the health care system, adjusting of the health care to long-term demographic trends and decreasing the gap between Poland and the EU average in terms of health care standards. These seem reasonable enough, however a sad reality is concealed behind their general wording: Polish health care system is one of the worst in Europe. This is reflected both by an objective measure of the Euro Health Consumer Index (the 26^th rank in 2009) and the results of opinion polls among patients (two thirds “not satisfied”). It is therefore very hard to describe the health care system in Poland in another way than through its numerous problems.

Among the most important are the following: Polish patients have to wait too long for a visit to a specialist (in many cases more than 6 months) or for a surgery. Another painful issue is lack of access to new medications, especially advanced anti-cancer therapies. Patients have no choice but to wait for several months for a bed in an oncology hospital ward. No wonder that the successful treatment ratio is one of the lowest in Europe, both in case of diseases specific to women (e.g. breast, cervix, ovary cancer) and men (prostate, lung). Waiting time for more simple diagnostic examination is measured in months, too. Unlike many Europeans, Poles do not have a chance to obtain a specialist’s second opinion (in theory they do but to that end they would have to obtain a second request from a general practitioner and to wait another couple of months for the visit to the other specialist). Another thing is that people in Poland do not have the access to 24-hour hour information on medical aid and there is no full and exhaustive register of all physicians in the country.

The standards of HIV/AIDS prevention and treatment are unsatisfactory, too. Currently there are 22 so called Points of Consultancy and Diagnosis financed by the Ministry of Health, where free HIV testing and consultancy is available. The increasing of the availability of free testing is a big challenge: it is estimated that only 30% of those infected are aware of their condition which is to say that two thirds of all those HIV-positive evade statistics. The European survey of HIV policy (EHIVI) ranked Poland 20^th out of 29 countries in terms of the care and conditions for people living with HIV. It is impossible to obtain data on general medical outcomes, such as the number of people receiving HIV treatment. People with HIV do not get screened for sexually transmitted diseases and hepatitis, and people with tuberculosis are not screened for HIV.

All the above mentioned ailments of Polish medicine are partly due to the fact that the governments, one after another, have been very reluctant to increase the alarmingly low spending on the health care. This results in low efficiency of the system. The physicians in the public health sector are underpaid (thence informal and illegal remunerations given to them are still an existing problem). This has led to the opening of many private doctor’s offices, and private medical subscriptions and health care policies have already been sold to two million people.

Unfortunately, the 2010 outlook for the public health care sector is even gloomier. The National Health Fund predicts that its revenues from the subscriptions will be lower by 1,2 billion zlotys than this year’s 53,7 billion. Further cutting of expenses means that all problems, instead of being solved, will accumulate.

The access to modern pharmacotherapy is also below acceptance. The registration of innovative pharmaceuticals is dragging on endlessly (by far longer than the EU average). Poland spends 30%-40% less than countries with comparable living standard for the refunding of medicines. But here improvement is at sight: the Ministry of Health announced that the spending was to increase and new, modern drugs would be on the refunding list. The priority is to ease the financial burden to people with chronic diseases (e.g. unlike today, sustained-release insulin will be refunded). Another bright point lies in the area of intellectual property: the patents on many important (and very expensive) drugs are to expire soon. Savings will occur with the use of generic drugs produced by other producers than the current patent-holders.

The cases of “swine” flu have been quite scarce in Poland so far: approximately 200, compared with 20 000 in Germany (300 new cases daily). Germany is where the pandemic is likely to arrive in Poland from. It is foreseen that, like every year, on All Saints Day (November 1^st) many visitors will come to the Opole region, which is a homeland of German minority. An outburst of the epidemic is considered then. The Ministry of Health has purchased four million doses of vaccine by now. The vaccine is being tested and is not yet available for use. It has not yet been decided whether it should be used once or twice. The number of people to be protected will be four or two million respectively. The National Flu Pandemic Committee has announced that those to be vaccinated in the first place are: health care workers, pregnant women from risk groups (indicated by a physician), children above 6 months of age with chronic diseases, police, army and public transport workers.

SLOVAK REPUBLIC

The centre-right government (2002-2006) introduced more market elements in the health care system. Most notably the privatization of health insurance companies and introduction of fee of 0, 66 euro for one ambulance visit or one medicine prescription and 1, 66 euro for one-day-stay in the hospital. It was also designed to reduce the number of unnecessary visits and relieve the budget little bit. The new government of R. Fico (since 2006) abolished these unpopular fees.

Slovakia pours 6 % of the GDP into the healthcare system, which is less than the European average (8 %). Private health insurance (voluntary insurance) is not very widespread in Slovakia.

To eliminate the immense debt of hospitals the government decided to pour more money into the system. However, that did not stop further indebting. There were also plans to abolish 6 thousand hospital beds, which a commission of the ministry of Health found redundant. That should have happened without closing any of the hospitals. At the same time, the Ministry defined so called “minimal network of healthcare” which resulted in health insurance companies only concluding agreements with those facilities included in this minimal network.

In one of the controversial moves, government passed a law that prohibits private health insurance companies to produce profit, while not returning them the legal form of public institutions. The profit produced must be according to the new rules used on payments for healthcare. One of the owners, a company based in Netherlands, has launched a procedure before international arbitration court due to alleged breach of agreement on protection of investments. The sum they claim to have lost is 500 millions euro. Even European Commission has reservations about the imposed non-profit character of private health insurance houses.

Government also planned to introduce a centralized system of one state-controlled health insurance house. After strong criticism it abstained from these plans. 

The healthcare professionals generally suffer from low remuneration; the average wage of doctors and nurses was 1529 and 794 euro respectively in 2008. The brain drain of newly graduated doctors is also a problem. Experts also cite discontinuity in the governing of the resort as a problem. According to them politicians should develop more coherent long-term vision.

Also, the consumption of drugs is rising in Slovakia; especially the consumption of very pricy drugs - innovative oncology drugs - is rising due to the rising incidence. Declared health priorities are cardiovascular diseased, oncology diseases and child care.

Slovakia has so far confirmed around 500 cases of new A (H1N1) flu, mostly concentrated in the capital Bratislava. There was only one reported case of death resulting from the new virus. The authorities call on the population to get vaccinated against the regular flu. These days government is finalizing the public procurement for purchase of one million vaccines against the swine flu. The name of the winner (pharmaceutical company) was still not publicly announced. This amount of vaccines will cover approx. 20 % of the population. In the future the country would like to be self-sufficient in production of the vaccines, said health minister Richard Raši.