Table Of ContentTrends in EU Health Care Systems
Trends in EU Health
Care Systems
Win de Gooijer
Win de Gooijer
Silodam 250
1013 AS Amsterdam
The Netherlands
[email protected]
Library of Congress Control Number:2006930266
ISBN-10:0-387-32747-9 e-ISBN-10:0-387-32748-7
ISBN-13:978-0-387-32747-1 e-ISBN-13:978-0-387-32748-8
Printed on acid-free paper.
© 2007 Springer Science+Business Media,LLC
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Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Part One: A Changing Social Context
Chapter 1. Moving Along a Continuum . . . . . . . . . . . . . . . . . . . . 3
Chapter 2. Promoting and Opposing the Market . . . . . . . . . . . . . 41
Chapter 3. The Arguments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 4. The Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Part Two: Consequences for Health Care Systems
Chapter 5. Health Care and the Economic Order . . . . . . . . . . . . 91
Chapter 6. Health Care Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . 118
Chapter 7. The Influence of the European Union . . . . . . . . . . . . . 139
Chapter 8. Investing in Health Care . . . . . . . . . . . . . . . . . . . . . . . 160
Chapter 9. Health Care Reforms . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Chapter 10. The Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
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viii Contents
Part Three: Reflections
Chapter 11. The Social Context Reconsidered . . . . . . . . . . . . . . . . 257
Chapter 12. On Managing Health Care . . . . . . . . . . . . . . . . . . . . . 288
Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Notes and References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Foreword
Since the beginning of the 1980s,governments all over the developed world
have been engaged in reforming their health care systems and in trying to
find ways of coping with the problem of continuously rising costs.Methods
aimed at improving the effectiveness and efficiency of health care delivery,
shifting the financial burden from public to private financing, as well as
reducing the health care infrastructure, are being studied and developed.
During the many years that I served on the Board of the Federation of
Dutch Health Care Organizations, including as Chairman from 1992 to
1999, I experienced directly the consequences of limiting the financial
resources available to health care.It became apparent to me during those
years that the social climate regarding health care in the Netherlands was
changing.That changing climate can be encapsulated by the word account-
ability.Accountability has come to mean that health care is the business of
a range of stakeholders,all of whom want developments to go their way.In
short,health care now has multiple owners.
Later,after I had joined the Governing Council of the International Hos-
pital Federation, I found that similar developments could be observed
throughout the developed world.These developments are characterized by
the decreasing involvement of governments in the financing and delivery
of health care.Instead,the market,and with it the price of health care,is
increasingly becoming the instrument for coordinating of supply and
demand.
The reform of health care systems in most of the countries of the
European Union is conditional on providing equal access for all citizens,
regardless of their ability to pay.National constitutions,or their equivalents,
mandate governments’ responsibility in this respect. As a consequence,
exemption regulations aimed at protecting vulnerable members of society
have been introduced by EU governments which have carried through cost-
saving measures. These regulations are meant to uphold the idea of
solidarity in health care.
Whether or not EU governments, by applying exemption regulations,
have succeeded in living up to their promise of equal access is,in fact,the
ix
x Foreword
theme of this book.In order to deal with it,the author has chosen an orig-
inal approach,by considering health care in the context of the recent devel-
opments in the international political economy.Since 1975,that context has
been characterized by governments of the developed world withdrawing
from the economic process and leaving the production and consumption of
goods and services increasingly to the market.As a consequence,inequali-
ties in health care—as in society as a whole—are increasing.The author
concludes that,despite the application of exemption regulations,increasing
inequalities put the solidarity principle,a mainstay of most EU health care
systems,at risk.
The arguments for governments to withdraw from the economic process
are twofold.Firstly,it is argued that the phenomenon of globalization forces
governments of the developed world to reduce the costs of labor in order
for businesses to stay competitive.Secondly,it is argued that a free market
economy with the price mechanism as the instrument for coordination,
instead of a government interfering in the economic process,better serves
to satisfy the needs of individual consumers.As a member of the Dutch
Social Economic Council in the 1990s, I was aware that these arguments
were applied to many spheres of economic activity.I concluded that these
two arguments are far less suitable for application to health care if the prin-
ciple of equal access is to be realized.Furthermore,according to the author
of this book, both arguments are controversial. Societies appear to have
more freedom to choose their social arrangements than the international
political economy wants us to believe.
After having read the manuscript,I unreservedly recommend the book
to politicians, health care policy-makers, insurers, managers, and all those
who take equity in health care to heart.
Ton Krol
Former President of the International Hospital Federation
Acknowledgments
I have worked at the CEO management level in health care in the Nether-
lands for more than 25 years. During those years, I experienced times of
plenty,when the sky was the limit,as well as times of want,when I had to
think of measures to increase the efficiency and effectiveness of daily oper-
ations.Working in health care was an enriching challenge for me,the more
so since I also had the honor to serve on several national governing boards.
That taught me how closely health care policy is connected to the economy
and to politics.
Furthermore,I had the privilege of representing the Federation of Dutch
Health Care Organizations in the European Hospital and Health Care Fed-
eration (HOPE) for more than 20 years.Because this federation appointed
me to the office of President of its Subcommittee on Economics and Plan-
ning,I had the opportunity to learn about health care developments in the
other countries of the European Union.
During the years when I worked in and for health care,I had the plea-
sure to meet with experts from the Netherlands and abroad.Many of them
have become friends.Knowing that I was working on this book,they not
only brought me important information, but they were also prepared to
discuss my ideas and to comment on draft versions of the book.Now that
the book is finished,it’s time to express my gratitude for their kindness.
First of all I want to thank several members of the European Hospital
and Health Care Federation to whom I am particularly grateful.They are
Kris Schutyser (Belgium), former Secretary-General of HOPE; Brian
Edwards (United Kingdom), the president of HOPE, who regularly
informed me about publications that could be useful for the manuscript,as
did his predecessors Gérard Vincent (France) and Denis Doherty (Ireland).
The latter also commented on earlier draft versions of the manuscript.As
for other (observer) members of HOPE,it is with pleasure that I thank the
Secretary-General, Pascal Garel (France); my successor as President of
the Subcommittee on Economics and Planning,Carine Boonen (Belgium);
as well as Ursula Fronaschütz (Austria), Anetta Dokova (Bulgaria),
György Harmat (Hungary), Willy Heuschen (Belgium), Lars Johansson
xi
