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Paper - Towards a European healthcare system (di Francesco Velo, Università di Pavia)

Health care has emerged in industrialised countries as an important pillar of national economies: for this reason, health care is now a matter of social and economic policy. This provides an opportunity for rethinking national and European health care policy, offering a stronger support to European competitiveness. At the same time, this may lead to a broader defense of the rights of European citizens and to a reinforcement of European institutions. by Francesco Velo, Università di Pavia

Today, Europe is facing two alternatives. The first one consists of developing its ability to supply top level health care services and to develop research programmes: this means that investments will be oriented by a long-term vision. The second alternative is to become a buyer of services, delegating to other systems the task of developing technologies and know-how; this means that European financial resources will be used on international markets to buy health care services for European citizens from other nations. The healthcare sector towards the 20th century. For a long time, health care has been considered almost exclusively as a matter of social policy makers. Nowadays, the importance of the health care sector is growing, because of its social relevance, but also because of its economic and financial significance. The key point is that health care has to be considered as an economic sector, which may contribute to create health, as well as wealth. During the 20th century, health care systems have changed. The needs of citizens and customers have evolved, growing in number and quality. The demand for more complex health care services, the rising costs of health care technologies, the difficulty in raising the funds for health care expenditure has lead to the widespread appearance of a new approach: limited resources have to be used in a better way, and more attention to efficacy and efficiency is to be paid. Looking at what happened in all industrialised countries, we can identify two basic models to which we can refer: the European model, solidarity oriented, and the United States model, individualistic oriented. Within the two alternatives, public and private subjects play different roles. Historically, the United States model has mostly pursued efficiency. The primary targets of the European model can be identified in the protection of the equal and universal access to services. The limitations of the European model have therefore usually been identified in the fact that the patients’ freedom of choice, efficiency and the development of innovation and research programmes are in fact second-choice targets. Most European countries have developed their own model, away from the traditions of the old continent. In this situation, some Countries have developed a specific national model that is different from the European traditional model. Through this course of action, they have begun developing a new model, leading a bottom-up experimental process without the guidelines of a coherent European initiative. Efforts have been made to get over the specific limitations of the two traditional models of health care services. The development of solidarity measures, by hand of public and private subjects, has mitigated the individualistic nature of the United States model. Considering the health care reforms that have been carried out in European Countries, some considerations can be made. Firstly, today’s European health care reforms share the common goal of improving health care management, a goal that is pursued by promoting competition between the players that offer health care services. For this reason, in every national system we are now facing a re-equilibration process between public and private sectors (profit and non-profit), as a tool for reinforcing the functionality of the health care system. Similarly, it is possible to set rules between public players in order to increase competition and, as a result, improve their efficiency. Secondly, the improvement of health care system management has been pursued by an attempt to reinforce the ability of institutions to play a regulatory role. This has been done to temper the benefits of competition, with the protection of the quality of services, and those of the level of solidarity traditionally granted by the system. Similarly, the role of National Authorities is evolving in several countries, where the financing of health care expenditure is delegated to a wider range of subjects. Financial backers of health care expenditure tend to form a network, organized by a common project or by a spontaneous competitive adaptation process. The way this network is organized may vary from one country to the next, but it tends to abide by the principle of subsidiarity in almost every country. Thirdly, most European Countries are approaching health care sector criticalities by prioritising short term consumption over long term investments. This means that an erosion of the assets accumulated in previous years is in progress which passes on to future generations the task of restarting the accumulation process on which the development and modernization of the whole system depends. Several European health care services seem to have chosen to promote immediate consumption in order to reach a higher level of short term solidarity. The alternative is to use the scarce resources available to start investments and to promote long-term development. Investments promote intergenerational solidarity and may involve present as well as future generations: this is particularly true in reference to long-term investments. The development of the immediate consumption of health care services advances solidarity among co-existing generations, from younger to older citizens. The fact that every system is trying to improve health care management can be described as an effort to solve the dilemma of long-term investments versus short-term solidarity, which would free resources that may help in reaching the two goals. Cost-cut strategies cannot be considered as a solution to structural health care system problems, but only as a way to postpone the time when structural solutions will be implemented. Cost-cut strategies are in fact destructive if they are not jointly proposed with a long-term development and modernization-oriented strategy. The growth in public expenditure for health care is going to climb to 10% of GDP in Europe. In the USA, health expenditure is nearly 15% of GDP and it is expected to reach 20% in the coming years. In other sectors, the basic choice that started a new cycle of development and modernization was the participation in the European integration process. The creation of a single market has involved different sectors of the economy at different times, following a precise sequence characterized by the criticalities linked to every one of these sectors. A sensible thing to do would be to ask ourselves if times have come for an integration of health care in the single European market which would promote a development of the health care sector itself. In this framework, we need to ask ourselves in what way will the health care sector be affected by this process at the European and national levels, what shape will it take and how should we promote excellence and leading individual national experiences in order for them to evolve within a European dimension. A European healthcare sector. The integration of health care in the single European market can be seen as a radical transformation that will lead to several other transition processes. This integration process can also be seen as an opportunity to reinforce the development and modernization of the health care sector, by implementing those cost-cut and rationalization strategies that characterize most national systems today. The chief alternatives available to Europe are to build on its own ability to develop and offer highly specialized services, or high-level research programmes, or to delegate the development of know-how and technologies to other systems. The latter solution implies that Europe will use its financial resources to buy health care services made available on the market by other systems. The integration of health care in the single European market will probably change the way health care systems are governed: it will affect the organization and the allocation of competencies at the European, national and local level. This will be an opportunity to promote development and innovation. If it succeeds, a better use of resources and an increase of synergies within and among the health care and other sectors will be possible. This may lead to building a more solidaristic and modern European health care sector. The European health care sector can be expected to be based on the principle of subsidiarity, where local authorities will be in charge of basic health care services; in this specific sector, the continuity between today’s allocation of competencies and Europe’s future allocation will be at the highest level. This does not rule out the possibility of wider and deeper changes that may affect this sector following the construction of a modern European health care system. Insofar as the opening of national markets will create new opportunities for the most dynamic and innovative actors, it will consequently contribute to reinforce the subjects that have already emerged in the specialty health care services sector. Specialty health care services can be expected to be located predominantly in highly qualified centres: the creation of a European health care system will surely have a deep impact on this sector. Hospital facilities capable of responding to complex health care needs will continue to be deep-rooted in the territory, as is the case, for instance, of emergency services. Highly specialized health care services can be expected to be organized in order to meet the needs of large geographical areas, larger than actual catchments areas. It is realistic to predict that these services will undergo a reorganization process that will link them to one another within a network. This network may in turn comprise few excellence points, to act as reference for the entire European territory, and a number of widespread facilities, as the service provided tends to be less complex and specialized. This means that therapy treatments that involve patients’ mobility (evidence is given by today’s national and international shift towards excellence) do not have to be obstructed but rather governed by the system, while empowering and increasing the efficiency of health care services. The sector of research institutes, specialized in ground research or in applied research, will probably be the one that will most benefit from the development of a European health care system. Research has to be furthered by long-term visions, which neither major national enterprises nor national health authorities are able to develop. The United States experience demonstrates the importance, for the pharmaceutical and medical research sector, of reaching dimensional scales that only a continental market can provide. This is true if we refer to the market stricto sensu, the private market, or to the public sector, nourished by the decisions made by the authorities in charge of the sector’s operation. A discussion on medical research within the European framework raises the issue of industrial policy and of research programmes that the European Union will be able to develop. It is therefore necessary to determine if and how the integration of health care within the single market will be an opportunity to launch effective European initiatives that will sustain long-term investments, filling the gap run up by the national health care systems. Private and public initiatives may enforce one another by way of potential synergies. This cooperation will not materialize automatically following the development of a European health care sector, but it will gradually and increasingly take shape as adequate guidelines are established. The process that is affecting the health care sector today brings into question the role of the sector within the socio-economic system. The transformations currently in progress may make this sector become a mover of development, without contradicting its historical solidaristic roots.

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