Zoltán Massay-Kosubek

“It has been my observation that most people get ahead during the time that others waste.” ~Henry Ford

The Impression of an Independent Health Expert on the Spot – EPHA Conference 06/06/2012

Although there were several health related events on 6th June 2012, I decided to take part in the Annual Conference of the European Public Health Alliance (EPHA) organised under the auspices and financial contribution of the European Economic and Social Committee (EESC).

I didn’t make that choice only because of the impressive list of speakers. My motivation to do so came from my experiences when I attended several times the plenary meetings of the EP, where the crisis management was one of the most important issues put on the table. After having some ideas what the 7 main European political groups (EPP, S & D, ALDE, ECR, The Greens, GUE/NGL, EFD) think about an effective crisis management I was looking for the special answers for the health sector.

After thinking about the different health events, I found that the EPHA’s Annual Conference would be the most likely to give me the most relevant summary of the stay of play in the health sector under the turmoil of the crisis.

List of Speakers

Obviously, all of my perceptions are based on the useful inputs of the esteemed and distinguished invited speakers and panel Members. Since it is not up to me to prepare the detailed minutes of the conference, I will rather focus on the key messages. However, I am very pleased to provide you with the list of the guests with a helpful link about the person in every case, as follows:

List of Speakers

John DALLI, Commissioner responsible for Health and Consumer Policy
Zsuzsanna JAKAB, WHO Regional Director for Europe
Renate HEINISCH, Member of the European Economic and Social Committee
Archie TURNBULL, EPHA President
Carlos ARTUNDO PURROY, Director – Andalusian School of Public Health
Marietta GIANNAKOU, Member of the European Parliament, Head of the Greek EP Delegation to the EP
David STUCKLER, Social Epidemiologist and Lecturer- Cambridge University
Maria NYMAN, Director – Mental Health Europe
Paul DE RAEVE, Secretary General, European Federation of Nurses Association
Conny REUTER, President, Social Platform
Pervenche BERÈS, Member of the European Parliament, Chair of the Employment and Social Affairs Committee
Pascal GAREL, Chief executive, HOPE European Hospital and Healthcare Federation
Christoph SCHWIERZ, Policy Analyst, Economist Unit Sustainability of Public Finance DG Economic and Financial Affairs, European Commission
Valerie MORAN, Health analyst, Organization for Economic Co-operation and Development
Carola FISCHBACH-PYTTEL, General Secretary at the European Public Service Union (EPSU)
Sanjeev GUPTA, Deputy Director Fiscal Affairs Department – International Monetary Fund
Federico PAOLI, Policy Officer and socio-economic analyst – DG Health and Consumer Protection, European Commission
Josep FIGUERAS, Director, European Observatory on Health Systems and Policies Head – WHO European Centre of Health Policy
Susanne LOGSTRUP, Director, European Health Network
Alejandro CERCAS, Member of the European Parliament
Paul TIMMERS, Director, DG Information Society and Media, European Commission
John ASHTON, Joint Director of Public Health for NHS Cumbria and Cumbria County
Monika KOSINSKA, Secretary General, EPHA

General Comment: I would like to clarify for those who aren’t familiar with the way of function of NGOs: the conference wasn’t the usual, so-called General Assembly of EPHA according to its rules of procedures. Usually, the General Assemblies make the necessary organizational decisions (ex. adoption of the budget, election of chief officials, etc.) which are very important in the life of an NGO.

The current EPHA Annual Conference was rather a professional event the preparation of started at least 6 months before. In my opinion, the above mentioned list of invited speakers mirrors clearly its high professional quality. It was also very impressive for me that the organizers had to decide about the title half a year ago, when they couldn’t foresee the tragic events in Greece, the deepening of the economic and political crisis and the related political changes in some countries.

The Health sector/professionals were fragmented and weekly represented so far.

There is very difficult to find a consensus not only on the causes of but also on the appropriate responses to the crisis. One of the basic problems is that under the current economic situation the health system doesn’t have enough money to function. Unfortunately, the health and social sectors were hit the most by the required budget cuts given to the fact that those sectors hold a large amount of available public money. The decrease of health budget is underpinned by exact data and numbers in some EU countries such as LV, PT, IE, EL, CZ, FR, NL, AT, HU, ES. In the time of austerity, the available funds are more likely to being subject of cuts and it seems that the health professionals were not organized enough to protect the necessary resources so far.

It happened in some countries that patients with the worst conditions (cancer) had to pay the very costly (several 1000 euro) treatments in every months and only after a massive campaign from the general public and from the media normalized the situation for a while.

The health sector suffered major losses in recent time. 92% of nurses are women who lost 25% of their salary so far, and the general level of their monthly income is in some countries around 250 euro or even just 100 euro.

The projections aren’t optimistic either. The crisis will probably worsening in the sector and the intensity of fear paralyses our way to act innovatively and creatively. There is a matter of urgency to act since not surprisingly, always the poorest people are the most disproportionally affected by the crisis being not responsible for.

A very suggestive example to demonstrate it is the cross-cutting issue of Mental Health or the alarming increase of suicide rates. Before the crisis in Greece, the suicide rate was among the lowest and after the crisis it emerged. And the suicide rate is only the top of the iceberg. The ratio of HIV+ patients also emerged due to the more intensive drug use.

Thus, social safety belt and the health system are crucial for that people and austerity is threatening this stabilisation. No other industrial sector neglects as much its clients as the health sector does with its own patients.

Even the healthcare systems differ significantly in different Member States. In some country the system covers 90% of health expenditures than in others this ratio is only around 60%. Another difficulty is to see what problem is due to the crisis and what is to other causes.

In conclusion, the public health sector was too silent so far. But what can the health community do to improve the situation?

There is neither economic growth nor recovery without a robust health system.

Demographic changes, climate change and the appearance of new technologies create new challenges and opportunities for the health sector. The growing life expectations made visible the existing health inequalities in Europe. Therefore, a purely separated health policy cannot deal with these challenges anymore. Only the Health in all policies (HIAP) approach and linking health on social determinants (education, environment, industry) can produce the desired positive results.

There are several WHO studies presenting exact data and quoting exact numbers, how many percentage of GDP can be saved through preventing costly Non-communicable diseases (NCD) such as mental illnesses, cancer, respiratory diseases, heart attacks etc. by reducing alcohol consumption, smoke and by promoting a healthy lifestyle and diet. These are the best ways forawrd to prevent the undetected illnesses of tomorrow.

Today is it already widely recognised that good health is a prerequisite of economic well-being. Unfortunately it seems that the importance of social cohesion was neglected by member states so far.

There are also positive examples of regional co-operation. The Ministry of Health of Germany with the involvement of Belgium and Sweden has been participating in a special partnership with the Ministry of Health of Greece since 2010. This mutual co-operation is based on earlier professional contacts where German bodies try to share their positive experiences with the Greek health authorities. Such kind of programmes can be considered as very positive signs of hope.

The priority of health is a matter of political choice made not always by ministries of health.

The healthcare systems are neither the cause of the crisis nor an additional burden on the society.

There are 3 major parts of countries for the time being from the perspective of the crisis and the debt rate:

1. Countries with accumulated savings who have some room for manoeuvres.

2. Countries with a reduced and low level budget who can also opt for deficit financing

3. Countries with a high deficit rates who are in a very difficult situation since they are excluded from the solutions of options 1-2. No need the mention that a major part of the concerned European countries (at least 14 states) belong to the 3rd group.

But even these countries have the opportunity to move forward by putting health on a high priority of political agenda. Decisions (the size of the health budget) are often made by Finance Ministers and sometimes even at higher political level. Thus, the only way to have real impact on the governments’ policies is the level where the political decisions are made: at the level of prime ministers/presidents.

The short time cuts in the health sector are very damaging. Health expenditures aren’t simply costs but investments in the future.

The challenge of the crisis was somehow simple: there is a need to cut the expenses and countries had to act as quick as possible without counting on the long term negative consequences. Finance ministers were obliged to act with high debt levels with relatively low GDP growth and under high level of pressure (“To act quickly and dirty and to resolve the problem for now.”).

Due to the nature of the health sector, it was very difficult to accentuate the costs of the impacts since they occur and manifest in the form of cost savings in the long term. Cuts of costs without knowing the reason for it are always very dangerous.

Yes, we need cuts but not in the wrong places. (In some cases, the existing corruption can be the reason of relatively high spending.) The so-called ‘bookkeeper’ mentality must be abandoned for once at all since not everything can be let for the market. We cannot jeopardize the relatively high level of health care in comparison with other global players’ healthcare systems.

Health is the engine of economic growth. If life expectancy grows the GDP will emerge accordingly. Investing in health is a crucial factor for stimulating economic growth where we have to always bear in mind the importance of patient safety and the quality of care.

Sin-taxes can be considered as successful tools to achieve not only the balanced budget but also a higher level of public health. Taxing unhealthy products like tobacco, alcohol or unhealthy food doesn’t only result direct revenues to the public budget but also motivates people to give up those bad habits increasing the health consciousness in the wider society. It cannot only end in a WIN-WIN situation but these kind of taxes are usually widely recognised and supported by the general public.

The Financial turmoil can be used as an impetus for change, since simply spending more money doesn’t necessarily mean more equity in the system. The possible solution is therefore not to spend more money but to spend the existing resources better.

(Megjegyzés: Ehelyütt nincs hely sem mód egy létező probléma mibenlétének részletes kifejtésére megoldási javaslatokkal egyetemben, de alapelvként és kiindulópontként mindenképp ki kell jelenti, hogy a jelenlegi magyarországi gyakorlatban az a tény, hogy a betegek lényegében pszichikai/fizikai körülményeknél fogva kötelesek pénzt adni/ténylegesen pénzt adnak a jobb, vagy egyáltalán a normális ellátásért [amit a Magyar nyelvben hálapénznek nevezünk] az én fogalmaim szerint feltétlenül kimeríti a korrupció fogalmát. Ebből az alapelvből kiindulva, ezt követően minden vitának arra kell irányulnia szerintem, hogy lehet ezt a korrupt jelenséget maradéktalanul kiirtani a rendszerből.)

If the civil society wants to make its voice heard, NGOs should target national decision makers and the Commission respectively.

Only a well underpinned convincing action can successfully influence the decision makers. Such argumentation cannot go without appropriate data and numbers. Nevertheless, there are existing (WHO, OECD, European Observatory) data for that purpose and they must be used in a clever way.

Common international and European efforts are needed to collect the successful models in order to elevate the relatively low rate of use of social cohesion funds for health purposes.

There are health sub-sectors where a more rational allocation of financial resources is inevitable. It is vital to spend more efficiently the public money where the system wastes. The costly health administration and the inefficient services have to be changed. Investments to the infrastructure can lower the long term costs of running.

In some special cases, a large number of young doctors work at a very technical area with very few clinical examination which is not a healthy organization culture. The health sector needs quality employment not only new jobs.

The European semester and the country specific recommendations may have a health dimension and the European 2020 strategy can be an additional way to push the HIAP approach forward.

Instead of the hospitalization based approach a more strengthened public health is required.

Some think that the collective answer to the 1929-33 global economic and financial crisis was the New Deal politic but it couldn’t avoid the 2nd World War. Others say that the real answer was the establishment of the welfare state. In the Nordic countries the welfare state is especially well developed and the negative effects of the crisis in that region were lower than in other areas. In spite of the financial meltdown and the adopted icesave measures, the happiness index of Iceland is among the bests. Maybe, there is a connection between the good performance of the Nordic countries and their high standard of social security?

It is often forgotten that health doesn’t only mean costs. The cost saving approach narrows itself on health care system (1.) but another, important dimension of health is the population health (2), and the importance of the health of every human being cannot be stressed enough.

The financial crisis isn’t as bad is it seems since sometimes it implies the long overdue and needed reforms. It is not an option to regain just the ante-crisis situation. The lessons must be learned and new ways are to be discovered: a different model of growth must be found. Investments in primary and outpatient services can avoid additional costs related to potential hospitalisation which can manifest in a form of clear savings. The appropriate training of public health professionals is a possible way forward to achieve that goal.

Prevention is surely the most difficult but also the most effective method. The technology assessment requires additional resources since new technologies are expensive and in 2-3 years time, new inventions are available.

The establishment and use of a European wide, unique detailed monitoring system can provide the necessary feedbacks, as in important piece of an overall framework to have comparative data and the opportunity to make effective preventive measures.

An impressive positive example can be the e-Health initiative which can lead to lower number of physical examinations. An additional argument which promotes this initiative is that the cross-border healthcare directive contains a legal obligation to establish such a system. Another cost savings can be reached by creating interoperable systems.

It is up to the health professionals, up to us to influence accordingly the decision-makers to achieve the required results in the public financing.

There is no doubt that the right to health is a universal human right codified not only in all national constitutions but also to the Charter of Human Rights being part of the primary law of the Union.

Especially under the current circumstances, several European countries received financial aid from international actors.

(According to the EPHA summary these countries were:

2008. Iceland, Hungary

2009. Romania, Latvia

2010. Ukraine, Ireland, Greece

2012. Greece

The necessary meetings between the concerned governments and the international players (IMF, World Bank, ECB, Commission) took place always behind closed doors. Therefore, the obvious question emerges immediately: where are we? Where are the health professionals, doctors, nurses these decision may concern seriously?

One thing is clear: international financial organizations aren’t experts in health matters. They don’t have either the legal mandate to examine such questions or the special knowledge about it. But they have the overall overview of the financial sector. Therefore, the governments, who have the democratic mandate and the responsibility for the health policy of the country are in the position to argue for health investments against the international financial institutions. Therefore, these governments must be influenced. And since health professionals are who know the evidences, it is their task to bring them at appropriate levels. The existing evidences must be turned into action.

In countries where no recent elections have been taken in place, new governments must be set up with a fresh mandate and these newly elected bodies can rely on the new type of HIAP WHO policies. Even the municipalities and regions must be taken on board since the health-focused use of structural funds won’t be possible without them.

The future plans of the Commissions (to revise of the clinical trials directive and to present a new EU regulation on medical devices) provide with the possibility to further develop the efficiency of health systems at European level. Furthermore, there are other ambitious goals: the Commission intends to launch within 1 year other, concrete, real projects at the level of hospitals and patients.

We are waiting for the expected invitation of Commissioner John DALLI by the European Finance Ministers to the upcoming ECOFIN Council

Not only the European but also international fora dealt with the “silent killer” NCDs. On its 19-20 September 2011 high level meeting, the UN General Assembly adopted a political declaration on noncommunicable disease prevention and control.

There is always easier to influence the national decisions pointing at International/European examples/pressure. Since Finance Ministers are key decision makers and – apparently – they are not aware of the crucial importance of health therefore a potential meeting with Commissioner John DALLI can be the appropriate way of targeting that issue. The Health Commissioner himself can be especially well positioned to do so since Mr. DALLI has been served as Minister responsible for Finance at his home country Malta for more than 10 years before becoming Minister responsible for Health.

Even this conference intended to shape the expressed thoughts in a formal letter and send it to the European Council. In this future request, the joint will of the health professionals will be included and accentuated. I truly hope that this conference wasn’t the end, but on the contrary, only the beginning of such common thinking and there will be additional opportunity to contribute to the final content of that document from the part of the different health professionals.

Last but not least there are further opportunities under the upcoming Cypriote EU presidency the slogan of is Better Europe which means an enhanced social dimension of growth.


I will provide you with some additional details about Hungary. Since it doesn’t literally belong to the general subject, I will make it in Hungarian for the Hungarian speaking community. The motivation for doing so was the interaction with some participants on the spot, and the explicit reference made by some EPHA document distributed during the conference to the participants, which document was based on a meeting between EPHA and the Hungarian Minister of State for Health, MD Miklós SZÓCSKA held on 7th September 2011.

Comment: Although I belonged to the staff of the Hungarian Ministry of Health (called Ministry of National Resources) at that time I wasn’t involved in that meeting at all.

Nemcsak azért írok pár sort az anyanyelvemen is, mert ez a napirendi pont épp Magyarországot érinti – bár nyilván ez is közrejátszik benne. A fő ok, hogy így szeretnék nyomatékot adni az esemény magyar vonatkozásainak. Mindjárt az elején említést érdemelnek a magyar résztvevők, kezdve JAKAB Zsuzsannával, a WHO Európai regionális igazgatójával, aki maga is egykor az Egészségügyi Minisztériumban dolgozott, folytatva KAJTÁR Nórával, aki az Európai Bizottságnál dolgozik (szintén korábban az Egészségügyi Minisztérium dolgozója, a magyar elnökség előtt/alatt pedig egészségügyi attasé volt), de a meghívottak között szerepelt még Dr. ÁDÁNY Róza is, a Debreceni Egyetem Népegészségügyi Kara részéről.

Mivel magam is korábban az Egészségügyi Minisztérium (Nemzeti [Emberi] Erőforrás Minisztérium) dolgozója voltam, nyilván figyelemmel kísérem a további egészségügyi szakpolitikai fejleményeket is azzal, hogy független szakértőként nyilván egy kicsit más perspektívából kell szemlélnem az eseményeket. Valamely résztvevő rámutatott, hogy ’Magyarország’ bizonyos szempontból ’gyenge pont’ az egészségügyi szektorban, amivel nyilván az egészségügyi kiadások radikális csökkentésére utaltak, amely rendkívül hangsúlyos a konferencia témája szempontjából, hisz jelen konferencián a felszólalók többsége pont a kiadáscsökkentést magát ellenezte. S bár ismereteim szerint az EPHA nem rendelkezik magyar taggal, ennek ellenére mégis fontosnak ítélték a szervezők, hogy – más országokhoz hasonlóan – Magyarország is szerepeljen a fenti adatok mellett az EPHA által a konferencián kiosztott kiadványban.

Talán nem árt megemlíteni azt sem, hogy a fenti – a költségmegvonás szempontjából negatív – aspektus mellett kettő, kifejezetten pozitív példa is megemlítésre került: egyrészről az úgynevezett chips vagy hamburgeradó, amelyben az ország (Franciaország mellett) élen jár. Ez nemcsak költségvetési bevételt eredményez, hanem egyúttal szolgál népegészségügyi célt, nevezetesen az egészségügyi szempontból káros termékek fogyasztásának visszaszorítását. A másik pozitív példa pedig a közelmúltban nagy sikernek és elismerésnek örvendő dohányzási tilalom bevezetése volt a nyilvános helyeken.

Végül, de nem utolsó sorban: a konferencián ugyan nem hangzott el, de ide kívánkozik annak megemlítése is, hogy a közelmúltban történt megállapodás az egészségügyi kormányzat részéről a rezidensek fizetését illetően – ha nem is oldotta meg a kérdést egyszer, s mindenkorra, de – jelentős előrelépésnek tekinthető az egészségügyi ágazat konszolidációjának, és az ágazat egyensúlyának hosszú távú céljának eléréséhez.


– The Health sector/professionals were fragmented and weekly represented so far.

– Always the poorest people are the most disproportionally affected by the crisis being not responsible for.

– There is neither economic growth nor recovery without a robust health system.

– A purely separated health policy cannot deal with these challenges anymore.

– The priority of health is a matter of political choice made not always by ministries of health.

– The short time cuts in the health sector are very damaging.

– Health expenditures aren’t simply costs but investments in the future.

– If the civil society wants to make its voice heard, NGOs should target national decision makers and the Commission respectively.

– Instead of the hospitalization based approach a more strengthened public health is required.

– It is up to the health professionals, up to us to influence accordingly the decision-makers to achieve the required results in the public financing.

– We are waiting for the expected invitation of Commissioner John DALLI by the European Finance Ministers to the upcoming ECOFIN Council.

– EPHA Media Release – “The economic crisis should not turn into a health crisis” – John Dalli, Commissioner for Health and Consumer Protection

– EU commissioner John Dalli told a conference that the economic crisis should not turn into a “health crisis”.
– Euractive article – DALLI: ‘The economic crisis should not turn into a health crisis’
– Report from the Annual Conference of EPHA 2012 von Nora Laubstein (ANME e.V.)

I remain at your disposal.

the compressed URL of this blog entry ► http://bit.ly/123Qr3N

Related earlier updates:

The EU Health Strategy (2008-2013) reviewed by MEPs, the Commission and the Civil Society in order to make some useful remarks to the new Health Strategy (2014-2020)

Last But Not Least: Strategy for Strengthening the Rights of Vulnerable Consumers and the Democratic Function of the EP

Improving Patient Outcomes through Intensive Care Medicine (ICM) – Lessons Learned after the Policy Debate in the EP on 16/05/2012

Legal Framework for Public Health Policies and Financial Viability of Lifelong Disease Prevention

How Healthy is Our Way of Thinking about Healthcare Cost Cuts?

The Choice is Yours: either You Drink or… Re-think the EU’s Alcohol Strategy

(Photo © EPHA website)

Author :