The impact of the EU Directive on patients’ rights and cross border health care in Malta

The patients’ rights and cross-border health care directive was implemented in Malta in 2013. Malta's transposition of the directive used the discretionary elements allowable to retain national control on cross-border care to the fullest extent. This paper seeks to analyse the underlying dynamics of this directive on the Maltese health care system through the lens of key health system stakeholders. Thirty-three interviews were conducted. Qualitative content analysis of the interviews reveals six key themes: fear from the potential impact of increased patient mobility, strategies employed for damage control, opportunities exploited for health system reform, moderate enhancement of patients’ rights, negligible additional patient mobility and unforeseen health system reforms. The findings indicate that local stakeholders expected the directive to have significant negative effects and adopted measures to minimise these effects. In practice the directive has not affected patient mobility in Malta in the first months following its implementation. Government appears to have instrumentalised the implementation of the directive to implement certain reforms including legislation on patients’ rights, a health benefits package and compulsory indemnity insurance. Whilst the Maltese geo-demographic situation precludes automatic generalisation of the conclusions from this case study to other Member States, the findings serve to advance our understanding of the mechanisms through which European legislation on health services is influencing health systems, particularly in small EU Member States.     

A health systems approach to identifying barriers to breast cancer screening programmes. Methodology and application in six European countries

The benefits of population-based screening for breast cancer are now accepted although, in practice, programmes often fail to achieve their full potential. In this paper, we propose a conceptual model that situates screening programmes within the broader health system to understand the factors that influence their outcomes. We view the overall screening system as having multiple sub-systems to identify the population at risk, generate knowledge of effectiveness, maximise uptake, operate the programme, and optimise follow-up and assurance of subsequent treatment. Based on this model we have developed the Barriers to Effective Screening Tool (BEST) for analysing government-led, population-based screening programmes from a health systems perspective. Conceived as a self-assessment tool, we piloted the tool with key informants in six European countries (Estonia, Finland, Hungary, Italy, The Netherlands and Slovenia) to identify barriers to the optimal operation of population-based breast cancer screening programmes. The pilot provided valuable feedback on the barriers affecting breast cancer screening programmes and stimulated a greater recognition among those operating them of the need to take a health systems perspective. In addition, the pilot led to further development of the tool and provided a foundation for further research into how to overcome the identified barriers.     

Health promotion policies for elderly—Some comparisons across Germany,Italy, the Netherlands and Poland

ObjectiveThe aim of this study is to compare health promotion policies (HPP) for older adults in four European countries: Germany, Italy, the Netherlands and Poland. We focus on the design, regulations and implementation of policies in these countries.MethodAs policy relevant information is mostly available in national languages we have approached experts in each country. They filled in a specially designed questionnaire on the design, regulation and implementation of health promotion policies. To analyze the data collected via questionnaires, we use framework analyses. For each subject we define several themes.ResultsRegarding regulations, Poland and Italy have a top-down regulation system for health promotion policy. Germany and Netherlands have a mixed system of regulation. Regarding the scope of the policy, in all four countries both health promotion and prevention are included. Activities include promotion of a healthy life style and social inclusion measures. In Poland and Italy the implementation plans for policy measures are not clearly defined. Clear implementation plans and budgeting are available in Germany and the NetherlandsConclusionsIn all four countries there is no document that exclusively addresses health promotion policies for older adults. We also found that HPP for older adults appears to be gradually disappearing from the national agenda in all four countries.     

Comparison of the incidence of insulin-dependent diabetes mellitus in childhood among five Baltic populations during 1983-1988.

We have carried out a comparison of the incidence of childhood onset insulin-dependent diabetes mellitus (IDDM) between five populations around the Baltic Sea. These were Finland, Estonia, Latvia, Lithuania and Poland. The risk of IDDM is highest in the world in Finland and also very high in Sweden, on the western and northern side of the Baltic Sea. The risk of IDDM in children on the eastern side of the Baltic Sea has not been known before. The data collection period covered the years 1983-1988. A marked variation in incidence was seen within this relatively small geographical area. Among these five populations, the incidence increased with the latitude. Our present results confirmed the very high incidence of IDDM in Finland. The average age-standardized yearly incidence of IDDM/100,000 was in males under 15 years of age 36.9 in Finland, 10.7 in Estonia, 6.4 in Latvia, 6.5 in Lithuania and 6.0 in Poland. In females the incidence was 31.6, 10.0, 6.9, 7.0 and 6.4 in these five populations, respectively. The differential in incidence in Estonia as compared with Latvia, Lithuania and Poland was statistically significant (P = 0.0002). A slight male excess in incidence was found in countries with higher incidence--Finland and Estonia, but in lower incidence countries the sex ratio was opposite (P = 0.019 for the interaction sex-population). During 1983-1988 the incidence increased significantly in Finland but not in other populations although a large year-to-year variation in incidence was observed in each country, particularly in males. We recorded a peak in IDDM incidence in most of these populations around 1986.     

The role of national culture in shaping health workforce collaboration: Lessons learned from a case study on attitudes to interprofessional education in Malta

The World Health Organisation identifies interprofessional education (IPE) as a key element for preparing a collaborative workforce. However, global implementation remains challenging due to individual, professional and organisational barriers. A qualitative case study explored the concept of introducing an undergraduate IPE programme at the Faculty of Health Sciences, University of Malta. A combination of in-depth interviews and focus groups were conducted with a sample of sixty-four academics,health and education policy makers and newly qualified health professionals. The findings suggest that while participants support the notion of IPE, they identify multiple barriers that would challenge implementation. This includes particular cultural norms and values which participants perceived would conflict with IPE. These findings were interpreted through Hofstede’s theory of cultural dimensions as a means of theorising about the role that culture could play in implementing such an approach. This study contributes to the health policy debate by highlighting the potential impact of national culture in the planning, development and delivery of collaborative initiatives. It also highlights new insights for European small states and other countries by providing a lens through which culture needs to be taken into account in the transfer of innovation across health systems.     

Association between health behaviour and self-reported health in Estonia, Finland, Latvia and Lithuania

BACKGROUND: The aim of the present study is to examine the associations of the selected health behaviours (daily smoking, frequent strong alcohol use, consumption of fresh vegetables less than 3 days a week and leisure time physical activity less than two/three times a week) to the self-assessed health after adjustment to the age and education in Estonia, Finland, Latvia and Lithuania. METHODS: Data from cross-sectional surveys carried out in all the above-mentioned countries were used. The methodology and questionnaires of the surveys were standardized between the participating countries within the Finbalt Health Monitor System. Logistic regression was used to assess the effect of self-perceived health status on prevalence of health behaviours. RESULTS: In Finland both women and men rated their health better than both genders in all the Baltic countries. In Finland self-assessment of health is significantly associated with most health behaviours, but in the Baltic counties the associations are weak or unstable. CONCLUSION: The results suggest that in Finland as in many other stable countries self-assessed health status was related to health behaviours and can be used as an indicator of health behaviours. In the Baltic countries, factors other than health behaviours may be more relevant to the self assessment of health status.     

Health polarization and inequalities across Europe: an empirical approach

This paper examines inequality and polarization in self-assessed health, contributing towards the limited research existing on health economics. We use data from the European Health Interview Survey (EHIS) to investigate the relationship between health inequality and polarization across 27 European countries in two periods: 2006–2009 and 2013–2015. As our key variable is of an ordinal nature, we employ median based measures. Our empirical results suggest that Greece is the country with the highest level of health polarization in both periods, whereas Ireland has the lowest one when we consider countries where the median category is “very good”, coinciding with the findings obtained in the inequality index. Estonia, Hungary and Lithuania have the highest degree of health polarization in both periods while Malta, The Netherlands and Spain are the countries with the lowest when we focus on those countries whose median category is “good” health.     

Sociodemographic and health behaviour factors associated with obesity in adult populations in Estonia, Finland and Lithuania

BACKGROUND: The aim of this study was to analyse the pattern of sociodemographic variations in the prevalence of obesity in Estonia, Finland and Lithuania. In addition, the association between obesity and selected health behaviours was examined. METHODS: Cross-sectional surveys were conducted among representative national samples of adult populations in 1994, 1996 and 1998. The number of participants aged 20-64 was 3759 in Estonia, 9488 in Finland and 5635 in Lithuania. The data were obtained from mailed questionnaires (covering sociodemographic characteristics, health behaviour indicators, and self-reported height and weight). Obesity was defined as BMI > or = 30 kg/m2. RESULTS: The prevalence of obesity among men and women was 10% and 15% in Estonia, 11% and 10% in Finland, and 10% and 18% in Lithuania respectively. The prevalence of obesity increased only among Estonian men. Obesity was more prevalent among those aged over 50 in all three countries. It was also more prevalent among the less educated women in all countries and among the less educated men in Finland. Obesity was less prevalent among daily smokers among Estonian men and women and Lithuanian men. Physically inactive Estonian women and Finnish men and women were more likely to be obese. CONCLUSIONS: A significant association was found between low educational level and obesity in women in all the countries, but this association was found for men only in Finland. In Finland obesity was also more consistently associated with indicators of unhealthy behaviour than in Estonia and Lithuania. Thus, even though the social gradient of obesity was broadly similar in all the countries studied, differences emerged with regard to the behavioural correlates of obesity.     

DRG-Systeme in Europa

DRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.     

Trends in the magnitude of educational inequalities in health in Estonia, Latvia, Lithuania and Finland during 1994-2004

BACKGROUND: Socioeconomic inequalities in health in the Baltic countries are possibly increasing due to concomitant pressures. This study compared time trends from 1994 to 2004 in the pattern and magnitude of educational inequalities in health in Estonia, Latvia, Lithuania and Finland. METHODS: The data were gathered from cross-sectional postal surveys of the Finbalt project, conducted every second year since 1994 on adult populations (aged 20-64 years) in Estonia (n=9049), Latvia (n=7685), Lithuania (n=11,634) and Finland (n=18,821). Three self-reported health indicators were used: (i) less than good perceived health, (ii) diagnosed diseases, and (iii) symptoms. RESULTS: The existing educational inequalities in health in three Baltic countries and Finland remained generally stable over time from 1994 to 2004. Also, the overall prevalence of all three health indicators was generally stable, but in the Baltic countries improvement in perceived health was mainly found among the better-educated men and women. Diagnosed diseases increased in the Baltic countries, except Lithuania, where diseases decreased among the better-educated women. Symptoms increased among the better-educated Estonian and Finnish women. CONCLUSIONS: The period from 1994 to 2004 of relative stabilization since the worst conditions of the social transition has not been followed by notable changes in self-reported health, and this appears to be the situation across all educational groups in the Baltic countries. While health inequalities did not markedly change, substantial inequalities do remain, and there were indications of favourable developments mainly among the better-educated respondents. The factors contributing towards increasing health inequalities may only be visible in the future.     

The sociodemographic patterning of health in Estonia, Latvia, Lithuania and Finland

BACKGROUND: Public health problems in the Baltic countries are typical of Eastern European transition economies. A common assumption is that the economic transition has been particularly difficult for previously disadvantaged groups, and comparative research on the health differences between sociodemographic groups in the Baltic countries is therefore needed. This study compared associations of health with gender, age, education, level of urbanization and marital status in three Baltic countries and Finland. METHODS: The data were gathered from cross-sectional postal surveys conducted in 1994, 1996, 1998 and 2000 on adult populations (aged 20-64 years) in Estonia (n = 5052), Latvia (n = 4290), Lithuania (n = 7945) and Finland (n = 12796). Three self-reported health indicators were used: (i) perceived health, (ii) diagnosed diseases and (iii) symptoms. RESULTS: The prevalence of less-than-good perceived health (average, rather poor or poor) was higher in the Baltic countries (men 66-56%, women 68-64%) than in Finland (men 35%, women 31%). The odds ratios (with 95% confidence intervals) of less-than-good perceived health among the low educated compared to the highly educated in Estonia, Latvia, Lithuania and Finland were 2.03 (1.49-2.77), 2.00 (1.45-2.76), 2.27 (1.78-2.89) and 1.89 (1.61-2.20) among men, and 3.32 (2.43-4.55), 2.77 (2.04-3.77), 2.07 (1.61-2.66) and 1.89 (1.63-2.20) among women, respectively. Diseases and symptoms were also more common among the lower educated men and women in all four countries. However, urbanization and marital status were not consistently related to the health indicators. CONCLUSIONS: The Baltic countries share a similar sociodemographic patterning of health with most European countries, i.e. the lower educated have worse health. The methodological considerations of this study point out, however, that further research is needed to support public health policies aimed at the most vulnerable population groups.     

Cultural values and population health: a quantitative analysis of variations in cultural values,health behaviours and health outcomes among 42 European countries

Variations in ‘culture’ are often invoked to explain cross-national variations in health, but formal analyses of this relation are scarce. We studied the relation between three sets of cultural values and a wide range of health behaviours and health outcomes in Europe.Cultural values were measured according to Inglehart׳s two, Hofstede׳s six, and Schwartz׳s seven dimensions. Data on individual and collective health behaviours (30 indicators of fertility-related behaviours, adult lifestyles, use of preventive services, prevention policies, health care policies, and environmental policies) and health outcomes (35 indicators of general health and of specific health problems relating to fertility, adult lifestyles, prevention, health care, and violence) in 42 European countries around the year 2010 were extracted from harmonized international data sources. Multivariate regression analysis was used to relate health behaviours to value orientations, controlling for socioeconomic confounders.In univariate analyses, all scales are related to health behaviours and most scales are related to health outcomes, but in multivariate analyses Inglehart׳s ‘self-expression’ (versus ‘survival’) scale has by far the largest number of statistically significant associations. Countries with higher scores on ‘self-expression’ have better outcomes on 16 out of 30 health behaviours and on 19 out of 35 health indicators, and variations on this scale explain up to 26% of the variance in these outcomes in Europe. In mediation analyses the associations between cultural values and health outcomes are partly explained by differences in health behaviours. Variations in cultural values also appear to account for some of the striking variations in health behaviours between neighbouring countries in Europe (Sweden and Denmark, the Netherlands and Belgium, the Czech Republic and Slovakia, and Estonia and Latvia).This study is the first to provide systematic and coherent empirical evidence that differences between European countries in health behaviours and health outcomes may partly be determined by variations in culture. Paradoxically, a shift away from traditional ‘survival’ values seems to promote behaviours that increase longevity in high income countries.     

The 2017 reform to improve financial sustainability of national health insurance in Estonia: Analysis and first lessons on broadening the revenue base

In 2017, the Estonian government addressed the longstanding challenge of financial sustainability of the health system by expanding its revenue base. As a relatively low-spending country on health, Estonia relies predominantly on payroll contributions from the working population, which exposes the system to economic shocks and population ageing. In an effort to reduce these vulnerabilities, Estonia will gradually introduce a government transfer on behalf of pensioners, although long-term sustainability of the health system could still prove challenging as the overall health spending as a percentage of GDP is not expected to substantially increase. Estonia has rolled out the reform according to plan, but it has led to debate about the need to achieve universal population coverage (currently at about 95%). Moreover, the Estonian experience also holds important lessons for other countries looking to reform their health system. For example, policymakers should recognize that reforms require extensive preparation using consistent messaging over a long period of time, also to prevent prioritising short term and popular fixes over structural reforms. Additionally, collaboration between the health and financial ministries throughout the reform increases the buy-in for the reform and likelihood of adoption. Furthermore, health professionals play a significant role in advocacy, and seeking support from this group can smooth the path towards health system reform.     

Hepatitis B: vaccination programmes in Europe--an update

In the eight years since the Global Advisory Group of the Expanded Program on Immunisation set 1997 as the target for integrating hepatitis B (HB) vaccination into national immunisation programs world-wide, more than 116 countries have included HB vaccine as part of their routine infant or adolescent immunisation programs. Meanwhile, many countries have performed economic evaluation studies, while others have initiated sero-epidemiological studies to generate input data for burden of disease calculation. These studies have indicated that epidemiological and economic arguments cannot be used to delay the implementation of universal hepatitis B vaccination. Some countries have improved their surveillance system and included viral hepatitis in the surveillance programs. Other have put hepatitis B vaccination on the political agenda. By the year 2000, following countries of the WHO European Region (51 countries) have implemented a universal hepatitis B immunisation programme: Andorra, Albania, Austria, Belarus, Belgium, Bulgaria, Estonia, France, Germany, Greece, Italy, Israel, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Moldova, Monaco, Poland, Portugal, parts of the Russian Federation, Romania, Slovakia, Slovenia, San Marino, Spain, Switzerland, Turkey and Uzbekistan. The Netherlands and some other European countries are seriously studying the issues or are making budgetary provisions for introduction of HB vaccine into their vaccination programme. Most of the European countries, which now use the vaccine routinely, have started with adolescent or infant immunisation. Belgium (1999), France (1994) and Italy (1991) have begun with both adolescent and infant HB immunisation. France continues since 1st October 1998 with the infant immunisation programme only. The rewards of effective implementation of the programmes in these countries are becoming apparent; and their success offers an exemplary model for other countries. The deadline was 1997. Globally, work still remains to be done to support and implement interventions that will bring us closer to the WHO goal and to control, eliminate and eradicate hepatitis B in the coming generations at large. If all the 145 million infants born in 1991 had been vaccinated in this way, the number of chronic carriers would have been reduced by 7.5 million, and 1.8 million deaths prevented.     

International assistance and health care reform in Poland: barriers to project development and implementation

The restoration of democracy in Poland initiated a major system transformation including reform of the health sector. The international community were quick to respond to the need for assistance. Polish proposals were supported by international experts and projects were developed together with international development agencies and donors. Donors had no experience of central and eastern Europe, these countries had never been beneficiaries of aid and neither side had experience working together. Progress and absorption of funds was slow. Comparative experience from developing countries was used to analyze the barriers encountered in project development and implementation in Poland. The conditions necessary for implementation were not satisfied. Insufficient attention was paid to the project process. Barriers originate on the side of both donors and recipients and additionally from programme characteristics. The most serious problems experience in Poland were lack of government commitment to health care reform leading to failure to provide counterpart funds and low capacity for absorption of aid. Rent seeking attitudes were important. Donor paternalistic attitudes, complex procedures and lack of innovative approach were also present. Poor coordination was a problem on both sides. Multi-lateral projects were too complex and it was not always possible to integrate project activities with routine ones. External consultants played an excessive role in project development and implementation, absorbing a large portion of funds. The barriers have been operationalised to create a checklist which requires validation elsewhere and may be useful for those working in this field.     

不同形式结核病防治宣传活动成本效益分析

目的评价河北省16个结核防治项目县开展的不同形式结核病防治宣传活动的效果,分析不同结核病防治宣传活动的成本效益。方法利用河北FIDELIS结核病控制项目月报、季报和实施报告获得就诊患者数、不同结核病防治宣传活动开展的频度和成本。利用调查表,随机调查初诊患者的就诊信息来源。结果就诊患者就诊信息的3个主要来源是墙体广告(占26.4%)、电视(占17.4%)和政府布告(占15.1%)。在不同宣传活动中,获得一个就诊患者的平均成本从低到高依次为政府布告、电视、广播、墙体广告和宣传单/画。结论在开展结核病防治宣传活动时,应该结合当地实际情况,针对不同目标人群开展不同形式的宣传活动。充分利用政府布告、墙体广告和电视等覆盖面广,可信度高,成本效益好的宣传活动手段。     

The implementation of quality management systems in hospitals: a comparison between three countries

Background

Is the implementation of Quality Management (QM) in health care proceeding satisfactorily and can national health care policies influence the implementation process? Policymakers and researchers in a country need to know the answer to this question. Cross country comparisons can reveal whether sufficient progress is being made and how this can be stimulated. The objective of the study was to investigate agreement and disparities in the implementation of QMS between The Netherlands, Hungary and Finland with respect to the evaluation model used and the national policy strategy of the three countries.

Methods

The study has a cross sectional design, based on measurements in 2000. Empirical data about QM-activities in hospitals were gathered by a self-administered questionnaire. The questionnaires were answered by the directors of the hospitals or the quality coordinators. The analyses are based on data from 101 hospitals in the Netherlands, 116 hospitals in Hungary and 59 hospitals in Finland. Outcome measures are the developmental stage of the Quality Management System (QMS), the development within five focal areas, and distinct QM-activities which were listed in the questionnaire.

Results

A mean of 22 QM-activities per hospital was found in the Netherlands and Finland versus 20 QM-activities in Hungarian hospitals. Only a small number of hospitals has already implemented a QMS (4% in The Netherlands,0% in Hungary and 3% in Finland). More hospitals in the Netherlands are concentrating on quality documents, whereas Finnish hospitals are concentrating on training in QM and guidelines. Cyclic quality improvement activities have been developed in the three countries, but in most hospitals the results were not used for improvements. All three countries pay hardly any attention to patient participation.

Conclusion

The study demonstrates that the implementation of QM-activities can be measured at national level and that differences between countries can be assessed. The hypothesis that governmental legislation or financial reimbursement can stimulate the implementation of QM-activities, more than voluntary recommendations, could not be confirmed. However, the results show that specific obligations can stimulate the implementation of QM-activities more than general, framework legislation.     

Health behaviour in Estonia,Finland and Lithuania 1994-1998. Standardized comparison

BACKGROUND: The Finbalt Health Monitor project collects standardized information on health and health-related behavioural activity and related trends in Finland and those Baltic countries that have major public health problems with noncommunicable diseases related to lifestyle and behavioural factors. The aims of this study were to compare patterns of and trends in selected health behaviours and their socioeconomic associations in Estonia, Finland and Lithuania in the period 1994-1998. METHODS: Standardized questionnaires were posted to nationally representative samples in 1994, 1996 and 1998. Response rates varied between 62% and 83%. The total number of respondents was 3808 in Estonia, 9608 in Finland and 5716 in Lithuania. Prevalence of smoking, consumption of strong alcoholic beverages, use of vegetable oil in food preparation and leisure-time physical exercise were analysed in this study. RESULTS: No major changes in daily smoking, consumption of strong alcoholic beverages and leisure-time physical exercise emerged. However, the use of vegetable oil increased rapidly in Estonia and particularly in Lithuania (from 41% to 81%). In 1994 the prevalence of daily smoking was 53%, 28% and 44% among men and 24%, 18% and 6% among women in Estonia, Finland and Lithuania, respectively. In Lithuania the prevalence of smoking among women was notably low but increased (from 6% to 13%). The prevalence of strong alcoholic beverage consumption was similar in all countries. Leisure-time physical exercise was most common in Finland. The socioeconomic differences remained similar in all countries, unhealthy behaviours were typical among the less educated groups and men, especially in the age groups 34-49 years. CONCLUSIONS: The sociodemographic pattern of risk-related lifestyles appears to be rather similar and stable in Estonia, Finland and Lithuania. However, from the view point of possible public health implications the rapid changes in the prevalences of some behaviours are notable.     

A framework for analysing migrant health policies in Europe

Evidence suggests migrants experience inequalities in health and access to health care. However, to date there has been little analysis of the policies employed to address these inequalities. This article develops a framework to compare migrant health policies, focusing on England, Italy, the Netherlands and Sweden. The first issue addressed in the framework is data collection. All four countries collect migrant health data, but many methodological limitations remain. The second issue is targeting of population groups. Countries typically focus either on first generation immigrants or on ethnic minorities, but not both, despite the often divergent needs of the two groups. Another issue is whether specific diseases should take priority in migrant health policy. While communicable diseases, sexual and reproductive health and mental health have been targeted, there may be a lack of attention paid to lifestyle related risk factors and preventive care. Fourthly, decisions about the mix of demand and supply-side interventions need to be made and evaluated. Finally, the challenge of implementation is discussed. Although migrant health policy has been elaborated in the four countries, implementation has not necessarily reflected this on the ground. These experiences signal important policy issues and options in the development of migrant health policies in Europe.