International Journal of Integrated Care, 1 November 2000 - ISSN 1568-4156
Book review
Critical challenges for health care reform in Europe
Edited by Richard B. Saltman, Josep Figueras, Constantino Sakellarides
Open University Press, Buckingham: 1998, pp. XVI, 424,
ISBN 0 335 19970 4 Paperback
ISBN 0 335 19971 2 Hardback
Henry Scicluna

Health systems throughout Europe remained basically unchanged for decades. In general, it was only from around the 70s that Western European countries started looking closely at the performance of health system and questioning their cost/effectiveness.

This was due to a multitude of factors, but largely to the ageing of European populations, with all the health consequences it was thought to entail, the introduction of costly new technologies and the increasing demand of consumers aware of treatments available and of their right to have them.

European countries have a long tradition of equity and solidarity, embedded in their prevailing system (Beveridge, Bismarck or Semashko). Respect of these values inevitably entails an increase in expenditure as more people ask for more and better services.

“Critical Challenges for Health Care Reforms in Europe” is a detailed, objective and interesting account of how European countries set about resolving the dilemma of ensuring good quality care equitably within the limits of available funds. Each chapter is written by different authors, but the ensemble forms a very coherent and readable analysis. It should be of interest to students of heath policy and laymen alike. It is particularly useful for policy makers still battling with health reforms.

It comes out at a time when every European country is busy trying out or evaluating various reforms, and more interestingly, when Central and Eastern European countries, now freed from communism, are experimenting not—always successfully—with new health reforms.

It describes in detail, and with several examples the wide variety of reform methods currently or recently being explored—decentralisation, patient cost sharing, contracting models, payment systems for physicians. One is struck by the diversity of reforms tried out by different countries and sometimes by the same country. The authors do not pretend to present any one model to be followed rather than another. In fact, except where methods are known to have failed, evaluation is still frequently lacking, particularly in Central and Eastern European countries to demonstrate what works and what does not.

Reading through the chapters, however, one can trace certain important messages which are useful to policy makers in all European countries, one of which is focussed on the underlying raison d'tre of health reforms.

Such reforms should obviously be intended to ensure equity in access and good quality care within the limits of funds available. Yet reading through the various chapters, one gets the impression that, in initiating and implementing their reforms, European countries are primarily concerned about the cost of health, even while still being conscious of maintaining equity and solidarity.

The various chapters describe a variety of methods tried—and sometimes abandoned—by the various countries involving both demand-side and supply-side strategies and record findings that, to varying degrees many of these reforms have had, adverse effects on equity in access.

This publication could make policy makers reflect that if their health reforms focus on cost/effectiveness, equity will suffer.

Another message that comes through clearly is that reforms can improve the health system, but can never make it perfect. There are nonetheless several evidence-based indicators for countries to follow including the role of the state, in ensuring good quality health services and equity in access to them. Attempts at shedding state responsibility in health care have met with difficulties in several countries, particularly where privatisation was not accompanied by state control. Reforms in the Czech Republic are a classical example.

An interesting aspect which the authors emphasise is the force of tradition, history and beliefs of the various countries in carrying out any reforms. Health systems are the product of a nation's history and their reform will be conditioned by that historical context. In Western European countries, health systems founded on equity and solidarity have proved satisfactory to a large extent and their populations see no reason why services should be cut.

By contrast, Central and European countries are trying to eradicate their past history by radical market oriented reforms.

This brings me to another important issue raised by the authors: reforms should be built pragmatically, on what exists, and not conceived ideologically, in a vacuum. Health care involves many stakeholders: patients, health professionals, insurers, government bodies. Health reforms disturb the status quo and the vested interests of the various stakeholders. Radical reforms ignoring traditions and the views of the stakeholders are bound to meet with difficulties and also failure. Incremental reforms in consultation with the stakeholders are more likely, in the long run, to achieve a profound transformation of the health system.

If the diversity of reforms is often the result of different traditions and historical contexts, it is also an indication that countries often neglect to look at how things work—or fail—in their neighbouring countries. Through its trans-national analysis, the present study provides food for reflection on a more open, better-informed and unprejudiced approach to reforms carried out elsewhere.

The book would have benefited from more analysis of the important role of health promotion in several aspects of health system reforms. In fact health promotion underlines the role of the state in health matters, and has budgetary consequences in that it reduces curative care. It puts into question reforms based on individual patient demand.

It could also have benefited from more discussions on the education and training of health professionals. The authors deal in depth with payment systems for physicians and the regulation of expenditure on medicines. But the issue is not simply solved by motivation and competition. There is an ethical dimension to the issue which can best be ensured by a wider education of health professionals in the use of services, and particularly in avoiding unnecessary ones.

This book should be read by all those who want to know what is happening in health systems today and want to reflect on what reforms are needed for the future.