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wmj29<\/a><\/p>\n

vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, Inc
\nG20438
\nNr. 5, October 2010
\nEconomic Crises on National Health Care\u2022
\nSystems \u2013 Experience and Strategies
\nThe Impact of the Economic Recession on Nurses\u2022
\nand Nursing in Iceland
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nBachmer Str. 29-33
\nD-50931, K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nSerbian Orthodox Monastery Chilandar, found-
\ned in 1298 and The Medical Code of Chilandar
\nfrom the 16th
\ncentury.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
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\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7% MwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln, Germany
\nISSN: 0049-8122
\nDr. Dana HANSON
\nWMA President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nProf. Ketan D. DESAI
\nWMA President-Elect
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nI.M.A. House
\nIndia
\nProf. Dr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Yoram BLACHAR
\nWMA Immediate Past-President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNorway
\nProf. Dr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n167
\nAn exiting year lies behind us since the General Assembly in New
\nDelhi. Council and General Assembly will consider new policy and
\npotentially adopt new bylaws.The work groups will come back with
\nnew proposals and Council will start rolling out a new strategic plan
\nfor the coming years.
\nBy far the heaviest paper before Council (and if Council adopts
\nit – the General Assembly) will be a consolidated set of bylaws and
\nProcedures and Operating Policies which should bring logically
\ntogether what has developed as rules of the organization over the
\npast decades,but was scattered over different documents,sometimes
\nwith conflicting, often outdated wording.
\nOur rules weren’t bad at all, but they were from a time when mail
\ntook weeks, fax machines could only be found in the offices of the
\nbig newspapers and the Internet was unknown. The changes that
\nwere made merely adapted the old rules, but were added in sec-
\nondary documents, sometimes in contradiction to the still valid old
\nwording of the by- laws or, at least, leaving some ambiguities.
\nThe consolidation before Council does not bring new rules to be
\napplied, but it provides clarity and stringency returns to our bylaws.
\nAs in the past, the General Assembly will charge the Council with
\nthe operational policies and procedures,which then will form a clear
\nset of rules, hopefully leaving no questions open.
\nOur association has been in a difficult situation with our President-
\nElect, Dr. Ketan Desai, arrested on April 22nd this year. First, under
\ncharges of bribery, and as he was not indicted for that, thereafter
\nunder charges of \u00abdisproportionate assets\u00bb. He has been kept in cus-
\ntody.Months have gone by,but no \u201ccharge sheet\u201d,as indictments are
\ncalled in India, has been filed against him. At the end of Septem-
\nber he was released from custody and we are anxious to hear from
\nhim in Vancouver. His friends have always stated that the arrest
\nwas politically motivated. It was aimed to take him out of power as
\nthe government finally tried to dismantle physician self-governance
\nwith a new act on the Medical Council of India (MCI).
\nIndeed the new parliament hurried up and a few days after passing
\nthe law that is designed to turn the largest self-governed physician
\nbody of the world into a government watch dog Ketan Desai was
\nreleased. For nearly ten years he had combated the government\u2019s
\nattempts to get rid of the self-governed MCI, including protests
\nand a countrywide strike. The charismatic and powerful leader had
\nbecome a state-enemy.
\nThere are more questions open now than answers are available. But
\nthe real answer may lie in what the famous Andr\u00e9 Wynen told us
\nwhen he resigned from office: \u00abA medical leader should be intelli-
\ngent, but in the first place a leader should be courageous.\u00bb He knew
\nwhat he was talking about, as a member of the Belgian Resistance
\nhe spent the winter 1944 to 1945 as prisoner at the Concentra-
\ntion Camp in Buchenwald. We will have to be courageous and
\nintelligent.
\nDr. Otmar Kloiber
\nWMA Secretary General
\nComing to Vancouver
\nThe World Medical Association supports
\nphysicians in Saudi Arabia in refusing to
\ncarry out a punishment as suggested by a
\ncourt that would be a severe breach of med-
\nical ethics.
\nThis follows the recent request to hospitals
\nby a Saudi Arabian judge to damage a man\u2019s
\nspinal cord as a punishment for his attack-
\ning and paralyzing another man.
\nDr. Dana Hanson, President of the WMA,
\nsaid: \u201cThis is an appalling request and one
\nwhich every physician must resist. As the
\nWMA\u2019s Declaration of Tokyo clearly states
\nno physician should participate in the prac-
\ntice of torture or any other forms of cruel,
\ninhuman or degrading procedures,whatever
\nthe offence of which the victim of such pro-
\ncedures is suspected, accused or guilty of.
\nThe Declaration also includes a prohibition
\nof participation in the planning or advising
\nfor such a procedure.
\n\u201cPhysicians must at all times preserve their
\nethical independence. The Declaration of
\nGeneva states that, \u2018The health of my pa-
\ntient will be my first consideration,\u2019 and the
\nInternational Code of Medical Ethics de-
\nclares that, \u2018A physician shall act only in the
\npatient’s interest when providing medical
\ncare which might have the effect of weaken-
\ning the physical and mental condition of the
\npatient.\u2019
\n\u201cThis refers to all patients whatever their
\nstatus\u201d.
\nFor further information please contact:
\nDr. Otmar Kloiber
\nWMA Secretary General
\n+33 4 50 42 6757
\nNigel Duncan
\nWMA Public Relations Consultant
\n+44 (0) 20 8997 3653
\nWMA Supports Physicians in Refusing
\nPunishment Request
\nPress release, 24 August 2010
\n168
\nWMA news
\nThe most widely used indicator of an eco-
\nnomic crisis is the decline of the Gross
\nDomestic Product (GDP), which measures
\nthe economic activity in a country. When
\nGDP declines for at least two consecutive
\nquarters, an economy is typically declared
\nto be in recession. A GDP decline which is
\nsubstantial (e.g., – 10%) and sustained (e.g.,
\nlasting two or more years) is often called an
\neconomic depression.
\nWhile recessions are part of the business
\ncycle of economies and are nothing new,the
\nmost recent recession was unprecedented
\nin its scope. Reflecting the growing inter-
\ndependency of economies, it was the first
\nglobal recession, as shown in Figure 1.
\nThere are reasons to expect that the recent
\neconomic crisis may result in a health cri-
\nsis. Because of the economic crisis, health
\nexpenditure may be cut. Absent compen-
\nsating efficiency improvements, such a cut
\nmay lead to a deterioration in a population\u2019s
\nThe global economic crisis has made a sig-
\nnificant negative impact on public health
\nand health care systems all over the world.
\nThe impact has been particularly detrimen-
\ntal for the health of low-income population
\ngroups, as well as for women and children.
\nGrowing unemployment and poverty, as
\nwell as crisis-inflated payments for health-
\ncare services have frequently prevented
\npeople from turning to timely health-care.
\nThough countries have had varied success in
\nhandling the impact of the crisis on health-
\ncare systems, progress has been better in
\nthose countries where the respective gov-
\nernments have managed to maintain their
\nhealth budgets and have seen the crisis as an
\nopportunity for taking strong decisions on
\nthe reforms to be carried out, making long-
\nterm contributions to the management of
\nthe health-care system, prioritising on in-
\nvestments in human capital, improvement
\nof its productivity and better use.
\nEconomic crisis is a time for deeper con-
\ntemplation. Governments together with
\nmedical associations and health-care pro-
\nfessionals have to reconsider correlations
\nbetween economics and health-care policies
\nwith a clear understanding that investments
\nin health are investments in a country\u2019s hu-
\nman resources which are at the basis for the
\neconomic development of any country.
\nThe time of economic crisis is a time for op-
\nportunities. It is the right time for modi-
\nfying health-care systems, abandoning
\nwhat has been superfluous and excessive,
\nat the same time sustaining the resources
\nfor health-care. The emphasis should be on
\nadequate availability of services, through
\nproviding for evidence-based patient needs.
\nDecisions have to be taken by way of chan-
\nnelling new resources towards prevention,
\nhealth promotion and primary health care.
\nIt has to be acknowledged that in most
\ncountries allocations for prevention are dis-
\nproportionately small and they should not
\nbe further reduced during a time of crisis;
\non the contrary \u2013 we should look at addi-
\ntional and more focused investment in or-
\nder to reduce the long-term impact of the
\ncrisis on public health.
\nEconomic crisis is a time for taking respon-
\nsibility, with the public and private sectors
\nhaving particularly important roles to play
\nin placing health issues high on the public
\nand political agenda.Health budgets should
\nbe safeguarded and used rationally. Health
\nis hardly the sector to be reduced when
\ngovernments have a problem in coping with
\nbalancing the budget.
\nLessons learned from this conference in-
\nclude the vital importance of setting a high-
\ner priority on health-care and health-care
\nspending during times of economic down-
\nturn, while understanding and encouraging
\ncounter-cyclical health expenditure strate-
\ngies.Both the private and public health-care
\nsectors must understand that investment in
\nhealth-care, especially investment in human
\ncapital, continuing education and primary
\ncare, as well as research is critical for the
\nwellbeing and sustainability of health-care
\nand the economy for present and future
\ngenerations.
\nFinal Conclusions
\nWMA conference on \u201cFinancial crisis and its implications
\nfor health care\u201d, Riga, September 10-11th
\n2010
\nImpact of Economic Crises on National Health
\nCare Systems \u2013 Experience and Strategies
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\nReinhard Angelmar
\n169
\nWMA news
\nhealth status. An increase in the need for health care resulting from
\nthe negative effects of economic distress on health could further ag-
\ngravate this deterioration.
\nI will concentrate here on the impact of an economic crisis on health
\nexpenditure. Two main questions will be addressed: (1) Does a de-
\ncline in GDP always lead to a decline in health expenditure or, less
\ndamaging, to a slow-down in the growth of health expenditure? (2)
\nDo public and private health expenditure respond in the same way
\nto a decline in GDP?
\nDoes a decline in GDP always lead to a decline in health expen-
\nditure?
\nA decline in GDP generally leads to a decline in the financial re-
\nsources of households, firms, and governments due to rising un-
\nemployment, reduced profits, and lower tax revenues. When an
\neconomic crisis is accompanied by a financial crisis, the declining
\nvalue of stocks, houses and other assets further reduces the ability
\nto finance expenditures for health care and other items through the
\nsale of these assets. And when a crisis is global, remittances from
\nabroad and foreign aid are likely to diminish as well. Unless health
\nexpenditure is seen as a high priority compared with other types of
\nexpenditures, one would expect health expenditure to decline in a
\nrecession along with GDP.
\nThe expectation that a GDP decline leads to a decline in health
\nexpenditure is consistent with the many studies that have shown
\na positive relationship between the growth of GDP and of health
\nexpenditure [1]. If health expenditure goes up when GDP goes up,
\nit should also go down when GDP goes down.One would therefore
\nexpect that the number of years of declining health expenditure over
\ntime matches the number of recession years in a country.
\nFigure 2 plots the percent of years with negative GDP growth
\nagainst the percent of years with negative health expenditure growth
\nfor the 34 countries included in the OECD (Organization for Eco-
\nnomic Cooperation and Development) Health Data 2010 database.
\nBoth GDP and health expenditure growth are in real terms, that is,
\nremoving the effect of inflation, and on a per capita basis. For each
\ncountry, the analysis uses all available years since 1980.
\nThe diagonal line in Figure 2 represents the expectation that the
\nnumber of years with a decline in health expenditure (negative health
\nexpenditure growth) is equal to the number of recession years (years
\nwith negative GDP growth). Figure 2 shows that there is indeed a
\nnumber of countries which fit this expectation (e.g., Italy, Germany,
\nSpain, Chile, Korea) or come close to it (e.g., Israel, Denmark, Ire-
\nland). However, there are also three countries which, despite having
\nexperienced recessions, have not seen a cut in health expenditure
\n(USA, France, Australia). In the opposite direction, one finds coun-
\ntries in which a decline in health expenditure has occurred more
\nfrequently than a decline in GDP (e.g., Hungary and Norway).
\nEconomic crises and health expenditure crises therefore are not as
\ntightly connected as one would expect, at least in the OECD coun-
\ntries. A decline in GDP is neither a necessary (e.g., Hungary) nor
\na sufficient (e.g., USA) condition for health expenditure to decline.
\nWhether an economic crisis leads to a cut in health expenditure
\nvaries from one country to the next.
\nWhat explains the country differences in the link between economic
\nand health expenditure crises? Figure 3 indicates that a country\u2019s
\nincome plays a significant role. The greater a country\u2019s GDP per
\ncapita (at US$ purchasing power parity), the lower the frequency
\nFigure 1. Real Annual GDP Growth
\n-4
\n-2
\n0
\n2
\n4
\n6
\n8
\n10
\n1980
\n1981
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\n2009
\n2010
\n2011
\nRealGDPGrowth(%)
\nWorld Advanced economies Emerging and developing economies
\nSource : International Monetary Fund, World Economic Outlook
\nDatabase, April 2010
\nFigure 2. Frequency of Health Expenditure Decline and of GDP
\nDecline
\nUSA (1980-2008)
\nUK (1980-2008)
\nTUR (1983-2007)
\nCHE (1980-2008)
\nSWE (1980-2008)
\nESP (1980-2008)
\nSVN (1996-2008)
\nSVK (1998-2008)
\nPRT (1980-2006)
\nPOL (1991-2008)
\nNOR (1980-2008)
\nNZL (1980-2008)
\nNLD (1980-2008)
\nMEX (1991-2008)
\nLUX (1996-2006)
\nKOR (1981-2008)
\nJPN (1980-2007)
\nITA (1989-2008)
\nISR (1980-2008)
\nIRL (1980-2008)
\nISL (1980-2008)
\nHUN (1992-2008)
\nGRC (1988-2007)
\nDEU (1980-2008)
\nFRA (1991-2008)
\nFIN (1980-2008)
\nEST (2000-2008)
\nDNK (1980-2007)
\nCZE (1991-2008)
\nCHL (1996-2008)
\nCAN (1980-2008)
\nBEL (1980-2008)
\nAUT (1980-2008)
\nAUS (1980-2007)
\n0%
\n5%
\n10%
\n15%
\n20%
\n25%
\n30%
\n35%
\n0% 5% 10% 15% 20% 25% 30% 35%
\nPercentof years withGDPdecline
\n(onaverageevery7.1years)
\nPercentof years with
\nhealthexpenditure
\ndecline
\n(onaverageevery8.1
\nyears)
\nSource: OECD Health Data 2010
\n170
\nWMA news
\nof a decline in health expenditure compared with the frequency of
\na decline in GDP. In high-income countries, health expenditure is
\nmore protected in recession times than in lower-income countries.
\nDoes a decline in GDP always lead to a slow-down in the growth
\nof health expenditure?
\nThe preceding discussion has shown that the worst case outcome
\nof an economic crisis, namely a decline in health expenditure, does
\nnot always occur. But should one not at least see a slow-down in the
\ngrowth of health expenditure during a recession?
\nWhen one analyzes the evolution of GDP growth and health ex-
\npenditure growth over time, one sees a diverse pattern of health
\nexpenditure response to a recession, both within one country, and
\nacross countries. This diversity is illustrated in the following figures
\nfrom the U.S., the country with the highest per capita health ex-
\npenditure (2008), and from Turkey, the country with the lowest per
\ncapita health expenditure (2007) in the OECD health data.
\nFigure 4 shows the evolution of the growth of real per capita GDP
\nand health expenditure in the U.S. between 1979 and 2008. U.S.
\nGDP growth displays significant fluctuations,called business cycles,
\npunctuated by recessions in 1980 and 1982 (a \u201cdouble-dip\u201d reces-
\nsion), 1991, 2001 and 2008.Three different types of health expendi-
\nture response to a recession are apparent:
\nAcyclical behavior, in which health expenditure growth is unrelated
\nto GDP growth (no correlation between GDP growth and health
\nexpenditure growth): in 1982,GDP declined significantly,yet health
\nexpenditure growth changed very little; furthermore, while GDP
\ngrowth fluctuated widely between 1981 and 1985, health expendi-
\nture growth showed little variation during the same period.
\nPro-cyclical behavior, in which health expenditure growth increases
\nwhen GDP growth increases, and slows down when GDP growth
\nslows down (positive correlation between GDP growth and health
\nexpenditure growth): during the 1991 and 2008 recessions, health
\nexpenditure growth slowed down considerably.
\nCounter-cyclical behavior, in which health expenditure growth in-
\ncreases when GDP growth slows down, and goes down when GDP
\ngrowth goes up (negative correlation between GDP growth and
\nhealth expenditure growth): during the 1980 and 2001 recessions,
\nhealth expenditure growth actually increased; the years 2003 and
\n2004 also demonstrate counter-cyclical behavior: GDP growth in-
\ncreased whereas health expenditure growth declined.
\nThe diverse response pattern apparent in the U.S. stands in stark
\ncontrast to the consistent pro-cyclical behavior one sees in Turkey
\n(see Figure 5). In all recession years for which health expenditure
\ndata are available (1985, 1989, 1991, 1994, 2001), health expendi-
\nture behaved in a pro-cyclical manner, either declining (1985, 1994,
\n2001) or experiencing a growth slow-down (1989 and 1991). Pro-
\ncyclical behavior is also present in most non-recession years, with
\nhealth expenditure growth rising and falling in parallel with GDP
\ngrowth.
\nOnly a pro-cyclical behavior of health expenditure is consistent
\nwith the many studies that have found a positive relationship be-
\ntween GDP growth and health expenditure growth. Acyclical and
\ncounter-cyclical responses, such as the ones that one observes in the
\nU.S., are not. The solution to this puzzle may well lie in the meth-
\nods used in these studies. In a recent study of OECD countries,
\none econometric method found only positive relationships between
\nFigure 3. Years with Health Expenditure Decline \/ Years with GDP
\nDecline and GDP per capita (US$ PPP)
\nTUR
\nCHE
\nESP
\nUSA
\nUK
\nSVK PRT
\nPOL
\nNZL
\nNLD
\nMEX
\nKOR
\nJPN
\nITAISR
\nIRL
\nISL
\nHUN
\nGRC
\nDEU
\nFRA
\nFIN
\nEST
\nDNK
\nCZE
\nCHL
\nCAN
\nBEL AUT
\nAUS
\nNOR
\nLUX
\nR2 = 0.24
\n(excluding LUX & NOR)
\n0.0
\n0.5
\n1.0
\n1.5
\n2.0
\n2.5
\n3.0
\n3.5
\n4.0
\n0 10,000 20,000 30,000 40,000 50,000 60,000 70,000
\nGDP per capita US$ PPP
\nYears with health
\nexpenditure decline \/
\nYears with GDP decline
\nSource: OECD Health Data 2010
\nFigure 4. GDP Growth and Health Expenditure Growth in the US
\n-4%
\n-2%
\n0%
\n2%
\n4%
\n6%
\n8%
\n1979
\n1980
\n1981
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\nAnnualGrowth
\nGrowth of real per capita GDP Growth of real per capita health expenditure
\nSource: OECD Health Data 2010
\n171
\nWMA news
\nGDP growth and health expenditure growth, indicating procycli-
\ncal behavior of health expenditure in all countries. However, using
\nanother method, the authors found no or negative relationships for
\nsome countries, indicating acyclical or counter-cyclical health ex-
\npenditure behavior in these countries [3]. Again, the link between
\nthe evolution of GDP and health expenditure appears to vary great-
\nly across different countries.
\nDo public and private health expenditure respond in a similar way
\nto a GDP decline?
\nThe question of how health expenditure behaves over the business cy-
\ncle is particularly relevant for public health expenditure. Government
\npolicy makers might seek to stabilize health expenditure through a
\ncounter-cyclical public health expenditure policy, compensating pro-
\ncyclical private health expenditure. In addition, such a policy could
\nalso be an instrument for macroeconomic stabilization. Pro-cyclical
\npublic health spending, by contrast, might reflect a passive, hands-off
\napproach to health expenditure and economic fluctuations.
\nPanel A of Figure 6 shows the evolution of GDP growth and public
\nexpenditure growth in the U.S. between 1979 and 2008. In four
\nout of the five recessions during this period, public health expendi-
\nture increased, in addition to displaying counter-cyclical behavior in
\nmany non-recession years as well. In stark contrast to the counter-
\ncyclical behavior in the U.S., Panel B of Figure 6 shows that public
\nhealth expenditure in Turkey was highly pro-cyclical. Health ex-
\npenditure growth slowed down in all five recession years for which
\nhealth expenditure data are available. Throughout, health expendi-
\nture growth generally moved up and down in parallel with GDP
\ngrowth. The counter-cyclical behavior of public health expenditure
\nin the U.S. and its pro-cyclical behavior in Turkey observed here is
\nconsistent with the results obtained by Hercowitz and Strawczynski
\n[2] in their analysis of the cyclicality of total government expendi-
\nture in these two countries over the 1975-1998 period.
\nFigure 7 allows to compare the cyclical behavior of public and pri-
\nvate health expenditure. Panel A shows that the growth of public
\nand private health expenditure in the U.S. evolved in opposite di-
\nrections during three out of the five recession years, with growth
\nin non-recession years also often showing opposite behavior. This
\nindicates that public and private health expenditure in the U.S. were
\nto some extent substitutes,with private health expenditure compen-
\nsating for a slowdown in public health expenditure and vice versa.
\nSimilar to what one saw in the previous comparisons,the pattern for
\nTurkey in Panel B of Figure 7 is different from that for the U.S. In
\nTurkey, both public and private expenditure growth display pro-cy-
\nclical behavior, slowing down together in recession years. However,
\nwhereas private health expenditure declined or stopped growing in
\nFigure 5. GDP Growth and Health Expenditure Growth in Turkey
\n-40%
\n-30%
\n-20%
\n-10%
\n0%
\n10%
\n20%
\n30%
\n40%
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\n2009
\nAnnualgrowth(%)
\nGrowth of real per capita GDP Growth of real per capita health expenditure
\nSource: OECD Health Data 2010
\nFigure 6. GDP Growth and Public Health Expenditure Growth in the
\nUS and Turkey
\nA. US
\n-4%
\n-2%
\n0%
\n2%
\n4%
\n6%
\n8%
\n10%
\n1979
\n1980
\n1981
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\nAnnualGrowth
\nGrowthof realper capitaGDP Growthof realper capitapublic healthexpenditure
\nB. Turkey
\n-20%
\n-10%
\n0%
\n10%
\n20%
\n30%
\n40%
\n50%
\n60%
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\n2009
\nAnnualGrowth
\nGrowth of real per capita GDP Growth of real per capita public health expenditure
\nSource: OECD Health Data 2010
\n172
\nWMA news
\nall recession years, public health expenditure kept growing, albeit at
\na slower rate,in three of these years (1999,1991,2001) and declined
\nsignificantly less than private expenditure during the two other re-
\ncession years (1985 and 1994). Public health expenditure in Turkey
\nthus was much less negatively impacted in recession years than pri-
\nvate health expenditure, thereby softening the negative impact on
\nhealth expenditure of the latter.
\nBeyond their differences, there is therefore an important common-
\nality between the U.S. and Turkey. In both countries, private health
\nexpenditure responded more negatively to recessions than public
\nhealth expenditure, and the latter contributed to reducing the fluc-
\ntuation in health expenditure over the business cycle.
\nConclusion
\nIt is often thought that economic crises induce a reduction in the
\nlevel or growth of health expenditure. However, the data from
\nOECD countries examined here indicate that the impact of eco-
\nnomic crises on health expenditure is more varied than expected.
\nSome countries have never cut health expenditure in recent decades
\ndespite going through several recessions, others have experienced
\nsignificantly more years with expenditure cuts than years with re-
\ncessions, and many fall between the two extremes. And whereas in
\nmany countries as expected the growth of health expenditure slows
\ndown or becomes negative in response to a recession, one also finds
\ncountries where health expenditure growth displays a counter-cy-
\nclical behavior, going up when GDP declines, and slowing down
\nas GDP growth rises. Public health expenditure in particular may
\nshow such counter-cyclical behavior, or at least experience less of a
\ngrowth slow-down compared with private health expenditure.
\nHealth expenditure enjoys greater immunity against recession-in-
\nduced cuts in high-income than in lower-income countries. Future
\nresearch should identify other determinants and discover what ex-
\nplains counter-cyclical or pro-cyclical behavior of overall,public and
\nprivate health expenditure.
\nThis article has addressed only the question of how economic crises
\nimpact health expenditure. Considering their respective impact on
\nhealth during an economic crisis, a counter-cyclical health expendi-
\nture policy seems to be preferable to a pro-cyclical policy. However,
\nthe impact of health expenditure on health also depends on how
\nthe money is spent. An economic crisis may well be an opportunity
\nfor improving the efficiency and equity of health expenditure. One
\nwould hope that countries that cut health expenditure during a cri-
\nsis do so in a way that enhances both of these outcomes.
\nReferences
\nGerdtham UG, J\u00f6nsson B. International comparisons of health expendi-1.
\nture: theory, data and econometric analysis. In: Culyer AJ, Newhouse JP,
\neditors. Handbook of Health Economics. Vol. 1. 2000. p. 11-53.
\nHercowitz Z, Strawczynski M. Cyclical ratcheting in government spend-2.
\ning: evidence from the OECD. The Review of Economics and Statistics.
\n2004; 86(1): 353-61.
\nBaltagi BH, Moscone F. Health care expenditure and income in the3.
\nOECD reconsidered: evidence from panel data. Economic Modelling.
\n2010; 27: 804-11.
\nReinhard Angelmar
\nProfessor of Marketing
\nThe Salmon and Rameau Fellow in Healthcare Management
\nFigure 7. GDP Growth, Public and Private Health Expenditure
\nGrowth in the US and Turkey
\nA. US
\n-4%
\n-2%
\n0%
\n2%
\n4%
\n6%
\n8%
\n10%
\n12%
\n1979
\n1980
\n1981
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\nAnnualGrowth
\nGrowthof realper capitaGDP Growthof realper capitapublic healthexpenditure
\nGrowthof realper capitaprivatehealthexpenditure
\nB. Turkey
\n-60%
\n-40%
\n-20%
\n0%
\n20%
\n40%
\n60%
\n1982
\n1983
\n1984
\n1985
\n1986
\n1987
\n1988
\n1989
\n1990
\n1991
\n1992
\n1993
\n1994
\n1995
\n1996
\n1997
\n1998
\n1999
\n2000
\n2001
\n2002
\n2003
\n2004
\n2005
\n2006
\n2007
\n2008
\n2009
\nAnnualGrowth
\nGrowth of real per capita GDP Growth of real per capita public health expenditure
\nGrowth of per capita private health expenditure
\nSource: OECD Health Data 2010
\n173
\nWMA news
\nGirts Brigis
\nBackground
\nLatvia is one of the so-called Baltic coun-
\ntries with a population of 2.3 million and
\na territory of about 64,600 sq. kilometers.
\nIt joined the European Union in 2004. Al-
\nready before that Latvia experienced steep
\neconomic growth and continued it within
\nthe EU.The maximum increase was reached
\nduring the period between 2005 and 2008.
\nAnalysts of economy at that time called
\nthis process an \u201coverheating of economy\u201d
\nand warned about possible problems in the
\nfuture. This period was characterized by an
\nannual increase in GDP by 11% (Figure 1),
\nwith the annual consumer price inflation up
\nto 17% and high and uncritical crediting by
\nbanks leading to a real estate bubble.Despite
\nthis growth, the state budget remained with
\na fiscal deficit.This was different in compar-
\nison with the neighboring country Estonia,
\nwhere the budget reserve was accumulated
\nduring the economic growth. It should be
\nmentioned that a very important economic
\nsector in Latvia was banking which was ac-
\ntive in providing international services.
\nAfter the breaking down of the Soviet Union
\nLatvia inherited the tax-based health care
\nsystem. Despite some political willingness to
\nturn to social insurance system, due to prag-
\nmatic financial (e.g., relatively low income
\nand essential proportion of \u201cgrey\u201d economy)
\nand demographic reasons (e.g., large propor-
\ntion of the elderly) Latvia found this system
\nfeasible and efficient up to the present mo-
\nment. However, Latvia experienced a period
\nwith a marked proportion out of payroll tax
\nfor health care in the late nineties.The reason
\nto abandon this approach was the low popu-
\nlation income and the necessity to subsidize
\nhealth system from other taxes by state. Also
\nin the mid nineties Latvia introduced pri-
\nmary health care system with family physi-
\ncians, did a partial privatization of services,
\nand started successfully to introduce health
\npromotion [1].
\nHowever, health care has never been con-
\nsidered as a priority by the Latvian parlia-
\nment (Saeima) and government. Public
\nexpenditure for health has never exceeded
\n4% of GDP, which is one of the lowest pro-
\nportions in Europe. Despite that, in gen-
\neral, there was a trend of increase in public
\nspending for health during the years of eco-
\nnomic growth (Figure 2).
\nAt the beginning of this century, the Lat-
\nvian government took a World Bank\u2019s loan
\nto design and implement health sector re-
\nforms. One very important plan concerned
\nthe structural reforms of Latvian health
\ncare,because,from the Soviet times,the sys-
\ntem was oriented to inpatient care with too
\nmany hospitals,hospital beds in comparison
\nwith the Western European countries, and
\ncorrespondingly with an inefficient finan-
\ncial spending. Unfortunately the starting of
\nthis plan was delayed and it was not started
\nduring the so-called good years of economic
\ngrowth.
\nEffect of the global financial crisis on
\nthe financing of Latvia\u2019s health system
\nWhen the global financial crisis started
\nin 2008, many Latvian people did not pay
\nmuch attention to the events taking place in
\nthe American and British banks. Therefore
\nit was quite a shock to the Latvian people to
\nsuddenly hear about the bankruptcy of one
\nof the biggest banks in Latvia \u2013 Parex Bank.
\nMost of the biggest banks in Latvia are
\nowned by foreign (Scandinavian, German)
\ncompanies. Parex Bank was exceptionally
\nowned by local investors. After some hesi-
\ntation the Latvian government decided to
\nsave this bank. Buy the way, today this hesi-
\ntation is considered as a mistake with quite
\nbig losses. About one billion Latvian Lats
\n(about 1.4 billion Euros) were taken from
\nstate budget for a deposit in that bank.Tak-
\ning into account that the GDP in 2008 was
\nabout 15 billion Lats (in absolute prices),
\nthis decision lead to an immediate fiscal
\ncrisis with a following economic crisis. The
\nLatvian government of that time decided
\nto apply to the international community,
\nin particular to the International Monetary
\nFund, World Bank and European Commu-
\nnity, for a loan.The loan was given on a very
\nstrict condition that the state budget deficit
\nwas reduced. The essential budget consoli-
\ndation immediately influenced all the pub-
\nlic sector. The number of employees in the
\npublic sector reduced, salaries decreased, in-
\nstitutions closed, and taxis increased.This in
\nturn led to a further slowdown of the econ-
\nomy of Latvia by aggravating the economic
\ncrisis with progressing unemployment and
\nother social consequences. During the year
\nafter the beginning of crisis GDP decreased
\nby 18% (Figure 1).
\nGlobal and local financial crisis \u2013 a challenge
\nto the national health system.
\nExample of Latvia
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\n174
\nWMA news
\nState health budget was cut seriously. Figure 3 shows that during
\nthe following 2 years public health spending reduced by 25 % [2].
\nThe same can be seen in Figure 2: per capita expenditure decreased
\nfrom 253.9 Lats (362.7 EUR) in 2008 to 192.4 Lats (274.9 EUR)
\nin 2010 (budget plan). Already in 2008 out-of-pocket spending was
\nquite high in Latvia \u2013 about 39% according to WHO calculations [3].
\nThere is no updated evidence about the current situation, but every-
\nday experience shows that the decrease in public expenditure has led
\nto a dramatic increase in out-of-pocket spending leading to serious
\nproblems of access to health care of Latvian population. The Health
\nMinister of Latvia resigned in 2009 just after the categorical request
\nof the President of Ministers to do the next cut of health budget not
\nbelieving in the possibility to run the system with such a cut budget.
\nAt the beginning of 2010 the Minister of Finance and the President
\nof Ministers recommended the Minister of Health to create an expert
\nworking group to make an investigation into the possibilities for a
\nchange in the health financing system in Latvia. The idea was to in-
\ntroduce a private health insurance system with an aim to attract addi-
\ntional financial resources for health care and reduce the responsibility
\nof the government sector. The health financing models in the USA,
\nNetherlands, Austria and Estonia were analyzed. Despite disagree-
\nments between the experts of health sector and financial sector (Bank
\nof Latvia) the final conclusion was to deny the idea as this involved
\nunavoidable increase in payroll tax and was unacceptable to employers
\n[4]. However, the discussion about health insurance is ongoing up to
\nthe present moment, and outcome will depend on the results of the
\nParliamentary Election (October 2010).There is a threat that the fi-
\nnancial and economic crisis in Latvia can lead to mistakes and unjus-
\ntified reforms with longstanding consequences for the health system.
\nFigure 1. GDP of Latvia (in comparative prices by 2000)
\nSource: Database of the Central Statistical Bureau of Latvia.
\nFigure 2.Expenditure from health budget per capita and as % from GDP
\nSource: Ministry of Health of Latvia, 2010 Figure 3. Health budget of
\nLatvia (mill. LVL)
\nFigure 3. Health budget of Latvia (mill. LVL)
\nSource: Ministry of Health; Report to the Saeima about the current situ-
\nation in 2010.
\nFigure 4. Number of hospitals in Latvia
\nSource: Ministry of Health; Report to the Saeima about the current situ-
\nation in 2010.
\n175
\nWMA news
\nEffects of expenditure cuts on the Latvian health care system
\nAt the beginning of this decade the World Bank prepared a master
\nplan for the structural reforms of the health system of Latvia. Reduc-
\ntion of hospital beds was intended. The financial crisis and budget
\ncuts forced the Ministry of Health of Latvia to start immediate re-
\nforms. A number of hospitals were closed or transformed into social
\ncare institutions in 2009. Figure 4 shows the decrease in the number
\nof hospitals. This resulted in the reduction in the proportion of the
\nhealth budget spent for hospital care from 61.4% in 2008 to 27.1%
\nin 2010. The relative spending for outpatient care in this situation
\nincreased from 21.5% in 2008 to 30.7% in 2010.Unfortunately,there
\nwas no increase for outpatient care in absolute numbers (Figure 5)
\n[2]. Also, it means that there was no other aim for reform but cuts.
\nThis created additional burden for primary health care and emergency
\ncare with no additional resources. Moreover, due to the financial di-
\nsaster hospitals actually stopped all planned care financed with public
\nmoney.This raised additional demand for the delayed emergency and
\nacute care. Hospitals did not refuse acute care and found themselves
\nin serious debts. The Government, as an exclusion, allocated 26 mil-
\nlion Lats to partially cover these debts in the current year. It is nec-
\nessary to conclude that structural and probably other health system
\nreforms carriet out during the crisis with the only aim of financial cuts
\nare leading to system failure and social stress.
\nProbably the public health system (disease prevention,health promo-
\ntion, technology assessment, health information) suffered and is still
\nsuffering most of all during the financial crisis in Latvia.Table 1 pro-
\nvides some selected comparative data on financial cuts. Public health
\ncuts during 2009 and 2010 reached 88.6%. Two leading institutions,
\nthe Agency of Public Health and the Agency of Health Statistics and
\nMedical Technology, were closed leaving some minor functions to
\nthe Health Economy Center, the Health Inspectorate, and the Cen-
\nter of Infectology. An additional reason for that was pressure from
\nmass media and business to reconsider the functions of government
\nsector including health care and public health institutions. Poor un-
\nderstanding of the functions of public health led to the destruction
\nof the system which was successfully built for the last 15 years. Also,
\npublic health represents a long-term vision for health with sustainable
\nachievements. Unfortunately, the financial crisis cancels any long-
\nterm initiative.
\nAt present there are some signs of financial stabilization in Latvia.Nev-
\nertheless it is difficult to expect improvements in the near future. Be-
\ncause of the too high fiscal deficit, the International Monetary Fund, a
\nprovider of the loan, requires further cuts in government spending.The
\nlargest proportions of state expenditure perfain to social security, health
\ncare and education. Also, the forthcoming election of the parliament
\n(Saeima) is providing a lot of populistic promises in the mass media and
\ndelays serious budget planning. The nearest future will reveal the abil-
\nity of the State of Latvia to fulfil the obligation under its Constitution:
\nArticle 111 \u201cThe State shall protect human health and guarantee a basic
\nlevel of medical assistance for everyone\u201d[5] .
\nReferences
\nTragakes, E. et al. Latvia: Health system review. Health Systems in Transi-1.
\ntion.Vol.10.2008: European Observatory on Health Systems and Policies,
\n251.
\nInformative report \u00abOn the situation in health care\u00bb submitted to the Cab-2.
\ninet of Ministers on June 14, 2010. 2010, Ministry of Health of Latvia,
\nRiga.
\nEuropean Health for All Database (HFA-DB). 2010, World Health Or-3.
\nganization Regional Office for Europe.
\nReport on feasibility to introduce health insurance system in Latvia. 2010,4.
\nMinistry of Health of Latvia, Riga.
\nConstitution of Latvia. Available from: http:\/\/www.saeima.lv\/LapasEng-5.
\nlish\/Constitution_Saturs.htm
\nGirts Brigis, professor of Public Health and
\nEpidemiology at Riga Stradins University
\nFigure 5. Health budget distribution (in Lats); 2009 and 2010
\nSource: Ministry of Health; Report to the Saeima about the current situ-
\nation in 2010.
\nTable 1. Budget cuts in the health care of Latvia (selected)
\nFunc\ufffdon
\nCuts in 2009
\nagainst 2008 (%)
\nCuts in 2010
\nagainst 2008(%)
\nTreatment -10,2 -40,4
\nPublic health -24,0 -88,6
\nCentral administra\ufffdon -28,4 -58,6
\nMedical and health
\neduca\ufffdon at universty -27,1 -41,7
\nAdministra\ufffdon of health
\ncare \ufb01nancing -19,3 -67,7
\nSource: Ministry of Health and State\u2019s Chancellery of the Cabinet of
\nMinisters.
\n176
\nWMA news
\nKonstanty Radziwill
\nMost of the European States have got con-
\nstitutional provisions stating that everyone
\nhas the right for health. In most of them
\npublic authorities must ensure equal access
\nto health care services financed from public
\nfunds to all citizens, regardless of their fi-
\nnancial situation and a special health care is
\nprovided to children, pregnant women, dis-
\nabled, chronicly ill and elderly persons.
\nMany European States specify conditions
\nand scope of healthcare benefits in high-
\nlevel rulings. There is a long list of areas of
\nhealth care to be covered: disease prevention
\nand early detection of diseases (including
\nvaccinations), primary health care, outpa-
\ntient specialist services, medical rehabilita-
\ntion,dental care,hospital care,psychological
\ncare, long-term nursing and care (including
\npalliative and hospice care), spa treatment,
\nsupply of medicinal products, and devices ,
\ntransport , medical emergency services, etc.
\nOf course, the governments or parliaments
\nmake decisions on the level of public spend-
\ning on healthcare. However, in many Euro-
\npean States decisions on public expenditures
\non healthcare and the basket of healthcare
\nservices guaranteed to citizens are made
\nindependently. There is very little counting
\nhow much the medical services guaranteed
\ncost. Public spendings most often are col-
\nlected from citizens\u2019 contributions based
\non their income, but they differ very much.
\nPublic health spendings reached in Europe
\nan average level of 8.4% of GDP (ranging
\nfrom less than 3% in Cyprus to over 10%
\nin Sweden). It accounts for between 10 and
\n15% of total primary government spending
\nin most EU countries, although it is rang-
\ning from 6.0% in Cyprus to 18% in Norway.
\nOf course, taking into account differences
\nin the GDP level, in real figures they differ
\nmuch, much more.
\nThe share of healthcare spendings in all
\npublic expenditures in Europe has been
\ngrowing, suggesting that in majority of the
\nEuropean States health care budgets fared
\nbetter than other expenditure items during
\nperiods of \u201efiscal consolidation\u201d. Of course,
\nin some countries it has not.
\nPlanning how much should be spent on
\nhealth care the real dilemma is to be faced:
\nhow much responsibility for citizens\u2019 health
\nbelongs to the state and to which extent
\nindividuals should feel it is their own busi-
\nness?
\nThe basic basket of medical services guar-
\nanteed to all the citizens of particular coun-
\ntry may consist of medical rescue services,
\nprenatal care and newborn care, child care
\n(including assessment of health and devel-
\nopment and mandatory vaccinations), care
\nof women during pregnancy, childbirth, the
\npuerperium and of breast-feeding mothers,
\nlong-term nursing and care (including pal-
\nliative and hospice care), hospital care and
\noutpatient specialist services for chronically
\nill patients. If there are enough resources,
\nthe list can be prolonged with disease pre-
\nvention and early detection of diseases (in-
\ncluding adults\u2019vaccinations),primary health
\ncare, medical rehabilitation, dental care,
\npsychological care, spa treatment, supply of
\nmedicinal products and devices and medical
\ntransport.
\nIt seems that what is proved to be preven-
\ntive, urgent, necessary but expensive or
\nneeded by the weakest and most vulnerable
\npatients should be considered as basic.
\nPreventive measures, often very simple and
\nrelatively cheap, enable to save much in the
\nfuture. This is why health promotion and
\ninformation, preventive provisions (anti-
\ntobacco, anti-alcohol, anti-drugs, dietary,
\nsanitary, etc.) and necessary vaccinations
\n(also for adults) should be in the center of
\npublic interest.
\nUrgent measures, such as medical rescue
\nservices and emergent outpatient and hos-
\npital care must be given to all in need with-
\nout any difficulties. It should be given also
\nwith no limits to refugees, homeless unem-
\nployed, etc.
\nNecessary (from the evidence based medical
\npoint of view) but expensive hospital care
\nand one-day inpatient diagnostic\/therapeu-
\ntic procedures should be also in the basket.
\nProcedures needed by the weakest and
\nmost vulnerable patients, such as prenatal
\ncare and newborn care, child care, care of
\nwomen during pregnancy, childbirth, the
\npuerperium and of breast-feeding mothers
\nand long-term nursing and care (particu-
\nlarly palliative and hospice care) should be
\nalso guaranteed.
\nSummarizing, the division of the responsi-
\nbilities between the state and citizens should
\nWhat are the Minimal Services to be
\nProvided by the Healthcare System?
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\n177
\nWMA news
\nbe designed.The state must feel responsible
\nfor the health promotion, urgent, necessary
\nand expensive medical services and medi-
\ncal care over the weakest and most vulner-
\nable citizens. The individual citizens should
\ntake care of health prevention matters and
\nall preventable and cheap procedures. In the
\ntime of an aging population, rapid develop-
\nment of medical sciences and public money
\nconstrictions it is simply to be faced: \u201csub-
\nsidiarity of the state and not replacing all
\npeople\u2019s thinking is the must.\u201d
\nKonstanty Radziwill, MD, President,
\nStanding Committee of European Doctors
\nHaino Burmester
\nFrom a theoretical point of view it might seem
\nsimple to structure and manage health care
\nsystems in a way that makes them less vul-
\nnerable to crises and, therefore, able to play a
\nstabilizing role in economy.Since the variables
\ninvolved in managing such health systems can
\ngenerally be ascertained or predicted by demo-
\ngraphic an epidemiological studies, it should
\nbe possible to factor them into a mathemati-
\ncal model to create a program that works. Of
\ncourse,this is not so! In practice things are far
\nmore complicated and unpredictable then ex-
\npected.So,let us explore the difficulties.
\nThe problem with most health systems is
\nnot only lack of proper funding but it is also
\nthe amount of waste it is produced within
\nthem. Problems in these systems (mostly
\nin developing countries) are therefore both
\nfunding and management. Let\u2019s be pro-
\nvocative. Either we agree with the following
\nassertion of Prof. Rosenthal or we do not:
\n\u201cHealth care is the economy and fixing it
\nwould free up money for other priorities,
\nsuch as education and industrial innova-
\ntion.The health care system is dysfunctional
\nand full of waste \u2014 as much as 30% of all
\nspending. Unlike most other markets, con-
\nsumers rarely know which doctors, drugs
\nor treatments are best for them, don\u2019t price
\nshop and, if they\u2019re insured, don\u2019t know the
\nfull cost of care. And that all can lead to un-
\nnecessary spending\u201d. (Meredith Rosenthal,
\na Harvard University professor of health
\neconomics and policy).
\nIt is also important to consider health prob-
\nlems beyond local, regional or national con-
\ntexts only. As a report from the UN states:
\n\u201cthe paradigm of self-sufficiency has re-
\ncently been challenged.As part of the global
\nresponse to the HIV\/AIDS epidemic, the
\naim of national self-sufficiency was thrown
\noverboard by some activists. Wealthy na-
\ntions were pressured into contributing
\ntheir fair share by AIDS activists who ad-
\nopted human rights arguments to push for
\nexpanded access to AIDS treatment, for
\nwhich the cost at the time greatly exceeded
\nthe present and future financial capacity of
\nsome of the most seriously affected coun-
\ntries. This new development aid approach
\nis based on the idea of building sustained
\ntransnational redistributive fiscal transfers
\nand creating new within-country protective
\nmechanisms in poor nations.It appears to be
\ngaining ground. In April 2009, the Govern-
\nment of Ethiopia signed a Joint Financial
\nAgreement with the World Bank, the U.K.
\nDepartment for International Develop-
\nment, Ireland\u2019s Irish Aid, and other donor
\nand U.N. agencies, which stated that Ethio-
\npia needs an additional US$1.4 billion per
\nyear, as a starting redistribution of capital,
\nto achieve the health-related Millennium
\nDevelopment Goals. While this agreement
\nconstitutes merely an acknowledgment of a
\nfunding gap and a fundamental inequality
\nin resources, the fact that Ethiopia\u2019s pres-
\nent government health budget (including
\npresent \u201con budget\u201d development assis-
\ntance) stands at about US$400 million per
\nyear indicates that an ambitious target has
\nbeen agreed to,one that can only be reached
\nthrough sustained transnational redistribu-
\ntive fiscal transfers a form of global social
\nhealth protection\u201d.
\nIn light of this global concern,there are some
\npolicy questions that have to be answered to
\nsufficiently address the issue. These ques-
\ntions are related to the basic difficulties each
\nand every system must confront in order to
\nsolve its problems: How are resources mo-
\nbilized and managed? Who pays for what
\nand how? Who provides goods\/services and
\nwhat resources do they use? How are health
\ncare funds distributed across different ser-
\nvices \/ interventions \/ activities produced
\nby the health system? Who benefits from
\nhealth care expenditure? In other words:
\nHow can Health Care Systems be structured
\nand managed to be less sensitive to crisis and
\nplay a stabilizing role in economy?
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\n178
\nWMA news
\nhow the system is planned and how it is
\nmanaged?
\nWhat are the challenges health care systems
\nmust address under the stress of an econom-
\nic crisis? At the fundamental level, it must
\ncontribute to restoring confidence among
\nsociety as a whole by restoring\/maintain-
\ning the workers\u2019 health as well as the health
\nof families and communities. In doing so,
\nit will ultimately be contributing to restora-
\ntion of the economic health of businesses,
\nwhich is a vital factor in returning the over-
\nall economy to normal.
\nLow income countries suffer when there is
\nreduced demand for their exports,which re-
\nduces access to capital. Foreign investments
\ndecline as do remittances from people living
\nabroad. Unemployment comes and these
\ncountries usually have no adequate safety
\nnet to compensate for those in need. Pub-
\nlic sector services become the more favored
\nsource of health care at the very time when
\ngovernment revenues to finance these ser-
\nvices are under the greatest pressure.
\nHigh income countries also have their share of
\nhealth care problems.For example,the United
\nStates has an incredible amount of resources
\nan unthinkable amount for most countries.
\nAmericans spend more on health care than
\nthe entire Brazilian GDP, including expendi-
\nturesforhealthcareprovidersalaries,hospitals,
\noutpatient centers, Veterans Affairs and other
\nclinics, doctor and dentist practices, physical
\ntherapists, nursing homes, home health ser-
\nvices and on-site care at places such as schools
\nand work sites. It also includes retail sales of
\nprescription and nonprescription drugs, pre-
\nmiums paid to health insurers and producers
\nof medical devices, surgical equipment and
\ndurable medical equipment such as eyeglasses,
\nhearing aids and wheelchairs. It also accounts
\nfor out-of-pocket payments by consumers
\nfor health insurance premiums, deductibles
\nand co-payments. But, we will see that even
\nwith such massive amounts of money spent
\non health care, Americans also have problems
\nthat,as we all know,are not due to any specific
\nfinancial crisis. Health insurance premiums
\nhave skyrocketed, making it ever-tougher for
\nworkers and employers to afford them. From
\n1999 through 2008, annual health insurance
\npremiums jumped 119%. The average family
\npremium paid by workers rose from $1,543 to
\n$3,354 per year, and employer payments per
\nworker jumped from $4,247 to $9,325. Dur-
\ning that span, worker earnings rose only 34%
\nand overall inflation was just 29%. So worker
\nincome has barely kept pace with inflation,
\nmore of the paycheck is going to health costs,
\nand there is less income left over for things
\nlike vacations, home improvements or a new
\ncar \u2014 especially for low-wage workers and re-
\ntirees.This lack of disposable income for such
\nitems represents a huge drag on the economic
\ngrowth, considering that consumer spending
\npowers about 70% of the American economy.
\nFor employers, particularly small businesses,
\nrising insurance premiums mean far less
\nmoney for new equipment, better facilities,
\nresearch or expansion.That means fewer new
\njobs,plus smaller raises and higher health pre-
\nmiums for workers,further limiting consumer
\nspending.
\nHigh income countries take measures, in-
\ncluding complex and politically challeng-
\ning reform, in anticipation of increases in
\nspending on health and pensions. But there
\nis also evidence that plans to set aside re-
\nsources and create the fiscal space to address
\nthe future health needs of the elderly are
\nshelved as the crisis deepens.
\nIt is critical for countries to protect life
\nand livelihood and to boost productivity by
\nmaintaining levels of health and other so-
\ncial expenditures. If countries do not have
\nadequate reserves and revenues decline, the
\nshortfall will have to come from aid. And
\nthis aid will need to be skillfully managed
\nfor maximum impact. The critical point is
\nthat commitments to maintain levels of aid
\nare not an extra element in the recovery
\nagenda, but integral to its success.
\nUnder the circumstances of an economic cri-
\nsis, what can health systems do to help the
\neconomy as a whole? First and foremost it is
\nimportant to gather quality, real-time infor-
\nmation to guide the response; there is no way
\nto act properly without solid data that allows
\ndecision-makers, for example, to be able to
\nidentify groups most at risk; to ensure that
\nsafety net programs are well targeted so they
\nreach the most needy; to seek efficiencies in
\nspending where possible; to know where and
\nwhen external aid is required to ensure that it
\neffectively used.It is crucial to sustain spend-
\ning on prevention (which is often the first ca-
\nsualty of spending cuts). And it is important
\nto recognize that crisis often offer opportu-
\nnities for reform; some of the best managed
\nhealth systems in the world verify the poten-
\ntial to improve under critical circumstances.
\nThe former Canadian Minister of Health,
\nMarc Lalonde said in 1974 that the four
\ncornerstones of any health care system are:
\nhuman biology; the environment; lifestyle;
\nand health care organization. This theory is
\nas true today as it was in 1974. So, health
\ncare organization demands a management
\nmodel that should be as effective in times of
\ncrisis as in normal times.
\nLet us examine how the Brazilian health
\nsystem is structured and managed to be less
\nvulnerable to crisis and play a stabilizing
\nrole in economy, not because it is neces-
\nsarily a model to be followed but because
\nit has survived the economic crisis without
\nmajor decreases in supply of health services.
\nIn other words the system didn\u2019t change its
\nnormal level of effectiveness. It should be
\nnoted that the system\u2019s effectiveness may
\nstill have a long way to go in order to achieve
\nexcellence. But the system has a long his-
\ntory of trial and errors that brought it to its
\npresent stage: far from maturity but with a
\nwell-developed management model that is
\nconstantly being improved little by little.
\nThe principles of the Unified National
\nHealth System (SUS) are the ideological ref-
\nerences on which the system is based. They
\nderive from the Constitution that states
\nhealth care as a right of the people and a duty
\n179
\nWMA news
\nof the State to provide. At this moment, the
\nconcept is being questioned as far as the re-
\nsponsibility of the individuals themselves for
\ntheir own health. Universality means that
\nevery citizen has right to be cared for within
\nthe system, but at this point we should also
\nintroduce the duty of persons to care for their
\nown health with respect to other citizens.
\nIntegral is related to the types of services
\nprovides. The equity aspect is concerned
\nwith fairness, equal rights, or equality (same
\nopportunity to all). Another important prin-
\nciple is the socialcontrol over the system put
\ninto practice by participation of the people
\nin the Health Councils. Administrative and
\npolitical decentralization is a cornerstone
\nof the system. The hierarchy principle di-
\nrects access to the services and must be done
\naccording to the region where the person
\nresides and the acuteness of his or her con-
\ndition. Other principles that should be men-
\ntioned are: preservation of the autonomy of
\npatients facing diagnostic and therapeutic
\nprocedures; total access to information con-
\ncerning care delivered; total knowledge of
\nthe types of services provided by each facil-
\nity; use of epidemiological data to determine
\npriorities; integration of health care delivery
\nwith basic sanitation and environmental con-
\ncerns; coordinated use of federal, state and
\nmunicipal resources to avoid duplication of
\npublic services provided at the same location
\nand for the same purpose; and resolution of
\nproblems at the most appropriated level.
\nThe basic structure of the health care orga-
\nnization in Brazil is based on its division of
\nresponsibilities and attributions among the
\nthree layers of power: federal, state and mu-
\nnicipal.When these three sources of financ-
\ning act properly the system has a chance
\nto be successful. The three different levels
\nof financing according to the total budget
\nof each of these sectors of government are,
\nat a minimum: Federal Government 5%;
\nStates 12%; and Municipal Governments
\n15%. Municipalities are responsible for
\nemergencies and primary care; the states are
\nresponsible for secondary and tertiary care;
\nand the federal government is responsible
\nfor general policy making and strategic de-
\ncisions plus the federal university hospitals
\nand medical schools.
\nSUS provides primary, secondary and ter-
\ntiary care delivered under contract or at
\nits own facilities; control and supervision
\nof procedures, products and substances of
\ninterest to health and promoting the pro-
\nduction of medicines, equipment, immu-
\nnobiological products, blood products and
\nother inputs; performing actions of sanitary
\nand epidemiologic surveillance and workers\u2019
\nhealth; training and development of human
\nresources; policy formulation and imple-
\nmentation of basic sanitation; scientific
\nand technological development; oversight
\nand control of foodstuffs, including con-
\ntrol of their nutritional content and water
\nfor human consumption; participation in
\nthe supervision and control of production,
\ntransportation, storage and use of psychoac-
\ntive substances and products, toxic and ra-
\ndioactive products; collaboration in protect-
\ning the environment, including that of labor
\nconditions and workers\u2019 health.
\nIn conclusion, we must recognize that
\nhealth care is one of the pivotal factors that
\ncountries can use to overcome an economic
\ncrisis. In spite of all the problems we have
\nseen so far, the health care industry is still
\none of the engines of the economy and it
\nhelps countries to face the challenges of
\neconomic crisis creating jobs and maintain-
\ning consumption of goods and services. Of
\ncourse, there are always a need for improve-
\nment, such as eliminating waste, improving
\nefficiency and increasing preventive care.
\nIt is unlikely that health care provider jobs
\nwill decline during economic crisis, since
\ndemand and supply of health care services
\nare, or should be, basically inelastic.
\nHaino Burmester (reghaino.ops @ terra.com.
\nbr), is Phisicyan and Business Administrator,
\nwith a Masters Degree in Community
\nMedicine from the University of London;
\nProfessor of Hospital Administration at the
\nS\u00e3o Paulo School of Business Administration
\n(Fundac\u00e3o Getulio Vargas,Brazil), Chief of
\nStaff of the Superintendence of the University
\nHospital, S\u00e3o Paulo Medical School;
\nCoordinator of the Program Commitment to
\nHealth Quality (CQH) maintained by the
\nS\u00e3o Paulo Regional Council of Medicine and
\nthe Paulista Medical Association; Advisor to
\nthe World Health Organization; President
\nof the S\u00e3o Paulo Association for Preventive
\nMedicine and Health Administration.
\nImpact of Economic Growth and Financial
\nCrisis on Estonia\u2019s Health Care
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\nThis is a case study from Estonia \u2013 a
\ncountry where the health system en-
\njoyed annual budget increase of 20% dur-
\ning 2004 \u20132008 \u2013 and which now has to
\nmaintain and to improve performance
\nin the reality of economic recession. In
\nthis short paper some selective examples
\nwill be provided on the availability of re-
\nsources and use of services over the last
\ncouple of years as well as lessons learned
\nand challenges ahead.
\nDuring the years of economic growth,
\nthe Estonian Health Insurance Fund col-
\nlected financial reserves that can keep the
\nhealth system public expenditure during
\n2010\u20132011 at the level of 2007. However,
\nthe reserves will be exhausted in 2012 and if
\nnew taxes are not introduced to cover pub-
\nlic health care costs, the current health sys-
\n180
\nWMA news
\ntem shall face drastic cuts that will decrease
\navailability and access to services and care.
\nMoreover, currently there is no political will
\nand leadership to rearrange the financing
\nand governance of health system and ser-
\nvices into one based on rational use of re-
\nsources for the decade of no-growth.
\nProsperous years before the economic cri-
\nsis have allowed to invest heavily into new
\ntechnologies for both diagnosis and treat-
\nment, and to double the salaries of doctors
\nand nurses during 2005\u20132008 without in-
\ncrease in the volume of services.
\nUntil now (2010) the number of health
\nservices provided to the population have
\ndecreased by 2\u20134% in both out-patient and
\nhospital care, as compared to 2008, when
\nthe provision of services had reached its
\never highest level in Estonia. By 2008, the
\nmajor achievements can be summarised as
\nfollowing:
\n– patient satisfaction with availability and
\nquality of care was very high;
\n– emigration of doctors and nurses had
\nstopped;
\n– availability of high-tech diagnostic
\nequipment and rate of use had reached
\nEuropean top level;
\n– use of prescription medicines had dou-
\nbled in 8 years;
\n– availability and use of resource-inten-
\nsive services (hip replacement, invasive
\ncardiology) had doubled in recent years;
\n– a number of modern and expensive
\ntreatments in nephrology, oncology
\nand rheumatology were included to the
\npublic insurance basket of services.
\nDuring 2009 the economic crisis in Esto-
\nnia increased unemployment fourfold and it
\nreached 20% at highest. This has put pub-
\nlic sector finances under very serious con-
\nstraints and the governmental spending in
\n2010 has dropped to the level of 2006. As
\nthe need for social support has increased
\nseveralfold, the prospects of health care to
\nregain its financial basis are not good at all.
\nLessons learned:
\n– During recent years the economic growth
\nin Estonia allowed to introduce new tech-
\nnologies and to increase prices, which has
\npushed the medical profession to become a
\nservice provider for the medical and phar-
\nmaceutical industries.
\n– Economic growth and availability of
\nnew financial resources were not managed
\nand governed to increase the availability of
\nhuman resources and services in the most
\nunderdeveloped health sector in Estonia \u2013
\nnursing and rehabilitation \u2013 that lag behind
\nthe needs of the ageing population.
\nMorale for the medical profession
\nNow, when the politicians are not willing or
\nable to adapt the health system according to
\nthe economic reality,it is the opportunity for
\nthe medical profession to use its knowledge,
\nskills and prestige and to take the wheel for
\nthe benefit of patients and society.
\nRaul Kiivet, Professor of Health Care
\nManagement, Department of Public
\nHealth, University of Tartu, Estonia
\nTable 2. Change in selected economic indicators in Estonia (% as compared to previous year)
\n2007 2008 2009 2010 2011
\nChange in GDP 14.5% \u20133.6% \u201314.8% \u20132.8% 1.5%
\nUnemployment rate 4.9% 5.5% 14.4% 16.8% 16.6%
\nSocial tax 25.4% 14.8% \u201310.3% \u20134.0% ??
\nHealth Insurance Fund
\nspending
\n27.5% 20.5% \u20132.2% \u20134.7% ??
\nDoctors\u2019 salaries 22% 39% \u20136% ?? ??
\nTable 1. Increase in the volume of diagnostic
\ntests and procedures
\n2001 2004 2008
\nLab tests &
\nanalysis (106
\n)
\n9.5
\n(100%)
\n10.8
\n(115%)
\n15.1
\n(159%)
\nincl biochemi-
\nstry (106
\n)
\n3.8
\n(100%)
\n5.1
\n(134%)
\n8.6
\n(226%)
\nUltrasound
\ndiagnostics
\n429
\n000
\n(100%)
\n474
\n000
\n(110%)
\n654
\n000
\n(152%)
\nEndoscopic
\nprocedures
\n83 000
\n(100%)
\n79 000
\n(95%)
\n91 000
\n(109%)
\nCT and MRI
\ninvestigations
\n45 000
\n(100%)
\n96 000
\n(213%)
\n236 000
\n(536%)
\nRaul Kiivet
\n181
\nWMA news
\nMichael S. Chen
\nTaiwan\u2019s national health insurance (NHI)
\nprogram has won its share of international
\nattention for its accomplishments in terms
\nof universal coverage, comprehensive bene-
\nfit, efficient administration, up-to-par qual-
\nity of care, and affordability. In line of the
\ntheme of the 2010 Conference of the World
\nMedical Association, I shall begin this ar-
\nticle by giving an introduction of Taiwan\u2019s
\nNHI, followed by the major challenges that
\nthe NHI faces, and then, based on Taiwan\u2019s
\nexperience, summarize the institutional fac-
\ntors that would be inductive to the capacity
\nfor the program to neutralize, to certain ex-
\ntent, the impact of economic fluctuations in
\ngeneral, or financial crises in particular.
\nIf any lessons can be learned from Taiwan\u2019s
\nNHI, that would be: one must begin with
\nthe \u201cright\u201d structure when considering a
\nhealthcare system. The \u201cright\u201d structure will
\ngive the program the capacity to hold up
\nagainst the economic crisis. As summarized
\nby this article, three most prominent factors
\nfor the stability of the program are: a social
\ninsurance program based on premiums, a
\nsingle-payer program, and the built-in bal-
\nancing mechanism under a global budget-
\ning scheme.
\nHow did Taiwan\u2019s NHI come
\ninto what it is now?
\nTaiwan\u2019s NHI was implemented in 1995 by
\ntaking in the health components from the
\nthen existing social insurance programs and
\nextending the coverage to all others, nation-
\nals as well as expatriates who stay in Tai-
\nwan with valid residence permits. And out
\nof historical legacy, ideological split did not
\nstand in the way; instead, the political lead-
\nership, incumbent and the opposition, was
\ncommitted to providing universal health
\ncoverage and a health program as massive
\nas NHI was able to come into being.
\nInitially, the medical profession posed a
\nhostile gesture out of fear, uncertainty, and
\ndoubt, but soon realized that a health pro-
\ngram like this meant a wider clientele and
\nwould bring in a stable and ample income
\nstream.The medical profession then became
\ncooperative partners with the NHI, and in
\nthe process of working together closely,now
\nhas become an integral part of the NHI es-
\ntablishment.
\nInsurance industry, which bedeviled the US
\nhealthcare reform for many times over the
\npast decades, did not quite constitute a re-
\nsistance, because they were happy with the
\nlucrative business in life insurance and were
\nnot quite interested in extending their busi-
\nness to health insurance for the troublesome
\nadministrative loading. Surprises to many,
\nthe turf for commercial health insurance
\nhas expanded, rather than shrunk after the
\nNHI, possibly because people started to ap-
\npreciate the value of insurance and desired
\nto seek better protection against hazards of
\nall kinds.
\nCompetent authorities together took many
\nextra miles to put the program on its feet.As
\ntime passes, even without anyone\u2019s knowing
\nit, the program gradually got what it de-
\nserves: the satisfaction rates started to pick
\nup, and have been around 70% for quite
\nsome time up to present, ranking among
\nthe highest in the world. Delegations from
\nall around the world coming to Taiwan to
\nstudy the NHI, and more than one third of
\nthem are from the US, especially the staffs
\nfrom the Capitol Hill. Taiwan has offered
\ntraining courses to high-ranking health ad-
\nministrators from countries as important
\nas the Kingdom of Saudi Arabia, Thailand,
\nMongolia, the Philippines, Korea, Indone-
\nsia, etc.The Public Broadcast System has, in
\n\u201cFrontline \u2013 Sick Around the World\u201d, cho-
\nsen along with other four countries as the
\nmodels that the US can emulate. Taiwan\u2019s
\nNHI has won its reputation.
\nWhat are the main features
\nof Taiwan\u2019s NHI?
\nThe NHI is a compulsory program, which
\nrequires mandatory and universal enroll-
\nment, covering all nationals as well as expa-
\ntriates with valid residence permits on equal
\nterms. It is a single-payer program run by
\na governmental agency \u2013 Bureau of NHI.
\nAbility-to-pay is the fundamental financ-
\ning principle, with payroll-based premiums
\n(currently 5.17%) shared by the employee,
\nthe employer, and the government. NHI
\noffers comprehensive and uniform benefit
\npackage for all. The policy of contracting
\nThe Institutional Factors that help Health
\nCare System to hold up against Financial
\nCrisis
\nLessons based on Taiwan\u2019s experience
\nPresentation at the WMA conference on \u201cFinancial crisis and its implications for health
\ncare\u201d, Riga, September 10-11th
\n2010
\n182
\nWMA news
\nwith the medical facilities is on the basis of
\nall-willing-providers, and more than 90% of
\nthe providers are contracted with the pro-
\ngram. The payment system for the program
\nis run on a plural reimbursement schemes
\n(fee for service, case payment, pay for per-
\nformance, etc) under an overarching global
\nbudget.
\nWhat are the major accomplishments
\nin Taiwan\u2019s NHI?
\nThe best way to characterize Taiwan\u2019s NHI
\nis that the NHI is a program that defies
\nthe \u201cconventional wisdom\u201d. In the standard
\ntextbook of health economics,it is suggested
\nthat you can choose some of the virtues for
\nyour program; yet,you cannot expect to have
\nall the virtues in one program. These values
\nas indicated in the textbook are: universality,
\ncomprehensiveness, freedom of choice, and
\ncost containment. Taiwan\u2019s NHI, though
\nhas problems of its own, embodies all those
\nvirtues in one, and more.
\nUniversality
\nThough Taiwan\u2019s NHI is a compulsory pro-
\ngram,universality is not an action of the law.
\nInstead, it is the human action that brought
\nuniversality to the program, the human ac-
\ntion inspired by the belief that \u201cI am my
\nbrother\u2019s keeper.\u201d Soon after its implemen-
\ntation, the NHI has extended its coverage
\nfrom 59% to virtually all the population in
\nTaiwan. For those who could not pay the
\npremium, the NHI provides a pretty elabo-
\nrate safety net to make sure that everyone is
\nprotected:
\nthe premium is 100% subsidized for the\u2022
\nhouseholds below the poverty line;
\nif you are unable to pay the premium for\u2022
\nrunning into one of the vicissitudes in
\nyour life, interest-free loans are available
\nor you can apply to pay on installments;
\nor, Bureau of NHI can refer you to many\u2022
\nof the charitable organizations for help;
\nin the case when all these fail to work for\u2022
\nyou, you can simply take yourself to the
\nhospital should an emergency occur and
\nleave the financial problem to be taken
\ncare of between the hospital and the
\nBNHI;
\nwith this safety net in place, no single in-\u2022
\ndividual on this land can ever be denied
\nhealth care for lack of means or anything;
\nthere must be a way to get the help.
\nWith NHI, bankruptcies out of medical
\nbills have become unheard of since; we don\u2019t
\noften use the expression \u201chealth care as a
\nhuman right\u201d, yet universality testifies to
\nthat our program is an incarnation of the
\nvery ideal.
\nComprehensive and Uniform
\nBenefit Package
\nThe benefit package provided by the NHI is
\ncomprehensive; all medically necessary ser-
\nvices are covered. The package covers inpa-
\ntient, outpatient, dental services, traditional
\nChinese medicine, and maintains a very
\nlong list of nearly 20,000 items of prescrip-
\ntion drugs. Before the implementation of a
\nlong-term care insurance, the program also
\npays for home care, rehabilitative care, day
\ncare, and hospice care, provided that certain
\ncriteria are met.
\nSome of the target therapy drugs are cov-
\nered; many of the expensive drugs for rare
\ndiseases are covered too. To provide more
\noptions for the insured, some of the high-
\npriced devices such as drug-eluting stents,
\nintraocular lenses with special functions, are
\ncovered with extra billings.
\nThe benefit package is rather \u201cgenerous\u201d
\nwhen you compare with, say, that of Medi-
\ncare in the US. US Medicare requires the
\nbeneficiary to pay for the first day of hos-
\npitalization as deductible that could be as
\nmuch as $5,000 or even more, while our
\nprogram picks up the tab right from the
\nfirst dollar without any deductibles. For
\nnew treatments or drugs, there is a prompt
\nprocedure to get those items on the reim-
\nbursement list, provided that they are cost
\neffective.
\nThe co-payments are very little, even sym-
\nbolic in some cases.There is a 10% co-insur-
\nance for acute hospitalization,but the maxi-
\nmum amount of that co-payment is capped
\nby 10% of per-capita income. The benefits
\nare provided without any discrimination
\nwhatsoever. For instance, anyone who needs
\nand demands a renal dialysis will get one,
\nwithout discretions on age or anything,
\neven discretionary measures are prevalent in
\nmany countries.More importantly from the
\nstandpoint of equity, the benefit package is
\nuniform for all: the President of the nation
\nand the people in the street are entitled to
\nexactly the same package of benefits.
\nFreedom of Choice and Accessibility
\nTaiwan\u2019s NHI is a single-payer program
\nand therefore it offers no choice of the car-
\nrier; it,however,offers unlimited freedom of
\nchoice when it comes to the choice of the
\nproviders: you can choose your doctors and
\nhospitals from more than 18,000 contract-
\ned facilities. Everyone is issued an NHI IC
\ncard, with which you can just walk into any
\nof the facilities, oftentimes even without a
\nreservation.
\nThere is no waiting line, or at least not any-
\nthing like those in some other countries
\nwhere you might have to wait for months or
\neven years for selective surgeries. You may
\nsee people lying in the hallway around the
\nemergency room in some of the medical
\ncenters.But that is because the medical cen-
\nter won\u2019t turn patients away to the commu-
\nnity hospital where there are many vacant
\nbeds. And over 99% of those patients will
\nbe admitted to the ICU or a regular ward
\nwithin 48 hours.
\nSince a referral system virtually does not
\nexist, you can see a doctor or be admitted
\ninto a hospital any time if you are not too
\nparticular in choosing the facility. Normally,
\nit would take just about a couple of weeks to
\nget a major surgery at the location of your
\nchoice. For the people living in the moun-
\ntainous areas and off-shore islands,the NHI
\npays extra dollars for the integrated delivery
\nsystem (IDS) to deliver primary care and
\nsome of the specialty care.The co-payments
\nare waived in those areas. Care reaches ev-
\nery corner. Care is even provided in the off-
\n183
\nWMA news
\nbeaten recreational areas just to assure that
\nyou have a care-free weekend.
\nCost Containment and Affordability
\nHealth care inTaiwan is quite affordable:to-
\ntal healthcare expenditure accounts only for
\nabout 6.2% of GDP, lower than most of the
\nOECD countries, and slightly more than
\nhalf of it were spent on the NHI. A family
\nof four pays roughly US$100 per month as
\nthe premium, which is about one tenth that
\nof the US families, accounting for about 2%
\nof the averaged household income.
\nIt is more efficient to run the daily opera-
\ntions of a single-payer program than any
\nothers; and a single-payer system with the
\naid of information technology can even
\nbe more efficient. Billions of transactions
\nin claims and reimbursements are handled
\nelectronically. As results, the administrative
\ncosts for NHI have been controlled below
\n2% of the medical expenses.
\nQuality of Care
\nChanges in life expectancy (currently 82
\nyears for women, 76 years for men) testified
\nto the quality of care in Taiwan. According
\nto a newly released study,the life expectancy
\nfor the ten-year period after the NHI grew
\ntwice as fast as that of the ten-year period
\nbefore the NHI. Health disparities among
\nsocio-economic groups and geographic ar-
\neas had somehow narrowed, though not as
\nsignificant as one would like to see.
\nAnother piece of information on the quality
\nof care is the performance of organ trans-
\nplants: although Taiwan has a long way to
\ngo in the transplantation of the lung, the
\nrecords of the kidney, heart, and liver trans-
\nplantations are as good as that of the US.
\nWhat are the leading challenges
\nfaced by the NHI?
\nFinancial Shortfalls
\nThere are several factors contributing to
\nthe financial shortfalls. First is the inher-
\nent nature in the structure of the financ-
\ning scheme. The premium is based on the
\npayroll, and the increase rates in the pay-
\nroll always fall short of the increase in the
\nGDP, and the increase rates in GDP always
\nfall short of the increase rates in healthcare
\nexpenditures. As a result, there is always a
\ngap between the growth rates of the revenue
\nand the expense. Another factor is the aging
\npopulation. The aging factor alone explains
\na significant fraction of the increase rate
\nin the medical expenditure, and the global
\nbudget is ratcheted up every year as the ag-
\ning factor is a \u201cnon-negotiable\u201d component
\nto determine the global budget.
\nWhat makes the financial situation worse
\nis the political intervention. As stipulated
\nby the NHI Act, the premium rate must be
\nraised whenever the reserve fund is lower
\nthan one-month expenditure. In reality, out
\nof political reasons, premium raise is only
\nnext to impossible.
\nHaving said all this, the financial shortfall,
\nas much as tens of billions of NT dollars, is
\nnot a problem that would cut into the eco-
\nnomic competitiveness on the world mar-
\nket, as would the healthcare cost of the US,
\nbecause Taiwan can still afford to spend a
\nlittle more on health care.The deficit is basi-
\ncally a \u201cwhy-me\u201dproblem and can be settled
\nwith patient consensus-building process.
\nAnd the following are a couple of strategies
\nto keep the financial house in order:
\nStrategies to make both ends meet
\nPremium based on individual\u2019s total in-
\ncome
\nAn amendment to the NHI Act has been\u2022
\nproposed to put the premium on the in-
\ndividual\u2019s total income rather than solely
\non the payroll.
\nIncomes other than regular salary, if be-\u2022
\nyond certain amount, will be levied by
\na certain percentage for supplementary
\npremium.
\nThe amendment also calls for lowering\u2022
\npremiums paid by the union workers and
\nthose who do not have regular incomes.
\nIf enacted,the amendment can make both\u2022
\nends meet and has a positive implication
\nin social equity.
\nSupplementary revenues for NHI
\nBefore the NHI Act can be amended, the\u2022
\nDepartment of Health and BNHI have
\ngone out in search of all possible sources
\ntrying to control the deficit: putting more
\nsurtax on each pack of tobacco, raising
\nmore revenues from lotteries, going after
\nthose who could but failed to pay the pre-
\nmium, etc.
\nIn addition to making up NHI\u2019s deficit,\u2022
\nthe revenues from tobacco surtax will be
\nused to improve quality of care, provide
\nbetter care to those living in the remote
\nareas, assist the indigent to pay off the
\noverdue premium or pay the out-of-
\npocket expenses, etc.
\nEver-Rising Expectations
\nHealth care is a non-satiable good. More
\ncan be less, and you can easily fall victim of
\nyour own success. You can never catch up in
\nquality improvement; you can never match
\nthe demand on the benefit.
\nThis kind of Catch-22 situation is actually
\nfaced by all the public projects, and is espe-
\ncially troublesome in health care.To respond
\nto this situation, the BNHI constantly im-
\nproves on its service by adding new items
\non the benefit package,by introducing more
\nindicators for quality assurance, by control-
\nling the expenditure so as to defer the need
\nfor premium raise, and by providing more
\ninformation on the website to make the op-
\nerations of the system more transparent.
\nWhat are the key institutional factors
\nleading to stability over financial crises?
\nBased on taiwan\u2019s experience with the
\nNHI, I would like to summarize some of
\nthe factors built in the design of the sys-
\ntem that are inductive to the capacity for
\nthe program to somehow neutralize the
\nimpact of economic fluctuations. And the
\n184
\nWMA news
\nlesson is that, when it comes to the stabil-
\nity of the program, it is more important to
\nhave the \u201cstructure\u201d right, than to have the
\n\u201coperation\u201dor the \u201cadministration\u201dright. In
\nother words, it takes a structural reform in
\norder to put thing right. In the following
\nsection, I would just like to cite three of
\nthose institutional factors: the premium-
\nbased social insurance, the effectiveness of
\nthe single-payer system, and the built-in
\nbalancing mechanism centered around the
\nglobal budget.
\nStability of Premium-Based
\nSocial Insurance
\nThere are a number of options for one to
\nchoose as the financing basis for a health-
\ncare system, such as government budget
\nfrom general tax, a surcharge on top of in-
\ncome tax, and premium collected from in-
\ncome or wealth.
\nAs so vividly evidenced by the recent ex-
\nperience in Latvia, the system on govern-
\nment budget can be very vulnerable during
\neconomic downturns. A program based on
\na surcharge on top of income tax can have
\nthe similar instability, as those revenues can
\nbe hard-hit by the economic recessions. As
\na user\u2019s fee, premium can, to some extent,
\ninsulate the impact of a financial crisis, be-
\ncause it is independent from the real in-
\ncome, which can vary according to the eco-
\nnomic situation.
\nI would like to point out that, under cer-
\ntain situations, a user\u2019s fee can consti-
\ntute a burden for some people who just
\nencounter misfortune in the life. And
\ntherefore, it is important to have a safety
\nnet to come to rescue, as demonstrated in
\nTaiwan\u2019s NHI.
\nEffectiveness of the Single-
\nPayer System
\nTaiwan\u2019s NHI is a single-payer system that
\nhas proved very effective in providing neces-
\nsary care to all, particularly to those in pov-
\nerty and other disadvantaged groups.This is
\na cornerstone for solidarity, and enjoys the
\nmaximal capacity to spread out the risks.
\nA single-payer system serves as a platform
\nnot just to pull together all the risks,but also
\nto pull together dollars of various sources.
\nPooling all the risks in a single pool makes
\ncross-subsidization among the different so-
\ncio-economic groups very easy and effective;
\npooling together all the dollars from various
\nsources makes the money flow very efficient.
\nA single-payer system is flexible in that any
\nnewly added needs or newly added budgets,
\nresulted from, say, economic recessions,
\ncan be incorporated into the program with
\nease, and the safety net can be continuously
\nstrengthened without structural changes.
\nWith a single-payer system, the state acts
\nas a monopsonist on the healthcare market,
\nand the state can wield tremendous levering
\npower to co-opt the medical profession to
\nwork together for the good of the people.
\nBuilt-in Balancing Mechanism
\nUnder Global Budget
\nThe single most important instrument for
\ncost containment is the global budget sys-
\ntem, which puts a lid on the overall annual
\nNHI expenditure. The annual growth rates
\nof the global budget are negotiated every
\nyear through the Medical Cost Negotiation
\nCommittee, whose members comprise of
\nthe representatives from the payer groups as
\nwell as the provider groups.
\nWith such an overarching global budget,
\nthe payment for each service is defined in
\nterms of the number of points, rather than
\nthe number of dollars: the value of one point
\nwill be lower than one dollar, if the medical
\nprofession together provided more services
\nthan that expected by the Negotiation Com-
\nmittee. And therefore, when economic cri-
\nsis hits, the system will respond as a whole
\nby more stringent use of the resources. Of
\ncourse,the leadership of the medical profes-
\nsion must exercise its coordination power to
\nmake sure that, while saving resources, ad-
\nequate services will still be provided.
\nIn addition to the function of cost contain-
\nment, the global budget system is meant
\nto give incentive to the medical associa-
\ntions to rein in their members and ensure
\nappropriate care. The global budget system
\nhas worked pretty well, able to control the
\nincrease rates between 4% and 5% annually,
\nwithout compromising the quality of care
\nover these years.
\nLessons and Concluding Remarks
\nThe success of Taiwan\u2019s NHI, undoubt-
\nedly, should be, to an extent, attributed to
\nthe \u201coperation\u201d of the program \u2013 the \u201cextra
\nmiles\u201dthat the BNHI staff has put in.How-
\never, it is the \u201cstructure\u201dof the program that
\nconveys the resilience,flexibility,and tough-
\nness to this program so that the program
\ncan weather through the economic crises
\nwithout losing much capacity to uphold its
\nsafety net, which is so crucial for the less
\nfortunate. Therefore, when a nation consid-
\ners a healthcare system, the first thing com-
\ning to the minds of the architects is that the
\nprogram must be placed on a well thought-
\nout structure which will help the program
\nto hold up against the economic crises.
\nBased on Taiwan\u2019s experience with its NHI,
\nthe program better be financed by premiums
\nwhich, to a greater extent, are independent
\nfrom the financial crisis. A single-payer
\nsystem has the virtue of being efficient in
\nadministration, effective in cross-subsidiza-
\ntion, and therefore makes the safety net re-
\nsilient and tough to meet the challenges of
\na financial crisis.And finally,there must be a
\nbuilt-in mechanism that will automatically
\nbalance the books in bad economic times.
\nMichael S. Chen
\nFormer VP & CFO, Bureau of National
\nHealth Insurance, Taiwan Associate Professor,
\nDepartment of Social Welfare, National
\nChung-Cheng University
\ne-mail: aping_chen@yahoo.com.tw
\n185
\nWMA news
\nResponsibilities
\n1. Integrity: Researchers should take responsibility for the trust-
\nworthiness of their research.
\n2. Adherence to Regulations: Researchers should be aware of and
\nadhere to regulations and policies related to research.
\n3. Research Methods: Researchers should employ appropriate
\nresearch methods, base conclusions on critical analysis of the
\nevidence and report findings and interpretations fully and ob-
\njectively.
\n4. Research Records: Researchers should keep clear, accurate re-
\ncords of all research in ways that will allow verification and rep-
\nlication of their work by others.
\n5. Research Findings: Researchers should share data and findings
\nopenly and promptly,as soon as they have had an opportunity to
\nestablish priority and ownership claims.
\n6. Authorship: Researchers should take responsibility for their
\ncontributions to all publications, funding applications, reports
\nand other representations of their research. Lists of authors
\nshould include all those and only those who meet applicable
\nauthorship criteria.
\n7. Publication Acknowledgement: Researchers should acknowl-
\nedge in publications the names and roles of those who made sig-
\nnificant contributions to the research,including writers,funders,
\nsponsors, and others, but do not meet authorship criteria.
\n8. Peer Review:Researchers should provide fair,prompt and rigor-
\nous evaluations and respect confidentiality when reviewing oth-
\ners\u2019 work.
\n9. Conflict of Interest: Researchers should disclose financial and
\nother conflicts of interest that could compromise the trustwor-
\nthiness of their work in research proposals, publications and
\npublic communications as well as in all review activities.
\n10. Public Communication: Researchers should limit professional
\ncomments to their recognized expertise when engaged in pub-
\nlic discussions about the application and importance of research
\nfindings and clearly distinguish professional comments from
\nopinions based on personal views.
\n11. Reporting Irresponsible Research Practices:Researchers should
\nreport to the appropriate authorities any suspected research mis-
\nconduct, including fabrication, falsification or plagiarism, and
\nother irresponsible research practices that undermine the trust-
\nworthiness of research, such as carelessness, improperly listing
\nauthors, failing to report conflicting data, or the use of mislead-
\ning analytical methods.
\n12. Responding to Irresponsible Research Practices: Research in-
\nstitutions, as well as journals, professional organizations and
\nagencies that have commitments to research, should have pro-
\ncedures for responding to allegations of misconduct and other
\nirresponsible research practices and for protecting those who
\nreport such behavior in good faith. When misconduct or other
\nirresponsible research practice is confirmed, appropriate actions
\nshould be taken promptly, including correcting the research re-
\ncord.
\n13. Research Environments: Research institutions should create
\nand sustain environments that encourage integrity through edu-
\ncation, clear policies, and reasonable standards for advancement,
\nwhile fostering work environments that support research integ-
\nrity.
\n14. Societal Considerations: Researchers and research institutions
\nshould recognize that they have an ethical obligation to weigh
\nsocietal benefits against risks inherent their work.
\nSingapore Statement on Research Integrity
\nPreamble. The value and benefits of research are vitally dependent on the integrity of research. While there can be and are national and
\ndisciplinary differences in the way research is organized and conducted, there are also principles and professional responsibilities that are
\nfundamental to the integrity of research wherever it is undertaken.
\nPrinciples
\nHonesty in all aspects of research
\nAccountability in the conduct of research
\nProfessional courtesy and fairness in working with others
\nGood stewardship of research on behalf of others
\nThe Singapore Statement on Research Integrity was developed as part of the 2nd
\nWorld Conference on Research Integrity, 21\u201324 July 2010,
\nin Singapore, as a global guide to the responsible conduct of research. It is not a regulatory document and does not represent the official
\npolicies of the countries and organizations that funded and\/or participated in the Conference.For official policies,guidance,and regulations
\nrelating to research integrity, appropriate national bodies and organizations should be consulted.
\n186
\nEconomic Recession on Nurses
\nExecutive Summary
\nThe worldwide economic crisis has hit Ice-
\nland particularly hard and will lead to severe
\ncutbacks in all areas of Icelandic society,
\nincluding the health care system. The state
\nbudget for the year 2009 estimates that 115
\nbillion Icelandic krona (ISK) will be spent
\non Ministry of Health projects, or almost a
\nquarter of the entire state budget for the year
\n(equivalent to approximately \u20ac0.64 billion).1
\nIt has been proposed that health services
\nmust be cut back by ISK 8 billion (approxi-
\nmately \u20ac0.04 billion), or approximately 7%
\nthis year (2009), and additional ISK 8 bil-
\nlion in 2010. Possible cutbacks for 2011 and
\n2012 have not yet been announced,however
\nthe authorities have announced strict mea-
\nsures in order to curb public spending in
\nan effort to beat the recession. Health care
\nfacilities have been merged to decrease ad-
\nministrative costs, with reductions in over-
\ntime and shift supplement payments,termi-
\n1 All currency conversions in this paper reflect ex-
\nchange rates as at 17 August 2009, calculated using
\ncurrency converter at www.xe.com.
\nnations or cutbacks of contractual payments
\nto doctors, fewer paid study leaves, etc.
\nThe recession and the proposed cutbacks
\nhave already caused changes in Iceland\u2019s
\nnursing workforce.A large number of nurs-
\nes have increased their number of normal
\nhours as the former demand for overtime
\nwork has now vanished. Cutbacks, such as
\nreorganised shift routines and change in
\nskill mix, have also brought about a educ-
\ntion in the number of nurses needed. In-
\ncreasing nursing hours and in some cases
\ndelayed retirements are thus temporarily
\nhiding the shortage of nurses. The short-
\nage is however severe and will increase as
\nalmost a quarter of Icelandic nurses are
\nbetween 55 and 64 years of age and will
\ntherefore soon be reaching pensionable
\nage. The recession has also had dramatic
\neffect on the number of enrolled nursing
\nstudents which has doubled between the
\nyears 2008 and 2009.
\nThe Icelandic Nurses Association (INA)
\nhas increased its activities to assist its mem-
\nbers in adapting to altered working condi-
\ntions. The general assembly and board of
\nthe INA have passed resolutions on various
\ncurrent issues, primarily emphasising the
\nsafety and quality of health care services
\nand the importance of nursing. The INA
\nBoard published its priorities and propos-
\nals concerning health sector cutbacks at the
\nend of June 2009. This is an official policy
\ndeclaration by the association emphasizing
\nthe maintenance of quality and safety of
\nhealth care, the need to review the health
\ncare system and payments for services, the
\nnecessity to fix guidelines for prioritisation,
\nand the advantage of merging some health
\ncare facilities.
\nIntroduction
\nIceland has been hit particularly hard by the
\nglobal economic crisis. The rapid develop-
\nment and growth of the country’s banking
\nsystem rendered it vulnerable to the closing
\nof international credit markets.The govern-
\nment takeover of Icelandic banks and the
\nensuing debt guarantees demand related
\nto collapsed Icelandic banks in the United
\nKingdom and Holland led to severe cut-
\nbacks in all areas of Icelandic society, in-
\ncluding health care and education. The col-
\nlapse of the Icelandic krona (ISK) by around
\n50% in 2008 has restrained the purchasing
\npower of the general public and led to price
\nescalations as the domestic market is heav-
\nily reliant on the importation of commer-
\ncial goods. In fact, the economic recession
\nin Iceland has had an impact on everything
\nand everybody \u2013 on the homes and jobs of
\nIcelanders, social services, price levels and
\nmost aspects of daily life.
\nThe purpose of this article is to throw
\nsome light on the impact of the economic
\nrecession as already felt in Iceland with a
\nspecial emphasis on nurses and nursing.
\nThe article describes human resources in
\nnursing and the role and status of nurses
\nwithin the health care system. The article
\nalso deals with already announced gov-
\nernment measures and the foreseeable
\nimpact of these measures on nurses, nurs-
\nThe Impact of the Economic Recession on
\nNurses and Nursing in Iceland
\nElsa B. Fri\u00f0finnsd\u00f3ttir J\u00f3n A\u00f0albj\u00f6rn J\u00f3nsson
\n187
\nEconomic Recession on Nurses
\ning and health care services. A brief ac-
\ncount is given of nursing education and
\nremuneration matters. Finally, the article
\noutlines the priorities and measures of the
\nIcelandic Nurses Association in the wake
\nof changes within the health care system
\nand the impact of these changes on nurses
\nand nursing.
\nIceland\u2019s Nursing Workforce
\nThe current number of INA members is
\naround 3,600 and corresponds roughly to
\n90% of all registered nurses in Iceland. The
\nINA members\u2019 portfolio shows that around
\n2,800 nurses receive salaries on the basis of
\ncollective agreements made on their behalf
\nby the INA and 76% of them are employed
\nby public institutions. According to the
\nportfolio nearly half of all working nurses
\n(or 1,370) are employed by Landspitali,
\nwhich is the only university hospital in the
\ncountry and is located in the capital Reyk-
\njavik. The same INA data reveals that the
\naverage work time ratio of nurses in pub-
\nlic employ is currently around 80% of a full
\ntime equivalent. The privatisation of health
\ncare services is negligible in Iceland and
\nvery few nurses work for private institu-
\ntions.The public sector can thus be claimed
\nto be practically the sole employer of nurses
\nin Iceland, either in public institutions or
\nstate-funded private institutions caring for
\nthe elderly.
\nNursing in Iceland enjoys a strong legal
\nstatus. Nurses were guaranteed Professional
\nautonomy by law in 1978 and this autono-
\nmy was further enhanced by the entry into
\neffect of the new Health Service Act [1]
\non 1 September 2007. The President of the
\nINA served on a committee preparing the
\nbill to propose a new legislation on health
\nservices. The Health Service Act defines
\nthe Icelandic health care system as resting
\non two main pillars,nursing and medicine.
\nAll health care facilities shall, in addition to
\na director general,employ a nursing direc-
\ntor and a medical director. Nurses carry full
\nlegal responsibility for nursing.
\nHealth Sector Cutbacks
\nIn Iceland, the health care system is ad-
\nministered by the central government and
\naround 10% of GDP is allocated to it. The
\nsystem is financed from the state general
\nbudget, of which 83% is state financed and
\n17% are user fees [2].
\nThe state budget for the year 2009 [3] es-
\ntimates that ISK 115 billion will be spent
\non Ministry of Health projects, or almost
\na quarter of the entire state budget for the
\nyear. The largest single operational item on
\nthe budget is Landspitali University Hospi-
\ntal, which stands to receive ISK 33 billion
\n(\u20ac0.18 billion) according to the budget for
\n2009. At the beginning of 2009,the author-
\nities announced strict measures in order to
\ncurb public\u0113 spending in an effort to beat
\nthe recession. It is likely that the health care
\nsystem will need to be cut back by ISK 8
\nbillion (\u20ac0.04 billion) or approx 7% in 2009.
\nThis corresponds to the total budgetary re-
\nsources allocated to the Akureyri Hospital,
\nthe second largest hospital in the country
\nlocated in the north of Iceland, and to pri-
\nmary health care of the Capital Area which
\nserves around two-thirds of the country’s
\npopulation. Additional health service cuts
\nof ISK 8 billion are anticipated for the year
\n2010. The authorities have not, as yet, an-
\nnounced possible cutbacks for 2011 and
\n2012, but by 2013 the economy is expected
\nto begin to show signs of recovery.
\nGovernment Plans for Health
\nService Cutbacks
\nFollowing the collapse of the Icelandic
\nbanking system in early October 2008 it
\nbecame clear that dramatic cutbacks in
\npublic sector spending were imperative and
\nthese would also affect the health services.
\nAt a press conference on 7 January 2009 the
\nHealth Minister announced fundamental
\nchanges to the health care system. Twenty-
\ntwo health care facilities outside the capital
\narea were to be merged into a total of six
\nfacilities, a hospital in a municipality near
\nthe capital was to be changed into a geri-
\natric unit, small operating theatres in hos-
\npitals near the capital would be closed, and
\nso on [4]. The aim of these mergers was to
\ncut down administration costs rather than
\nthe patient care budget. Furthermore, user
\nfees for health services were increased and
\nmoderate admittance charges introduced
\nfor hospitals [5] in addition to plans to con-
\nsiderably curtail drug costs.
\nA new government took over in Iceland on
\n1 February 2009. The new Health Minister
\ncomes from a party to the extreme left in
\nIcelandic politics,while his predecessor rep-
\nresented the political right wing. Changes
\nwithin the Ministry of Health have had
\ndramatic effects. Two days after taking of-
\nfice, the new Health Minister revoked the
\nregulation on increased health service fees
\nand hospital admission charges[6].Over the
\nnext few days the Minister withdrew most
\nof the changes that had been prepared and
\nannounced by his predecessor [7].
\nOn 25 March 2009 the Minister of Health
\nannounced the principal features of ratio-
\nnalisation measures to be taken by hospitals
\nin the vicinity of Reykjavik [8].The focus of
\nthe Minister’s proposals was for these health
\ncare facilities to remain within the budget
\nand, in the long term, look to increase their
\ncooperation with Landspitali University
\nHospital with the aim to decrease overall
\ncosts without decreasing service rendered.
\nThe Minister’s proposals anticipated re-
\nductions in overtime and shift supplement
\npayments, terminations or cutbacks of con-
\ntractual payments to doctors, fewer admin-
\nistrative positions, fewer paid study leaves
\nand more [9].
\nSalaries make up around 75-80% of the
\noperating expenses of health care facilities.
\nIn 2008, an additional 50% on average was
\nadded to basic salaries for overtime and
\nshift supplement payments. Nurses receive
\njust under 25% of the total salaries paid
\nby health care facilities, whereas they fill
\naround 23% of total full-time positions. Av-
\n188
\nEconomic Recession on Nurses
\nerage overtime work for nurses was 32% of
\ntheir total hours in 2008 [10].
\nThe Health Minister’s overall approach
\nconcerning health sector cutbacks for the
\ncurrent year and the next years to come was
\nnot available when this article was written
\nat the beginning of July 2009. The Minis-
\nter has, however, announced the merger of
\nhealth care facilities in West Iceland [11]
\nas of 1 January 2010 as well as the merger
\nof two small facilities in the North [12]
\nthat will take effect at the same time. The
\nMinister has also fixed the maximum price
\nfor two common prescription drugs [13].
\nThe Health Minister places great emphasis
\non consulting the local population in the
\ndifferent health care regions but has not
\nlooked much to the INA for collaboration.
\nPress interviews with the Minister indicate
\nthat detailed proposals for health sector
\ncutbacks for this year and the next are to
\nbe expected within a few weeks [14]. The
\nuncertainty surrounding envisaged health
\nsector cutbacks makes all long-term plan-
\nning difficult for the directors of health care
\nfacilities.Lack of integration may mean that
\nrationalisation in one facility results in in-
\ncreased costs at another. The delay in min-
\nisterial decisions and proposals also creates
\nuncertainty among nurses as to their work-
\ning conditions and this environment of un-
\ncertainty makes it difficult for the INA to
\norganise its support and work on behalf of
\nits members.
\nImpact of Recession on
\nNursing Shortage
\nThere has always been a nursing shortage
\nin Iceland. When the first educated nurse
\ncame back home from her studies abroad
\nat the end of the 18th century people wel-
\ncomed her but also stated that there really
\nshould have been two of them!
\nIn 2006 the INA conducted an extensive
\nsurvey into human resources in nursing.
\nThe results of the survey were published in
\na report entitled Nursing Shortage [15] in
\nMarch 2007.In the survey nursing direc-
\ntors of health care facilities nationwide were
\nasked the following questions:
\n1. How many full-time positions are au-
\nthorised for nurses at the facility?
\n2. How many full-time positions for nurs-
\nes are occupied at the facility?
\n3. How many full-time positions occupied
\nby nurses have individuals on leave due
\nto childbirth, further education or pro-
\nlonged sickness?
\n4. How many nurses are required to fill the
\nfull-time positions authorised at the fa-
\ncility?
\n5. How many full-time positions for nurs-
\nes do you think are required by the fa-
\ncility on the basis of estimated need for
\nnurses?
\nThe results of the survey showed that in or-
\nder to fill the authorised nursing positions,
\nas well as those where individuals were on
\nmaternity, study or sick leave, the num-
\nber of nurses would need to be increased
\nby 15.75%. When taking into account the
\nnumber of full-time positions considered
\nnecessary by nursing directors in order to
\ndeliver optimum quality care, however, the
\noverall nursing shortage was estimated at
\n20.66%. In 2006 the average work-time ra-
\ntio of nurses was 76.45% and thus a total of
\n582 nurses were required in order to meet
\nthe need. Based on available data, the INA
\nput together a nursing shortage projection
\nfor the period 2006-2015 [16].
\nIn March this year the INA conducted an
\ninformal survey of nursing shortage [17] in
\nthe same health care facilities as participat-
\ned in the 2006 survey. Replies were received
\nfrom nursing directors at a total of 50 facili-
\nties which together command around 65%
\nof all fulltime positions in the country. The
\nquestions in this survey were comparable to
\nthose used in the previous survey.
\nThe results of the latest survey indicate that a
\nsignificant change has taken place. At pres-
\nent, nursing directors\u2019 professional assess-
\nment is that the nursing shortage, based on
\nestimated needs to fulfil service demands, is
\n3.84% compared with 21.5% in 2007.
\nRecent social upheavals have thus contribut-
\ned dramatically to reducing the shortage of
\nnurses. The change can partly be explained
\nby the INA collective agreement in 2008, in
\nwhich the aim was to reduce overtime and
\nincrease normal hours worked by nurses
\n(see page 190). As a result a large number
\nNursing Shortage Projection 2006-2015
\n0
\n100
\n200
\n300
\n400
\n500
\n600
\n700
\n800
\n2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
\nYear
\nNumber
\nFull-time positions Nurses needed for these positions
\nSource: Icelandic Nurses’ Association, 2007
\n189
\nEconomic Recession on Nurses
\nof nurses have increased their work-time
\nratios but, as already pointed out, health
\ncare facilities have in the past relied heav-
\nily on nurses working overtime. Directors
\nof health care facilities have welcomed this
\ntrend as it helps reduce overtime costs. The
\nINA predicts that the average total salaries
\nof nurses will slightly decrease but the re-
\nduction is accompanied by better working
\nenvironment due to higher staffing levels,
\nmore regular working hours and less over-
\ntime. Nurses have, most likely, opted for
\npart-time work due to family obligations
\nand the stress entailed in working shifts and
\ntherefore increased work-time ratios might
\nin the long run have detrimental effects on
\ntheir family lives. Various cutbacks, such as
\nreorganised shift routines,have also brought
\nabout a reduction in funded nursing posi-
\ntions. Finally, nurses previously employed in
\nprivate sector enterprises are now increas-
\ningly seeking positions in public sector fa-
\ncilities.
\nAs of now the INA is lacking data whether
\nsome individuals, who have nursing qualifi-
\ncations but were not working as nurses,have
\ncome back in to nursing employment. It
\nshould, however, be reiterated that this sur-
\nvey was an informal one and therefore the
\nfigures cited may not be entirely reliable. It
\nshould also be emphasised that this seem-
\ningly favourable trend may not necessarily
\nlast. While there is still uncertainty con-
\ncerning the measures intended by the au-
\nthorities and the Health Minister in order
\nto bring about the extensive rationalisation
\nnecessary within the health service sector in
\ncoming months, some health care facilities
\nmay even resort to layoffs.
\nSo far there have been no mass redundan-
\ncies, but the directors of many health care
\nfacilities have stopped filling vacant posi-
\ntions when nurses either retire or go away
\non leave. In some facilities there are now
\nfewer nursing positions than before and
\nthis inevitably increases the strain on nurses
\nwho are still at work. Organisational chang-
\nes and new shift routines have forced nurses
\nto move between places of work and even
\nchange from regular daytime work to doing
\nshifts.
\nEmphasis in INA Collective
\nAgreements
\nCollective agreements between the INA
\nand its counterparties ceased to apply in the
\nearly months of 2008 as planned. In light
\nof the downward trend in work-time ratios
\nand the apparent nursing shortage [18],
\ncoupled with the relatively high proportion
\nof overtime in the gross pay of nurses [19],
\nthe Association placed heavy emphasis on
\nincreasing basic salaries.Following intensive
\nnegotiations and an imminent overtime ban
\nfor nurses,a collective agreement was signed
\non 9 July 2008 which fixed the hourly rate
\nfor overtime work at 0.95% of an individual
\nnurse’s basic monthly salary instead of the
\nearlier amount of 1.0385%. The average in-
\ncrease in basic salaries thus came to around
\n14%. The collective agreement was valid for
\nnine months only, or from 1 July 2008 to 31
\nMarch 2009. Based on information gath-
\nered from nursing directors at the largest
\nhealth care facilities, these salary changes
\nhad a considerable impact on nurses raising
\ntheir work-time ratios and reducing over-
\ntime work. As stated above, the recession
\nthen had a further impact on staffing and
\nwork-time ratios.
\nThe INA’s collective agreement has now
\nbeen open for three months. The INA, as
\nmember of the Association of Academics,
\nhas participated in the formation of a sta-
\nbility pact between Icelandic employees, the
\ngovernment and the business community.
\nThe pact is part of the government’s strat-
\negy in facing the economic crisis and aims
\nprimarily at reaching some sort of stability
\nwithin the national economy and the em-
\nployment market, the key element being
\nobjectives regarding inflation levels, interest
\nrates, unemployment levels, exchange rates
\nof the Icelandic krona, etc. It is clear that
\nnurses will not receive any pay increases in
\nthe coming months, but the INA will focus
\non protecting the jobs of nurses as well as
\nthe salaries and conditions that have already
\nbeen achieved.
\nImpact of Recession on
\nNursing Education
\nAll nursing education in Iceland has been at
\nuniversity level since 1986. Nursing is cur-
\nrently taught at two universities: the Uni-
\nversity of Iceland in Reykjavik and the Uni-
\nversity of Akureyri. The study programme
\ntakes four years and concludes with a BSc
\ndegree in nursing. Graduate programmes
\non offer in Iceland include midwifery, a
\ndiploma programme in specialised nurs-
\ning, MSc in nursing, interdisciplinary pro-
\ngrammes in health informatics and public
\nhealth sciences, and a PhD in nursing.
\nAccording to the nursing shortage report of
\n2007 [20] a total of 145 nurses are expected
\nto graduate each year. During the period of
\neconomic expansion and growth there was a
\ndecline in the number of students enrolled
\nin the nursing programmes at the universi-
\nties and in the last three years only around
\n100 students have graduated. This spring,
\nhowever, in a climate of recession, the num-
\nber of applications for nursing studies has
\nmore than doubled. In the spring of 2008
\na total of 173 students applied to be en-
\nrolled in the nursing programmes at both
\nuniversities. This year has seen a total of
\n369 applications. Owing to a tight budget
\nand a lack of clinical placements only 170
\nstudents will, however, be allowed to con-
\ntinue with their studies on the strength of
\ntheir examination results at the end of the
\nfirst semester. The INA believes that 170
\nnew nurses need to enter the profession an-
\nnually in order to maintain the status quo.
\nThis estimate is based on the large number
\nof nurses reaching retirement age over the
\nnext few years [21].
\nAlmost a quarter of all nurses working in
\nthe country are between 55 and 64 years
\nof age and will therefore soon be reaching
\npensionable age.In recent years, nurses have
\n190
\nEconomic Recession on Nurses
\non average started drawing pension at the
\nage of 64, but given the current economic
\nconditions it is to be expected that many
\nwill choose to delay their retirement by a
\nyear or two. This ageing of the nurse popu-
\nlation is taken in to account in the former
\noutlined projection of nursing shortage till
\nthe year 2015.
\nDespite the disappearance of the nursing
\nshortage in recent months it is important
\nto remain vigilant and to ensure that there
\nare sufficient numbers of newly-graduated
\nnurses to meet the needs of society, not least
\nwhen the nation has managed to weather
\nthis economic storm. When such a time
\ncomes, Iceland may again be faced with a
\nshortfall of qualified nurses.
\nVarious changes within the health service as
\nwell as in the Icelandic society require more
\nnurses to be employed. In the INA’s Policy
\non Nursing and Health Care it is stated that
\nthe needs of the public for nursing services
\nare the cornerstone of nurses work. Nurses
\nmust, under all conditions, ensure they de-
\nliver high-quality nursing services while
\nhaving the best interests of their clients at
\nheart at all times [22]. More work needs to
\nbe done in areas of prevention and health
\npromotion. Shorter hospitalisation periods
\nmean that health care is transferred to other
\nfacilities as well as the homes of the patients
\nand this calls for increased nursing services.
\nAt the same time, the age composition of
\nthe population is changing. Improved treat-
\nment possibilities increase longevity, but as
\nthe population grows older the number of
\nserious and chronic health problems also in-
\ncreases. In times of recession the population
\nmay require different types of health service
\nand it is important that these needs are as-
\nsessed so that appropriate measures can be
\ntaken.
\nINA Emphases and Actions
\nThe 3,600 member association of Icelandic
\nnurses represents nearly 90% of all nurses li-
\ncensed to practice in the country. Member-
\nship is voluntary and annual dues amount to
\n1.5% of a nurse’s basic salary. The INA was
\nestablished in 1919 and acts on behalf of
\nits members in matters concerning profes-
\nsional issues, economic interests and work-
\ning conditions. The Association is a profes-
\nsional body as well as a union of nurses. Its
\npurpose is to:
\na) Be an advocacy for nursing and nurses
\nand safeguard their interests.
\nb) Protect the image and autonomy of
\nthe nursing profession, encourage co-
\noperation between nurses and promote
\nprofessional and social awareness.
\nc) Negotiate with employers on pay and
\nconditions on behalf of its members as
\nwell as other issues covered by its man-
\ndate.
\nd) Promote the development of nursing as
\nan academic field of study.
\ne) Participate in international collabora-
\ntion among nurses for the benefit of the
\nprofession.
\nf) Participate in the formulation of poli-
\ncies concerning health care.
\nThrough new emphases in collective bar-
\ngaining, the INA has been successful in
\nimproving the salaries and working hours
\nof nurses. As the recession forces health
\ncare facilities into reorganising their work
\nschedules,i.e.by reducing overtime as much
\nas possible, it can be safely maintained that
\nthe move made in the 2008 collective agree-
\nment was both correct and timely.
\nSince the collapse of the financial system
\nin October 2008 the INA has focused
\nits activities on assisting its members in
\nadapting to altered working conditions, for
\ninstance through active dissemination of
\ninformation. Already in January 2009 the
\nbudget of the INA was amended so as to
\nallow for improved services to association
\nmembers. To make room for this change
\nit was decided to cut down on overseas
\ntravel in connection with international
\nprojects. There has been detailed coverage
\nof health sector changes in The Icelandic
\nJournal of Nursing which is published five
\ntimes a year and distributed by mail to all
\nINA members. Every two weeks the INA
\npublishes an electronic bulletin which is
\nsent out to 2120 members registered on
\nthe association’s distribution list.The news
\nsection on the website www.hjukrun.is is
\nalso regularly updated. Advisory services to
\nindividuals have been increasing, particu-
\nlarly in matters relating to working hours,
\nstatutory sick pay and rules on dismissal.
\nAge distribution of nurses, 5 years grouped together (June 2009)
\nIcelandic residents, 70 years of age and younger
\n0
\n100
\n200
\n300
\n400
\n500
\n600
\n700
\n20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70
\nAge (years)
\nNumber
\nSource: Directorate of Health, Register of Nurses, 2009
\n191
\nEconomic Recession on Nurses
\nAll changes give rise to a range of ques-
\ntions concerning employee rights and the
\nINA considers it to be its duty to assist
\nmembers in these matters.
\nThe President of the INA and Associa-
\ntion employees have actively participated
\nin consultations with authorities, served
\non committees, and attended meetings and
\nconferences. A good case in point is the re-
\ncent collaboration with the Directorate of
\nHealth on a report concerning human re-
\nsources in nursing. The General Assembly
\nand Board of the INA have passed resolu-
\ntions on various current issues, primarily
\nemphasising the safety and quality of health
\ncare services and the importance of nurs-
\ning. All resolutions are forwarded to the
\nauthorities, published on the INA website
\nand sent to the media, who have generally
\nbeen very positive in their coverage of the
\nAssociation’s activities.
\nThe Board of the INA published its empha-
\nses and proposals concerning health sector
\ncutbacks at the end of June [23]. This is an
\nofficial policy declaration by the Associa-
\ntion and was sent to the Minister of Health,
\npublished on the INA website and for-
\nwarded to the national media. The Board’s
\nemphases are fourfold:
\n\u2022\tTo maintain quality and safety
\nThe INA emphasises that all decisions con-
\ncerning health sector cutbacks must take
\nthe interests of the population as a whole
\ninto account, there must be consistency in
\nthe actions taken between institutions and
\nhealth care regions, and the importance of
\nsecuring the quality and safety of services
\nfor all members of the community should
\nbe used as a guiding principle at all times.
\nThe INA Board stresses that care should be
\ntaken not to make any changes to the health
\ncare system that cannot be reversed when
\nthe economic climate begins to change for
\nthe better. No measures should force spe-
\ncially qualified health service personnel to
\nleave parts of the country or even the coun-
\ntry itself, because the quality of the health
\nservices provided rests primarily on the
\nknowledge and skill of the individuals who
\nwork in the field.
\n\u2022\t To review the healthcare system and pay-
\nments for services
\nThe Board of the INA urges the Health
\nMinister to spearhead a thorough review
\nof the health care system, to determine
\nwhat should be done and where, and what
\nshould be financed from public funds. The
\nkind of services covered (as well as those
\nnot covered) by health insurance as de-
\nfined in the Social Security Act needs to
\nbe specified. Decisions must also be taken
\nas to whether health care personnel are
\npermitted to provide services that are not
\ncovered by health insurance, since their cli-
\nents would need to pay the entire cost of
\nsuch services.
\n\u2022\tTo fix guidelines for prioritisation
\nThe INA Board emphasises the need for de-
\nfining the extent to which treatment should
\nbe provided under specific conditions. Pa-
\ntients, relatives and the general public must
\nbe aware that treatment limitations apply
\nequally to all individuals who are in a simi-
\nlar position, i.e. that such decisions are not
\nbe taken as a result of limited human re-
\nsources or finances when and if the situation
\nmight arise.
\n\u2022\tTo continue the merger of health care facili-
\nties
\nThere are at present 20 hospitals in Iceland
\nand it is natural to question whether this is,
\nin fact,necessary or sensible for such a small
\npopulation. The INA Board calls for a pre-
\ncise definition of what constitutes basic ser-
\nvices that should be provided in each com-
\nmunity and then how many hospitals are
\nactually required and where they should be
\nlocated. The safety of the population must
\nof course be the focal point of any such de-
\nliberations.
\nBased on these emphases, the INS Board
\nhas presented the following proposals to the
\nMinister of Health:
\n\u2022\tThat\t the\t Minister\t of\t Health\t establish\t a
\nfive-person task force to work, full time, on
\ndeveloping a health service plan for Iceland
\nup to 2015. The task force will be entrusted
\nwith setting out proposals for health sector
\ncutbacks for the next three years by consid-
\nering, for instance, areas where action needs
\nto be taken,how basic services should be de-
\nfined and where hospitals should be located
\nin the future. The group should also specify
\nwhat kind of services are to be covered by
\nhealth insurance and then to what extent,
\neither temporarily or permanently,as well as
\npatient contributions towards health service
\ncosts, privatisation in the health care sector,
\nand the kind of services that should be per-
\nmitted outside the health insurance system.
\nThe proposals should also suggest ways in
\nwhich to reconstruct the health care system
\nat the end of the recession. The INA Board
\nis prepared to nominate its representative
\nto serve on this task force and to assist the
\ngroup in any way possible.
\n\u2022\tThat\tthe\tMinister\tof\tHealth\timmediately
\nappoint a committee on the prioritisation of
\nhealth services which will be entrusted with
\nmaking proposals concerning the limita-
\ntion of treatment and how services should
\nbe prioritised. Various other nations have
\nalready specified such limitations. It is nec-
\nessary that this group becomes a permanent
\nadvisory committee to the Minister and also
\nhandles the introduction of new treatment
\npossibilities within the health service. The
\nINA Board suggests that this committee
\nshould be comprised of an expert on eth-
\nics,a health economist,a nurse,a doctor and
\npolitical appointees.
\n\u2022\t That\t work\t continues\t on\t the\t merger\t of
\nhealth care facilities on the basis of the
\nHealth Service Act and regulation on health
\nregions. Special attention needs, however, to
\nbe paid to the safety of people in rural areas
\nin this respect. Ease of transportation and
\n192
\nEconomic Recession on Nurses
\nthe burden of cost for the local population
\nmust also be considered when planning the
\nmerger of facilities and organising basic ser-
\nvices and hospital locations. Decisions on
\nthe mergers of health care facilities should
\nform part of the work of the special task
\nforce mentioned in the first proposal above.
\nConclusion
\nThere is no doubt that Icelandic nurses, as
\nwell as the entire population of the country,
\nare entering into hard times.The health care
\nsystem is one of the pillars of the community
\nand it is important that good standard that
\nIceland has already achieved is maintained.
\nThe knowledge and skills of nurses and oth-
\ner health care workers is the foundation on
\nwhich the health service is built.Therefore it
\nis now more important than ever to secure
\na solid education for Icelandic nurses and
\nthat sufficient numbers graduate each year,
\nthat new knowledge is put to use within the
\nhealth care system and that every effort is
\nmade to prevent a human capital flight of
\nnurses to neighbouring countries.
\nAll the same, the recession brings opportu-
\nnities. A higher number of nurses are now
\nworking more regular hours than before.
\nWith more nurses on each shift it is easi-
\ner to plan nursing care, aiming to increase
\nthe quality of nursing care for each patient.
\nThere are endless opportunities to enhance
\nthe quality of nursing and to prove the ef-
\nfectiveness of nursing treatments as well
\nas becoming more visible as profession-
\nals. Nurses can also take on various differ-
\nent tasks within primary health care, such
\nas patient reception, health protection, etc.
\nNurses can also enhance and improve gen-
\neral and specialised home nursing. Nurses
\nin sparsely populated areas need to be given
\nthe opportunity to work independently.
\nNurses should take a more active part in the
\nmedical surveillance of clients with chronic
\nillnesses, for instance by receiving them at
\nspecial nursing clinics, and press for licences
\nto issue prescriptions for common drugs.
\nBut the recession also brings serious threats.
\nAlthough the immediate effects of the
\nrecession can be valued as positive by in-
\ncreasing nursing hours and in some cases
\ndelaying some retirements and thus hiding
\ntemporary the shortage of nurses,the short-
\nage is still underlying and serious and can-
\nnot be ignored.The nursing community and
\nthe health care authorities still need to focus
\non replacing and increasing the number of
\nnurses in Iceland, to decrease the long term
\nshortage of nurses and to insure that the
\nhealth care needs of the population are met.
\nThere is also regrettably always the threat
\nthat the authorities will resort to measures
\ndealing with the economic crisis that might
\nhave a lasting impact on the health service
\nand lead to a reduction in the number of
\nnurses.
\nThe Icelandic Nurses Association will con-
\ntinue to keep up a reliable flow of informa-
\ntion to its members. In the upcoming pay
\nnegotiations the Association will focus
\non protecting the jobs of nurses. The As-
\nsociation will also step up its participation
\nin public debates on health care issues and
\npromote the fact that the knowledge and
\nskills of Icelandic nurses are the best tools to
\nsecure an efficient and safe nursing service.
\nReferences
\nHealth Service Act (2007). no. 40 www.eng.1.
\nheilbrigdisraduneyti.is\/media\/Laws%20
\nin%20english\/Health_service_act.pdf
\nOECD (2007). Health at a Glance2.
\n2007.Statistics Iceland: www.statice.is\/
\nPages\/444?NewsID=3333 accessed 6 August
\n2007
\nAl\u00feingi (the Icelandic Parliament) (2008).3.
\nGeneral Budget for 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (7 January 2009).4. Skip-
\nulagsbreytingar heilbrig\u00f0is\u00fej\u00f3nustunnar \u00ed land-
\ninu. Organisational changes within the health
\ncare system.ww.heilbrigdisraduneyti.is\/frettir\/
\nnr\/2957accessed 6 August 2007.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (29 December 2008).5.
\nRegluger\u00f0 um hlutdeild sj\u00fakratrygg\u00f0ra \u00ed kost-
\nna\u00f0i vegna heilbrig\u00f0is\u00fej\u00f3nustu. Regulation on
\npatient participation in health service costs.
\nwww.heilbrigdisraduneyti.is\/frettir\/nr\/2955
\naccessed 2 July 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (2 February 2009).6.
\nInnritunargj\u00f6ld \u00e1 sj\u00fakrah\u00fas og heilbrig\u00f0isstof-
\nnanir felld ni\u00f0ur. Hospital admission charges
\nrevoked. www.heilbrigdisraduneyti.is\/frettir\/
\nnr\/2988 accessed 2 July 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (19 February 2009).7.
\nSt. J\u00f3sefsp\u00edtali samh\u00e6f\u00f0ur starfsemi Landsp\u00edta-
\nla. St.J\u00f3sefsp\u00edtali Hospital harmonised with
\nLandspitali University Hospital. www.heil-
\nbrigdisraduneyti.is\/frettir\/nr\/2991 accessed 2
\nJuly 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (25 March 2009).8. Spar-
\nna\u00f0ur og skert kj\u00f6r \u00ed sta\u00f0 st\u00f3rfelldra uppsagna
\nstarfsmanna.Cutbacks and lower pay instead of
\nmass redundancies. www.heilbrigdisraduneyti.
\nis\/frettir\/nr\/3015 accessed 2 July 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (25 March 2009).9. Spar-
\nna\u00f0ur og skert kj\u00f6r \u00ed sta\u00f0 st\u00f3rfelldra uppsagna
\nstarfsmanna. Ibid.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (25 March 2009).10. Spar-
\nna\u00f0ur og skert kj\u00f6r \u00ed sta\u00f0 st\u00f3rfelldra uppsagna
\nstarfsmanna. Ibid.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (12 May 2009).11. \u00c1tta
\nheilbrig\u00f0isstofnanir sameinast um \u00e1ram\u00f3tin
\nEight healthcare facilities to merge at year-
\nend. www.heilbrigdisraduneyti.is\/frettir\/
\nnr\/3040 accessed 2 July 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (12 June 2009).12. Stof-
\nnanir \u00ed Fjallabygg\u00f0a sameina\u00f0ar. Institutions
\nin the Fjallabygg\u00f0 region to merge).www.heil-
\nbrigdisraduneyti.is\/frettir\/nr\/3060 accessed 2
\nJuly 2009.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (3 March 2009).13. N\u00fd
\nlyfjaver\u00f0skr\u00e1 tekur gildi. New price levels for
\nprescription drugs. www.heilbrigdisraduneyti.
\nis\/frettir\/nr\/2999 accessed 2 July 2009:
\nMorgunbladid Daily Newspaper (25 June14.
\n2009). \u00d6gmundi stillt upp vi\u00f0 vegg. Health
\nMinister faces barrage www.mbl.is\/mm\/fret-
\ntir\/innlent\/2009\/06\/25\/ogmundi_stillt_upp_
\nvid_vegg\/ accessed 2 July 2009:
\nIcelandic Nurses Association (March 2007).15.
\nMannekla \u00ed hj\u00fakrun (Nursing Shortage).
\nIcelandic Nurses Association (March 2007)16.
\nIbid.
\nTalnabrunnur (2009).17. Miklar breytingar \u00e1
\nm\u00f6nnun \u00ed hj\u00fakrun (Dramatic staffing changes
\nin nursing), Directorate of Health Bulletin on
\nHealth Statistics 3(6).www.landlaeknir.is\/lis-
\nalib\/getfile.aspx?itemid=4021 accessed 3 July
\n2009.
\nIcelandic Nurses Association (March 2007).18.
\nOp. cit.
\nHeilbrig\u00f0isr\u00e1\u00f0uneyti\u00f0 (25 March 2009).19. Spar-
\nna\u00f0ur og skert kj\u00f6r \u00ed sta\u00f0 st\u00f3rfelldra uppsagna
\nstarfsmanna. Op. cit.
\nIcelandic Nurses Association (March 2007).20.
\nOp. cit.
\nTalnabrunnur (2009). Op. cit.21.
\n193
\nMedical Education
\nIcelandic Nurses Association (May 1997).22.
\nPolicy on Nursing and Health Care. www.
\nhjukrun.is\/lisalib\/getfile.aspx?itemid=34 ac-
\ncessed 3 July 2009.
\nIcelandic Nurses Association (29 June 2009).23.
\nEmphases and proposals of INA’s Administrative
\nBoard in connection with health sector cutbacks.
\nwww.hjukrun.is\/?PageID=33&NewsID=3749
\naccessed 3 July 2009.
\nElsa B. Fri\u00f0finnsd\u00f3ttir RN, MSN,
\nPresident of the Icelandic Nurses\u00b4 Association.
\ne-mail SElsa@hjukrun.is
\nJ\u00f3n A\u00f0albj\u00f6rn J\u00f3nsson
\nInternational Secretary and Project Manager
\nat the Icelandic Nurses\u2018 Association
\ne-mail Jon@hjukrun.is
\nFor free access to full this document and
\nother original research on nursing human
\nresources, please visit the ICN’s Interna-
\ntional Centre for Human Resources in
\nNursing at www.ichrn.org.
\nIntroduction
\nMedical students and doctors experience
\nhigh rates of psychological morbidity due to
\ntheir work and study environment. Medi-
\ncal students are initially similar to general
\nstudent populations prior to commenc-
\ning their medical course. As their training
\ncommences, however, the reductions in
\npsychological well-being have been dem-
\nonstrated to increase [1][2]. Stress may be
\na contributing factor for unhealthy behav-
\niors and co-morbidities. Previous research
\nhas estimated that up to half of the medical
\nstudents reportedly abuse alcohol as well as
\nillicit substances such as marijuana. Other
\naspects of student health and lifestyle, such
\nas reduced physical activity and poor diet,
\nalso suffer with increased workloads [6].
\nWith increases in obesity levels,fast-food con-
\nsumption, smoking rates, alcohol consump-
\ntion, and illicit drug use, it is uncertain what
\nthe increase of these factors will cause over the
\nnext couple of decades. It is inevitable, how-
\never, that the diseases which progress from
\npoor lifestyle choices such as regular smoking,
\npoor nutrition and poor exercise will be expe-
\nrienced by the doctors of the future.
\nMethodology and Results
\nThe International Federation of Medical
\nStudents Association (IFMSA) represents
\n1.2 million medical students from over
\nninety countries worldwide. IFMSA holds
\nbiannual general assemblies, hosted by
\nelected member countries.These assemblies
\ngather around 700 medical students,making
\nit an excellent forum for discussion, team
\nbuilding, and cultural acceptance and sen-
\nsitivity. With such a large number of medi-
\ncal students attending these meetings, pri-
\nmarily to advocate for improved health, the
\nevents provide an excellent opportunity to
\nconduct surveys regarding healthy lifestyles.
\nTherefore, a cross-sectional study was con-
\nducted at IFMSA\u2019s general assembly held
\nin Macedonia in August, 2009. The socio-
\ndemographic data was collected on lifestyle
\nchoices, tobacco consumption (cigarette,
\npipe tobacco and tobacco use in any other
\nform), exercise that lasts for 30 minutes or
\nlonger, dietary habits (including fruit, veg-
\netable and fast food consumption), alcohol
\nconsumption and sexual activity [6].
\nA quarter of the students exercised regularly
\nwith no difference between the genders.The
\nmajority of respondents consumed fruit and
\nvegetables on a daily basis. A third of the
\nstudents also reported regular consumption
\nof fast food.Female students were reported-
\nly healthier in their nutritional choices with
\nhigher consumption of fruit and vegetables
\nthat their male counterparts. Less than a
\nquarter of the medical students smoked on
\na regular basis. When comparing genders;
\nmales were significantly more likely to be
\nsmokers than females.Living in Europe,the
\nAmericas or in the Eastern Mediterranean
\nregion also predisposed students to smok-
\ning. Sixty percent of the medical students
\nconsumed alcoholic beverages on a regular
\nbasis. There was no difference in alcohol
\nconsumption between the genders.
\nWith regard to sexual health; the mean age of
\nfirst intercourse was 17.7 years.Regarding sex-
\nual orientation; an absolute majority reported
\nbeing heterosexual with a small fraction (5%)
\nreporting their orientation as homosexual or
\nbisexual. An overwhelming majority stated
\nregular contraceptive use; the most popular
\nmethods of contraception being the condom
\nor the contraceptive pill.Over half of the sexu-
\nally active respondents reported having just
\none sexual partner over the previous year.Male
\nstudents reported having twice as many sexual
\npartners as female students. Students from
\nEuropean or American countries reported the
\nhighest proportion of sexual activity.
\nRegardless of predisposing factors, lifestyle
\nchoices have a great influence on morbidity
\nand mortality in life. Due to the cumula-
\ntive effect of adverse factors throughout the
\nlife of individuals, it is important to adopt a
\nhealthy diet and lifestyle practice.This study
\nassessed the dietary habits and lifestyle
\nchoices made by medical students, who are
\na significant community of future health-
\ncare practitioners. Correct lifestyle choices
\nmade early on during the medical education
\nperiod will produce physicians practising as
\nwell as promoting a healthy lifestyle. There
\nis a visible need for improvement in some of
\nthe lifestyle choices made by medical stu-
\ndents. The response rate of the study may
\nhave been limited by the sensitive nature of
\nsome of the questions and also due to pos-
\nsible language barriers.
\nLifestyle Practices of Medical Students
\nattending an International Student
\nConference
\n194
\nMedical Education
\nSimilar studies conducted in Pakistan and the
\nUnited Arab Emirates have shown similar
\nfindings with poor lifestyle choices made by
\nmedical students [7][8]. Nisar et al. found a
\nvery low smoking prevalence which correlates
\nwith our study\u2019s regional results described for
\nsmoking [9]. A number of American stud-
\nies also found a relatively low prevalence of
\nsmoking amongst medical students [10]. It
\nis a well known fact that health providers
\n(including medical students) smoke and in
\n2005 the WHO Centre for Disease Preven-
\ntion and the Canadian Public Health Asso-
\nciation developed the Global Health Profes-
\nsionals Survey to survey smoking habits of
\nmedical, nursing, dental and pharmacy stu-
\ndents in a variety of WHO member states.
\nThe results were published in 2005 [11].
\nAlthough a large number of medical stu-
\ndents smoke regularly there is also evidence
\nto support the fact that the same subset of
\nhealthcare students know and understand
\nthe health risks of smoking and are ready to
\npromote smoking cessation to their patients.
\nIn a recent review of smoking in medical
\nstudents the rates of smoking were described
\nto increase incrementally with each year of
\nstudy and it was also suggested that smoking
\ncessation strategies should be put in place by
\nthe medical schools themselves [12].
\nPoor diet has been documented in medi-
\ncal students with nutritional intake being
\ndocumented to worsen closer to exam pe-
\nriods [13]. British and Greek studies found
\nsimilar results when reviewing the amount
\nof fruit consumed by medical students with
\nthe majority eating fruit regularly but with
\nvery few actually consuming the five por-
\ntions of fruit per day advised by health au-
\nthorities [14].
\nStudies on sexual activity in medical students
\nhave found similar results as found in our sur-
\nvey with similar mean ages for first intercourse
\nas well as similar preferences of contraceptive
\nmethods [15]. The results of the international
\nsurvey show a high prevalence of sexual activ-
\nity and an equally high prevalence of contra-
\nceptive use with a proportion of the subjects
\nreportedly using two or more forms of contra-
\nception; the male condom and the oral con-
\ntraceptive pill being the most common forms.
\nSame-sex behaviour described in the literature
\ncorrelates well with the low levels of homosex-
\nual or bisexual activity elicited in the medical
\nstudent international community [16].
\nConclusion
\nThe self-reported lifestyle choices and hab-
\nits of international medical students dis-
\nplayed choices of a healthy and unhealthy
\nnature with a predominance of high con-
\nsumption of tobacco, fast food and alco-
\nhol. The healthy choices made by the study
\ngroup however indicate that some aspects
\nof health promotion may permeate into the
\nlifestyle choices made by medical students,
\nas is shown in the positive prevalence of
\ncontraceptive use.The high rates of exercise
\nas well as the clearly demonstrated levels of
\nfruit and vegetable consumption were also
\nsome of the positive behaviors elicited.
\nIt is possible that some lifestyle choices made
\nby medical students may be inevitable due to
\nthe educational schedule,many of whom live
\nfar away from home. It is possible that more
\ndirected dietary and tobacco advice may be
\nrequired as a preventive strategy for this
\nstudy group.The findings of our study,as well
\nas other studies held in the past, suggest the
\nneed for a larger study across more countries
\nso that adequate arrangements can be made
\nfor student healthcare [17].
\nReferences
\nStewart SM, Betson C, Marshall I, Wong1.
\nCM, Lee PW and Lam TH. Stress and vul-
\nnerability in medical students. Medical educa-
\ntion (2006) 29(2), 119-127
\nGuthrie EA, Black D, Shaw CM, Hamilton J,2.
\nCreed FH and Tomenson B. Embarking upon
\na medical career: Psychological morbidity in
\nfirst year medical students. Medical Educa-
\ntion. (1995) 29, 337-341
\nDanaei G, Ding EL, Mozaffarian D,Taylor B,3.
\nRehm J, et al. (2009) The preventable causes of
\ndeath in the United States: Comparative risk
\nassessment of dietary, lifestyle, and metabolic
\nrisk factors. PLoS Medicine 6(4): e1000058.
\ndoi:10.1371\/journal.pmed.1000058
\nCarter AO, Elzubeir M, Abdulrazzaq YM,4.
\nRevel AD, Townsend A. Health and lifestyle
\nneeds assessment of medical students in the
\nUnited Arab Emirates. Med Teach 2003; 25:
\n492-6
\nNisar N, Qadri MH, Fatima K, Perveen S. Di-5.
\netary habits and life style among the students
\nof a private medical university Karachi. J Pak
\nMed Assoc 2009; 59: 98-101
\nNisar N, Qadri MH, Fatima K, Perveen S. Di-6.
\netary habits and life style among the students
\nof a private medical university Karachi. J Pak
\nMed Assoc 2009; 59: 98-101
\nConard S,Hughes P,Baldwin DC,Achenbach7.
\nKE, Sheehan DV. Substance use by fourth-
\nyear students at 13 U.S. medical schools. Jour-
\nnal of Medical Education (1988) 63:747-758
\nCenters for Disease Control and Prevention8.
\n(CDC). Tobacco use and cessation counsel-
\nling \u2013 Global health professionals survey pi-
\nlot study, 10 countries, 2005. MMWR Morb
\nMortal Wkly Rep 2005;54:505-9.
\nSmith DR, Leggat PA. An international re-9.
\nview of tobacco smoking among medical stu-
\ndents. J Postgrad Med (2007) 53:55-62
\nWolf TM, Kissling GE. Changes in life-style10.
\ncharacteristics, health, and mood of freshman
\nmedical students. Journal of Medical Educa-
\ntion. (1984) 59:806-814
\nBertsias G, Linardakis M, Mammas I, Kafatos11.
\nA. Fruit and vegetables consumption in rela-
\ntion to health and diet of medical students in
\nCrete, Greece. International Journal for Vita-
\nmin & Nutrition Research. (2005) 75(2):107-
\n17
\nOrtiz-Ortega A, Garc\u00eda de la Torre G, Galv\u00e1n12.
\nF, Cravioto P, Paz F, D\u00edaz-Olavarrieta C, El-
\nlertson C, and Cravioto A. Abortion, contra-
\nceptive use, and adolescent pregnancy among
\nfirst-year medical students at a major public
\nuniversity in Mexico City. Rev Panam Salud
\nPublica\/Pan Am J Public Health (2003) 14(2):
\n125-130
\nMcConaghy N, Armstrong MS, Birrell PC,13.
\nBuhrich N. The incidence of bisexual feel-
\nings and opposite sex behaviour in medical
\nstudents. The Journal of Nervous and Mental
\nDisease. (1979) 167(11):685-8
\nAshton CH, Kamali F. Personality, lifestyles,14.
\nalcohol and drug consumption in a sample of
\nBritish medical students. Medical Education.
\n(1995) 29(3):187-192. DOI:10.1111\/j.1365-
\n2923.1995.tb02828.x
\nDr. Jonathan Mamo MD MSc
\ne-mail: Chantal.Fenech@gmail.com
\nDr. Chantal Fenech MD
\ne-mail: Jonathan.Mamo@yahoo.com
\n195
\nRegional and NMA news
\nOrganisation and membership
\nThe Norwegian Medical Association
\n(NMA) was founded in 1886 as a profes-
\nsional association and trade union for Nor-
\nwegian physicians.Membership is voluntary
\nand approximately 96% of the Norwegian
\nphysicians are members. The main aims of
\nthe NMA are to protect and develop the
\nprofessional, social and financial interests
\nof its members, to promote their interests
\nin matters concerning medical education,
\nprofessional development and scientific
\nactivities, and to advance the quality of the
\nNorwegian health care system.
\nMain bodies of the Norwegian Medical
\nAssociation
\nThe Annual Representative Meeting
\n(ARM) is the chief decision-making body
\nand elects the Central Board of 9 members,
\nincluding the president and vice-president.
\nThe election period for the board is two
\nyears. ARM also elects the Medical Ethics
\nCommittee.
\nThe NMA consists of 19 local branches (one
\nin each county),7 occupational branches,44
\nspecialty branches, one for retired doctors
\nand one student organisation.
\nThe seven occupational branches organise
\nmembers that share occupational interests:
\njunior doctors, consultants, general prac-
\ntitioners, researchers, occupational health
\ndoctors, private practicing specialists and
\npublic health doctors. The occupational
\nbranches have their main interests in sala-
\nries and working conditions, while the spe-
\ncialty branches are engaged in scientific and
\nprofessional activities like education,quality
\nimprovement, etc.
\nThe secretariat
\nThe secretariat has five departments: Dep. of
\nprofessional affairs, Dep. of information and
\nhealth policy, Dep. of finance and adminis-
\ntration, Dep. of negotiation and legal section
\nand The Norwegian Medical Journal. The
\nnumber of full-time staff members is 130.
\nThe role of The Norwegian Medical As-
\nsociation
\nThe Norwegian Medical Association is the
\nonly medical association for doctors in Nor-
\nway. The NMA has two main responsibili-
\nties:
\nnegotiating salaries and working condi-\u2022
\ntions for the members;
\ntaking care of the members professional\u2022
\nand scientific interests.
\nIn addition the NMA is responsible for
\nmuch of the post-graduate specialist educa-
\ntion.
\nPrioritised areas
\nThe Norwegian Medical Association will
\nfor the next two years (2009\u20131011) particu-
\nlarly work for:
\n1. Quality work and measurements, work-
\ning environment and economy in hos-
\npitals. Hospitals have too little focus on
\nquality and working conditions com-
\npared to economy.
\n2. Permanent positions for all doctors in
\nhospitals. Almost all junior doctors to-
\nday have temporary engagements.
\n3. Improved interaction between various
\nlevels of the health care system.
\n4. Further development of primary health
\ncare, especially the list patient system.
\n5. Promotion of medical research and pro-
\nfessional development.
\n6. Recruiting, supporting and educating
\nrepresentatives for the NMA (union of-
\nficials).
\nSome data about Norway
\nNorway has a population of 4,850,000 and
\nis situated in the northern part of Europe,
\nbeing bordered by Sweden, Finland and
\nRussia.
\nHealthcare and health services are financed
\nby taxation and are designed to be equally
\naccessible to all residents, independent of
\nsocial status. With its 220,000 employees,
\nthe health sector is one of the largest sectors
\nin Norway.
\nThe healthcare system is under the jurisdic-
\ntion of the Ministry of Health and Care
\nThe Norwegian Medical Association
\nGeir Riise Torunn Janbu
\n196
\nRegional and NMA news
\nSharfuddin Ahmed
\nBackground
\nThe Bangladesh Medical Association
\n(BMA) is the national association of doc-
\ntors of Bangladesh. It represents 46,000
\nphysicians nationwide and has 67 district
\nbranches working all over the country. The
\nBMA looks after the healthcare system of
\nthe country, the interests of the doctors, and
\nthe overall well-being of the medical com-
\nmunity.A 47 member central executive runs
\nthe association. The BMA is working hard
\nto ensure good health for every citizen of
\nBangladesh.
\nOverview of the country\u2019s
\nhealthcare system
\nA wide range of therapeutic choices are
\navailable in Bangladesh, ranging from self-
\ncare to traditional and western medicine.
\nThe public sector is largely used for in-
\npatient and preventative care while the pri-
\nvate sector is used for curative care. Primary
\nHealth Care (PHC) has been chosen by the
\ngovernment of Bangladesh as the strategy to
\nachieve their goal of \u201cHealth for all\u201d, which
\nis now being implemented as Revitalized
\nPrimary Health Care.
\nPublic sector healthcare services
\nPrimary care in the public sector is organ-
\nized around the Upazila Health Complex
\n(UHC) at a sub-district level, which works
\nBangladesh Medical Association (BMA)
\nservices, which is responsible for planning
\nand monitoring national health policy. Re-
\nsponsibility for provision of services is de-
\ncentralised to the municipal and regional
\nlevel. The municipalities are in charge of
\nproviding primary health services, while the
\nfour Health regions provide the specialised
\nmedical services, mainly hospital care.
\nGeneral practice is organised through a list
\npatient system. The list patient system is a
\nnational system organised and run through
\nagreements between the NMA and the
\nhealth authorities where the general practi-
\ntioners are mainly self-employed.
\nThere are some specialist practices working
\nunder agreements with the Health regions.
\nNorway only has a small number of author-
\nised private hospitals and health services in
\naddition to the public facilities.
\nThe number of doctors, including students
\nand retired doctors, are about 27 000. In
\nrelation to inhabitants we have one of the
\nlargest numbers of doctors in Europe, in
\n2007 the ratio was one doctor per 244 in-
\nhabitants.
\nThe Committee on Human Rights
\nSince the early 1990s, the NMA has run
\nhuman rights programmes in Turkey, the
\nformer Yugoslavia and now in China.These
\nactivities are funded mainly by The Nor-
\nwegian Ministry of Foreign Affaires. In
\ncooperation with WMA, the International
\nRed Cross and Amnesty International the
\nassociation has published, on the web, free
\nof charge, a course for prison doctors.
\nThe Journal of the Norwegian Medical
\nAssociation is issued every second week.
\nPost-graduate medical education
\nThere are 44 recognised medical specialties
\nin Norway of which eight are subspecial-
\nties under internal medicine and five are
\nsubspecialties under general surgery. The
\nmajority of the specialties relate to health
\nservices in institutions (hospitals). Special-
\nties in primary health care are family medi-
\ncine,community medicine and occupational
\nmedicine.
\nHealth politics
\nThe NMA is involved in many of the activi-
\nties run by the health authorities through
\nmeetings, working groups and political
\nwork. The NMA also appoints members
\nto participate in different task groups and
\nmeetings with the political parties in the
\nParliament.
\nOfficers
\nPresident Dr. Torunn Janbu, Ph. D., Vice-
\npresident Dr.Arne L.Refsum and Secretary
\nGeneral Dr. Geir Riise.
\nThe Medical Ethics Committee: chairper-
\nson Dr.Trond Markestad, Ph. D.
\nContact information:
\nThe Norwegian Medical Association
\nP.O. Box 1152 Sentrum
\nNO-0107 Oslo
\nPhone +47 23 10 90 00
\nTelefax +47 23 10 90 10
\nwww.legeforeningen.no
\nDr. Torunn Janbu, President
\nDr. Geir Riise, Secretary General
\n197
\nRegional and NMA news
\nas a health-care hub.These Units have both
\nin-patient and out-patient services and fa-
\ncilities. Most have in-patient care support
\nwith a 31 bed capacity, while some UHC\u2019s
\nhave over 50 beds. Many UHC Units have
\na package service called \u201ccomprehensive
\nemergency obstetric care services\u201d (EOC)
\navailable, with an expert gynecologist, an
\nanaesthetist and skilled support nurses on
\nduty around-the-clock as well as in-house
\nbasic laboratory facilities.At a lower tier,the
\nUnion Health and Family Welfare Centres
\n(UHFWC) are operational, consisting of
\ntwo or three sub-centers at the lowest ad-
\nministrative level, and a network of field-
\nbased functionaries. Above the sub-district
\nare the district hospitals (100-250 beds) and
\nmedical colleges (serving a group of districts
\nwith approximately 650 beds), providing
\nsecondary care, and national tertiary level
\ncare facilities.
\nPrivate sector healthcare services
\nIn the private sector, there are traditional
\nhealers, homeopathic practitioners, village
\ndoctors, community health workers, and,
\nfinally, retail drugstores that sell allopathic
\nmedicine on demand. In addition to dis-
\npensing medicine, sellers at these mostly
\nunlicensed and unregulated retail outlets
\nalso diagnose and treat illnesses despite
\nhaving no formal professional training.
\nTraditional medical practices
\nGrouped under \u201ctraditional medicine\u201d are
\nmost of the medical practices that fall out-
\nside the realm of \u2018scientific\u2019 medicine. Thus
\nKabiraj, totka, herbalists, practitioners of
\n\u2018Folk Medicine\u2019 and faith healers of differ-
\nent shades fall under this broad umbrella.
\nMany of these healers (e.g. faith healers)
\nprovide a much narrower range of services
\nfor a more limited set of conditions.
\nThe BMA supports the country\u2019s strategic
\nhealth profile through different activities,
\nwhich include involving the healthcare sec-
\ntor in decision making, raising its voice to
\nguide the country\u2019s heath policy,and arrang-
\ning meetings, seminars, and symposiums to
\ncreate awareness of the country\u2019s key health
\nissues.The BMA also involves itself directly
\nin professional matters such as:
\n1. The promotion of public doctors
\n2. The provision of legal support to doc-
\ntors, if needed
\n3. Support for an effective primary, sec-
\nondary and tertiary referral system
\n4. Acting as a legal body to oversee physi-
\ncians\u2019 problems
\n5. The improvement of medical education
\n6. Solutions for different national issues
\n7. The training of private doctors as well as
\nhealthcare providers
\n8. Liaising with different international
\norganizations including International
\nPhysicians for the Prevention of Nucle-
\nar War (IPPNW), the Commonwealth
\nMedical Association (CMA),the World
\nMedical Association (WMA) and other
\nnational medical associations.
\nProfessor Dr. Md. Sharfuddin Ahmed
\nChairman,
\nDepartment of Ophthalmology,
\nBangabandhu Sheikh Mujib Medical
\nUniversity,
\nSecretary General,
\nBangladesh Medical Association
\nEger Istvan
\nThe history and function of the Hungarian
\nMedical Chamber are closely tied to Hun-
\ngary\u2019s political history. After the 2nd World
\nWar, Hungary\u2019s communist political regime
\nordered the HMC inactive. A trade union
\nof common health care professionals was
\ncreated in its place and strictly controlled by
\nthe government with no possibility for self-
\ngovernance by Hungarian doctors during
\nthe 40 years of the communist regime. The
\nhealthcare system was financed by the state
\nand no provisions were made for a health
\ninsurance system. During this time, Doc-
\ntors salaries were low, paid by the govern-
\nment who (unofficially) encouraged \u201cunder
\nthe table\u201d payments from patients.
\nDuring the early 1990s Eastern Central
\nEurope, including Hungary, underwent
\nmajor fundamental structural changes. Not
\nonly did the political system transform, but
\na new healthcare system was developed
\nand agreed upon as well. Public healthcare
\ncosts were financed through a health insur-
\nance company that was paid by the state
\nand whose budget was provided mainly by
\ntaxes. Physicians who had previously been
\ngovernment employees gradually became
\nindependent practitioners that contracted
\ndirectly with the health insurance compa-
\nnies,however doctors who worked in hospi-
\ntals and outpatient care facilities remained
\ngovernment employees. Despite the many
\nchanges that occurred within Hungary\u2019s
\nhealthcare system, healthcare providers sal-
\naries remained quite low.
\nHungarian Medical Chamber in the Last
\nTwenty Years
\n198
\nRegional and NMA news
\nIn 1989, doctors began to anticipate the up-
\ncoming changes and possibilities that were
\nfacing their nation and a few enthusiastic
\nmembers of the physician workforce re-es-
\ntablished the Hungarian Medical Chamber.
\nIn the first period membership was volun-
\ntary. The HMC\u2019s top priority was creating a
\nnew ethical structure, writing an ethical code
\nand organizing committees (e.g. professional,
\neducational, legal, etc ). Moreover they con-
\ntinually sought to connect with stakeholders
\nand decision-makers in an effort to establish
\ntheir influence and ensure their input regard-
\ning important questions of healthcare practice
\nand policy. In 1994,five years after the HMC
\nwas re-established, the Hungarian Parlia-
\nment drafted and voted into law legislation
\nthat made the HMC (and the pharmaceutical
\nchamber) part of the public sector.
\nThe most important change as a result of the
\nnew law was that membership in the HMC
\nbecame mandatory. Mandatory membership
\ngave the chamber a powerful regulatory posi-
\ntionwithinthehealthcaresystemsincedoctors
\nmemberships could be cancelled or suspended
\nfor ethical violations, which would prohibit
\nthem from continuing to treat patients. In
\naddition, the HMC was charged with tasks
\nregarding ethical issues, including the regis-
\ntration of doctors, organizing and control-
\nling continual medical education and creating
\nrecommendations regarding medical practice.
\nThey were also given the right to voice their
\nopinion regarding proposed healthcare laws.
\nMost importantly, the HMC had a right of
\nconcordance (it had a negative voice) regard-
\ning the main points of contribution with the
\nhealth insurance company. The HMC has
\nlimited financial resources to broaden their
\naffiliation with international organizations
\nbut has been able to represent Hungary in the
\nStanding Committee of European Doctors
\n(CPME) since 2003.
\nIn the second half of the nineties and par-
\nticularly after 2000, the financial state and
\nfunctionality of Hungary\u2019s healthcare sys-
\ntem was in a continual decline. In response,
\nthe HMC changed its focus in an effort to
\nprovide constructive criticism that would
\nbenefit the best interests of the healthcare
\nsystem. The percentage of GDP dedicated
\nto the healthcare sector decreased year by
\nyear (nowadays it is significantly lower than
\n5%!),as did the quality of care offered to pa-
\ntients. The shortage of medical profession-
\nals continued to rise due to low salaries and
\npoor working conditions, and became so
\nsevere that by 2004 the media was reporting
\non the difficulty of the situation. Although
\nthe previous government searched for an-
\nswers and solutions to the crisis,their meth-
\nods were ineffective and unsuccessful.
\nAfter Hungary joined the European Union
\nin 2004, Hungary\u2019s healthcare crisis wors-
\nened considerably as its doctors and nurses
\nsought better working conditions and wages
\nelsewhere in the EU.The Hungarian govern-
\nment seemed uninterested in restoring the
\nfailing healthcare system. They refused to
\nhear and understand the HMC\u2019s many rec-
\nommendations for the troubled healthcare
\nsystem and resented the HMC\u2019s strong voice
\nof opinion. In 2007 the government tried
\nto destroy the HMC (and the pharmaceu-
\ntical and nurses chambers) by reversing the
\nlaw requiring mandatory membership to the
\nchambers. To further weaken the chambers,
\nthe law refused to recognize any member-
\nship obtained during the mandatory mem-
\nbership period and as of April 1, 2007 not
\none official member remained in any cham-
\nber. The amount of administrative work in
\nre-establishing membership in the interest
\nof preserving the community of doctors was
\noverwhelming,but in the end the HMC was
\nable to restore 80% of their membership vol-
\nuntarily. It was a great success for the HMC
\nand the two other chambers (which had also
\nsuccessfully recovered their members) and a
\nbig defeat for the government. The political
\nparties in parliament that were in opposition
\nwith the majority at that time promised to
\nreinstitute the government\u2019s earlier position
\non mandatory membership if at all possible.
\nThe HMC\u2019s greatest success in the last few
\nyears has been the successful protection of
\nthe existing public health insurance system
\nfrom a dangerous decision by the previ-
\nous regime to organize a public health in-
\nsurance system based on a business model
\ncomprised of several competing health in-
\nsurance companies. In 2008 there was a ref-
\nerendum about these proposed changes and
\nas a result of the voting, parliament had to
\nwithdraw the law to create the new health
\ninsurance system. During this whole pro-
\ncess the Hungarian Medical Chamber had
\nvery important role, and we are very proud
\nof our activity regarding this issue.
\nIn the spring of 2010 a new government was
\nelected in Hungary. The previous opposi-
\ntion became the new majority in the gov-
\nernment. The Hungarian Medical Cham-
\nber prepared a new proposal to change the
\nlaw about the chambers within the health-
\ncare system. This will be discussed at the
\nautumn session of parliament and we are
\nhopeful that membership within the HMC
\nwill be mandatory again by January 1, 2011.
\nThe public body of Hungarian physicians
\nwould like to become more influential in
\nthe development of Hungary\u2019s healthcare
\nsystem in the future.
\nDr. Eger Istvan, Hungarian
\nMedical Chamber, President
\nBuilding of the Hungarian Medical Chamber
\n199
\nRegional and NMA news
\nB\u00e9la Szalma
\nMOTESZ, the most widespread organiza-
\ntion of Hungarian medical doctors based on
\nvoluntary membership, had the opportunity
\nto introduce itself in the WMA\u2019s periodical
\npublication in 2006. Below is an overview
\nof our organization and what we have been
\ndoing the past several years.
\nMOTESZ was established in 1966 with 36
\nmember societies. Since that time, numer-
\nous health care organizations have joined
\nour association. At the moment we have
\n129 member societies, meaning that some
\n30,000 medical doctors,dentists,researchers
\nand scientists are connected to MOTESZ.
\nFor almost four and a half decades we have
\nbeen making efforts to carry out our main
\ntasks: to coordinate the activities and coop-
\neration of the member societies at the as-
\nsociation level, and to promote the solution
\nof common problems.
\nNational activities
\nMOTESZ has been making significant ef-
\nforts to facilitate the addressing of interests
\nof member societies in health care-related
\nlegislation and enforcement. As a perma-
\nnent invited body, MOTESZ observes leg-
\nislation in the Health Care Committee of
\nthe Parliament and gives its opinion con-
\ncerning significant issues directly affecting
\nthe medical profession.
\nOn request, MOTESZ, through its profes-
\nsional committees, regularly provides opin-
\nions on health care-related bills forwarded
\nby the Ministry of Health, as well as dis-
\ncussing and formulating, topics affecting all
\nstakeholders in Hungarian health care.
\nIn February 2008 the Ministry of Health
\nrequested that we prepare coordinated and
\nreconciled professional proposals. To fulfil
\nthis duty,we created the ETSZ-MADOFE
\nProgram (Program on Regulating Health
\nCare Activity), a program plan to regulate
\nthe handling of operational data, documen-
\ntation, financing and controlling activity in
\nhealth care, in order to improve the system
\nof health care services.
\nAs to its principles and essence, the MA-
\nDOFE program is consistent with the pro-
\ngram plan of the Hungarian government,
\n(\u201cSafety and Partnership: tasks in health
\ncare until 2010\u201d), which was submitted to
\nwidespread social discussion. Our associa-
\ntion, based on the request of the Ministry,
\nhas organized a sectoral consensus confer-
\nence to summarize the material that was
\nsubmitted for discussion.
\nWe continued the National Program on
\nPrevention and Cure of Heart and Circula-
\ntory Diseases that was elaborated, accepted
\nand announced by MOTESZ and profes-
\nsionally relevant member societies in 2006.
\nThe results of the program were revealed in
\n2008 to the Health Care Committee of the
\nParliament, and in 2009, lectures were held
\non the status of the program and on further
\ntasks of realization at different scientific
\nprofessional forums.
\nMeeting legislative requirements, the min-
\nister of health entrusted us to organize and
\nexecute the election of the professional
\nboards, the minister\u2019s consultative body.
\nMOTESZ successfully carried out this task
\nthis year as well.
\nThe association formed an agreement of
\ncooperation with the Ministry of Health,
\nwhich entailed cooperating with profession-
\nals to evaluate bills on the minimum require-
\nments expected from health care providers.
\nIn addition, we formulated a professional
\nproposal on the modernization of the present
\nstructure of health care services. Professional
\ndocuments consisted of complex solution
\nprograms to develop both basic and emer-
\ngency health care services and out-patient
\nand in-patient professional care.
\nThe organizing activities of MOTESZ,
\nwhich are conducted by its Congress and
\nTravel Agency, also play a significant role in
\nthe organization. Besides promoting inter-
\nnational recognition of the knowledge and
\nresults of Hungarian medical doctors at both
\nnational congresses with international par-
\nticipants and international conferences,these
\nevents are indispensable pillars of continuing
\neducation within the profession nationwide.
\nIn addition to overseeing the events them-
\nselves,the Travel Agency deals with organiz-
\ning travel, accommodation, and program-
\nming for medical doctors, researchers and
\ntheoreticians.
\nOur scientific, political, and informative
\nperiodical, MOTESZ Magazin, which has
\nbeen reaching readers for 18 years, appeared
\nwith new design and content in 2009. To
\nfurther vivify our professional dialogue with
\nour readers, the website of MOTESZ in-
\ncludes an interactive correspondence col-
\numn and a forum are linked to all columns
\nof the periodical, facilitating the sharing of
\nopinions on all themes appearing in the pe-
\nriodical.
\nMOTESZ \u2013 Association of Hungarian
\nMedical Societies
\n200
\nRegional and NMA news
\nOur homepage provides up-to-date infor-
\nmation on professional political events and
\non the progress of the association\u2019s work; we
\nalso provide a place for the announcements
\nof our member societies.
\nOur international activities
\nWe consider it a priority that our organiza-
\ntion\u2019s activities fit that of the national and
\ninternational organizations of the medical
\nprofession. Our relations with the follow-
\ning organizations are of major importance:
\nStanding Committee of European Doc-
\ntors (CPME), World Medical Association
\n(WMA), European Forum of Medical As-
\nsociations (EFMA), World Health Organi-
\nsation (WHO), European Union of Medi-
\ncal Specialists (UEMS),European Union of
\nGeneral Practitioners (UEMO), European
\nworking group of practitioners and special-
\nists in free practice (EANA).
\nThough our financial resources make it dif-
\nficult for us to take part in sessions of in-
\nternational organizations regularly, we can
\nreport several positive results from sessions
\nattended.A great point of pride is that at the
\ngeneral meeting of UEMS in Copenhagen
\nheld in October 2008, Dr. Zolt\u00e1n Magyari,
\nmember of the international committee of
\nMOTESZ, was the only vice-president, to
\nbe reelected, indicating the level of recog-
\nnition of his work and an appreciation of
\nHungary\u2019s role. Dr. Magyari continues to
\nplay an active role,primarily in accreditation
\nof international congresses.
\nIt is also significant that at the 2009 general
\nassembly of UEMO,held in Budapest,Prof.
\nDr. Ferenc Hajnal was elected as president,
\nDr. Ren\u00e1ta Papp as secretary-general, and
\nDr. S\u00e1ndor Balogh as treasurer, starting in
\n2011. They are all members of the inter-
\nnational committee of MOTESZ. In the
\noperative work of the UEMO Presidency
\nwe work in collaboration with other profes-
\nsional organizations.
\nAs to our bilateral relations, our coopera-
\ntion with the German Medical Association
\n(Bundes\u00e4rztekammer) is very active; we
\nparticipate on a regular basis in the annual
\nGerman Medical Assembly. We also main-
\ntain relations with the American Medical
\nAssociation, the French Medical Associa-
\ntion (Conseil National de L\u2019Ordre des M\u00e9-
\ndecins), the Chinese Medical Association,
\nand the Chinese Medical University in
\nHeilongjiang.
\nWe evaluate the results of relations with
\nthe Chinese Medical Association each year.
\nSince 2004, we have alternated sending the
\nMOTESZ delegation to visit their Chinese
\ncounterparts one year and hosting a Chinese
\ndelegation the following year. In autumn of
\n2009, in collaboration with Semmelweis
\nUniversity\u2019s Faculty of Health Sciences, we
\nhosted two Chinese delegations in Hungary,
\nfrom both the Chinese Association of Tra-
\nditional Chinese Medicine and the Chinese
\nMedical Association. Our association was
\ninstrumental in integrating the teaching of
\ntraditional Chinese medicine (TCM) into
\nthe system of Hungarian medical educa-
\ntion, and in securing recognition of Chinese
\nTCM diplomas in Hungary.
\nOur association returned the visit on 24-25
\nApril 2010,when a delegation was invited to
\nthe 24th National Congress of the Chinese
\nMedical Association, held in Beijing. Our
\ndelegation held talks with the leaders of the
\nMedical Center of the Beijing University in
\norder to facilitate the establishment of a re-
\nlationship with the Semmelweis University
\nof Budapest and the University of P\u00e9cs, as
\nwell as to form an agreement of cooperation
\nwith the Chinese.
\nThe major duty of our association is repre-
\nsenting the interests of our member societ-
\nies, and through them, the interests of the
\nmedical profession. All our member orga-
\nnizations are informed about our national
\nand international activities on a regular ba-
\nsis through the quarterly meetings of the
\nAssociation Council, the body consisting
\nof the presidents of the member societies of
\nMOTESZ.
\nDr. B\u00e9la Szalma, the Secretary
\nGeneral of the MOTESZ
\nWhat are we doing?
\nContinuing medical education is a never-
\nending story for doctors who want to be up
\nto date and to give their patients the best
\ncare possible. What follows is a short intro-
\nduction to our organization, whose primary
\ngoal is to offer theoretical as well as practical
\neducation for doctors from more than 100
\ncountries.
\nTHE AMERICAN AUSTRIAN FOUN-
\nDATION (http:\/\/www.aaf-online.org) is a
\nnon-profit, non-governmental organization
\nthat seeks to prevent brain drain and foster
\nbrain gain in countries of transition through
\nexchanges in medicine, communications,
\nscience and the arts.
\nBackground:
\nIn 1984,a group of Americans and Austrians
\ninterested in fostering closer relations be-
\ntween the United States and Austria estab-
\nlished The American Austrian Foundation
\n(AAF). In the years since, the foundation
\nhas grown from a bilateral to a multilateral,
\ninternational institution partnering with
\nAmerican \u2013 Austrian Foundation in
\nMacedonia
\n201
\nnon-governmental organizations (NGOs),
\ngovernments, and individuals.
\nMission:
\nThe American Austrian Foundation
\nseeks to bridge the knowledge gap by
\nproviding qualified individuals with fel-
\nlowships to pursue postgraduate educa-
\ntion in medicine, media and the arts.
\nThe AAF’s fellowship programs, ini-
\ntially offered to Americans and Austri-
\nans, now include participants from more
\nthan 100 countries worldwide.The AAF
\nconducts its own programs and joint
\nprograms with American, Austrian and
\ninternational organizations. To facilitate
\nthe operation of programs in Austria, the
\nfriends of the American Austrian Foun-
\ndation founded The Salzburg Stafing in
\n1995, and the Vienna Chapter in 2002.
\nIn 2005 the AAF, the Open Society In-
\nstitute, and the Austrian Ministry of
\nScience and Education established the
\nOpen Medical Institute (OMI) to con-
\nsolidate the Salzburg Medical Seminars
\nInternational and the Observerships
\nunder one name. Later, The Vienna
\nOpen Medical Institute (Vienna OMI)
\n(http:\/\/www.aaf-online.org\/vienna-
\nomi) was established as a joint initia-
\ntive of the Vienna Hospital Association
\n(VHA) (www.wien.gv.at), the American
\nAustrian Foundation (AAF), the Vien-
\nnese Society of Physicians, the Austrian
\nAcademy of Sciences and the Vienna
\nSchool of Clinical Research (VSCR)
\n(www.vscr.at), to provide scientific and
\nclinical postgraduate education in med-
\nicine using Vienna’s excellent resources.
\nSo far, more than 10,000 physicians
\nfrom countries in transition (fellows)
\nhave attended seminars; of these, 1500
\nhave also participated in one-month ob-
\nserverships at Austrian hospitals.
\nMedical Programs
\nThe medical educational process is orga-
\nnized through three steps:
\nStep One: KnowledgeTransfer – Salzburg
\nMedical Seminars
\nFirst established in 1993, today there are
\naround thirty seminars per year.These semi-
\nnars are postgraduate medical educational
\nprograms provided by physicians from
\nleading American medical schools and hos-
\npitals, including New York-Presbyterian
\nHospital,The Children’s Hospital of Phila-
\ndelphia, Memorial Sloan-Kettering Cancer
\nCenter, The Hospital for Special Surgery,
\nDuke University Medical Center, Cleve-
\nland Clinic,and Methodist Hospital,as well
\nas leading European centers. These physi-
\ncians spend one week in Salzburg working
\npro bono to teach their English-speaking
\ncolleagues from countries in transition.
\nThe seminars provide personal contacts
\nand small working groups for fellows, who
\nare admitted through a highly competitive
\nselection process. More than 500 seminars
\nhave been organized with 35-40 partici-
\npants attending each one.
\nStep Two: Experience Exchange –
\nOmi Observerships
\nThe aim of the OMI-Medical Observer-
\nship Program is to integrate seminar alumni
\ninto the international medical community
\nby inviting them to spend up to 3 months,
\nin one-month periods, at Austrian hospitals
\nto improve their clinical skills. Organizing
\nthe Vienna OMI has enabled an increas-
\ning number of participants in Observership
\nprograms in the last few years. All Vienna
\nhospitals are open to fellows, who conduct
\ntheir Observership programs in many dif-
\nferent areas.
\nStep Three: Capacity Building \u2013
\nDistance Learning
\nThe Foundation brings distinguished lec-
\nturers into different countries by organizing
\nsatellite symposia and visiting professor-
\nships. Two-day OMI satellite symposia are
\nheld in the region with the aim of reaching
\na larger audience of physicians and health
\ncare workers. At the same time, they are an
\nimportant opportunity to learn about local
\nconditions and foster relationships among
\nsenior physicians in the region and Ameri-
\ncan and Austrian faculty members. Satellite
\nsymposia typically include six lectures, a
\nhospital visit, and a round-table discussion
\non a topic agreed by local and international
\nfaculty. One-day visiting professorship pro-
\ngrams typically include three to four lec-
\nRegional and NMA news
\nMarija Vavlukis
\nGraphic 1.
\n202
\nEducation
\ntures, case reports, and an optional hospital
\nvisit.
\nOmi Alumni Network
\nThe OMI Alumni Network is organized
\nas an open network for all fellows, provid-
\ning open access to state-of-the-art medical
\ninformation via Medical Handbook Online
\nand video conferences. This network also
\nhelps in the support and improvement of
\nlocal healthcare systems by providing the
\npossibility of a second opinion in patient
\ncare, local knowledge transfer, and a chance
\nto attract new medical talent.
\nActivity Report from Macedonia
\nAs a local coordinator, my routine activities
\ninclude:
\nContinuous management of the fellows\u2019\u2022
\ndata in the AAF\/OMI database in order
\nto facilitate their selection, travel arrange-
\nments, etc;
\nEnglish testing, screening of the appli-\u2022
\ncants and fellows, and recommendations
\nto the Program Director;
\nMaintaining relationships with local\u2022
\nOMI alumni fellows;
\nMaintaining relationships with other lo-\u2022
\ncal coordinators in order to collaborate in
\nthe organisation of local activities;
\nPromoting the benefits and opportunities\u2022
\nof such collaborations with AAF\/OMI in
\norder to facilitate the development of the
\nregional health care systems and scientific
\nresearch;
\nEstablishing partnerships with local\u2022
\nmedical and educational institutions;
\nSubmitting regular progress reports to the\u2022
\nNetwork Coordinator to ensure progress
\nmilestones, or to identify issues and prob-
\nlems that may necessitate assistance from
\nAAF\/OMI;
\nWorking collaboratively with the Net-\u2022
\nwork Coordinator and members of the
\nAAF\/OMI team;
\nOrganisation and administration of satel-\u2022
\nlite symposia and visiting professorships.
\nMost Significant Accomplishments
\nThe most significant accomplishments of
\nthe past two years include:
\n1.Organisation and administration of OMC-
\nMACEDONIA as a virtual space for pro-
\nmoting the AAF-OMI programs and com-
\nmunication of the Macedonian fellows with
\none another and with the OMI alumni net-
\nwork. The OMI Alumni Network \u2013 OMC
\nMacedonia (http:\/\/www.webdoctor .com.
\nmk; http: \/\/www.webdoctor.com.mk\/index.
\naspx?IDPage=273) currently functions as a
\nvirtual network where graduates of the OMI-
\nSalzburg Medical Seminars International
\n(SMSI) can come together, share experi-
\nences, and acquire new medical information
\ntogether with the Macedonian doctors. Open
\nMedical Club activities currently include an-
\nnouncing the Salzburg Medical Seminars and
\npublishing reports of the Macedonian fellows
\nthat attend Salzburg Medical Seminars.These
\nreports include their activities and impressions
\nfrom the seminar,topics and faculty.
\n2. Increasing the number of Macedonian
\napplicants for Salzburg Medical Seminars
\nfrom 24 in 2006 to 52 in 2007, 75 in 2009,
\nand over 100 in 2010.
\nIn the graphic below, we can see the chang-
\nes in applications and attendance of the
\nSalzburg Seminars and Observerships since
\n1994, when the first Macedonian fellow
\nparticipated at a Salzburg Medical Semi-
\nnar. Currently, we have 4-6 applications
\nper seminar, which improves the selection
\nprocess and guarantees the quality of the
\nselected doctors.There are about 600 Mace-
\ndonian doctors affiliated with the program.
\nSince 1994 there have been 460 applications
\nfor Salzburg seminars, 160 of which were
\nmade during the past two years (during the
\nauthor\u2019s tenure as coordinator). Of 230 total
\nseminar attendees, more than 40 occurred
\nin the past two years. We have more than
\n100 Observership applications, 77 of them
\nrealized since 1995,and that is the area with
\nthe greatest need for improvement. At the
\nmoment, about 25 Macedonian fellows are
\non the Observership waiting list.
\nThis is the greatest indication of my prima-
\nry goal \u2013 the promotion of the programs of
\nAAF-OMI and the entry of more Macedo-
\nnian fellows therein.
\nPartnerships and Alliances
\nOne of my activities as coordinator is es-
\ntablishing partnerships and alliances with
\nmedical institutions and organisations with-
\nin Macedonia. At present, we have signed
\nMemorandums of Understanding between
\nthe Open Medical Institute (a program of
\nthe \u201cAssociation of Friends of the American
\nAustrian Foundation\u201d) as well as the Medi-
\ncal Faculty, University St. Cyril and Metho-
\ndius, Skopje, and the Clinical Center Trifun
\nTalevski, Bitola.
\nWe have also established contacts with lo-
\ncal medical and educational institutions,
\nincluding the Macedonian Medical Cham-
\nber,University Clinic for Pediatric Diseases,
\nUniversity Clinic for Gynecology and Ob-
\nstetrics, and Psychiatric Hospital Skopje.
\nGoal Achieved in 2010:
\nOrganisation of the Very First Omi
\nVisiting Profesorship Program
\nin Cardiology in Macedonia
\nThe first Macedonian visiting professorship
\nprogram in cardiology was organized un-
\nder the auspices of the American-Austrian
\nFoundation, the Open Society Institute and
\nthe Medical University Graz,Austria,in co-
\nordination with the medical faculty of the
\nUniversity St. Cyril and Methodius, Skopje,
\nthe University Clinic of Cardiology, and the
\nMacedonian Society for Cardiology. It was
\norganized as precongress activity within the
\nfourth Macedonian Cardiology Congress,
\nwhich was held from June 2-5, 2010, in
\nOhrid.
\nOur first guest was Professor Rainer Rien-
\nm\u00fcller, who is Professor of Radiology and
\n203
\nhead of the department of General Diag-
\nnostic Radiology in the University Hospital
\nof Graz, as well as a professor at the Medi-
\ncal University of Graz Austria and at the
\nUniversity of Munich, Germany. The sym-
\nposium consisted of four hour-long lectures
\ngiven by the professor, followed by a session
\nof six case reports from our daily clinical
\npractice, accompanied by interactive discus-
\nsions throughout the day. Of course, it was
\na great pleasure for the regional coordinator
\nof the AAF for Macedonia finally to see the
\nfirst such symposium in the country become
\nreality. Preparations are underway to orga-
\nnize the second one during this calendar
\nyear in the area of neurology in strategic
\npartnership with Clinical Hospital \u201cTrifun
\nPanovski\u201d from Bitola.
\nSpreading knowledge among doctors is
\nchallenging and dynamic work; though it
\ndiffers greatly from the everyday work of a
\npracticing physician, it nonetheless comple-
\nments and supports the primary goal of
\nimproving ourselves in order to improve pa-
\ntient care.
\nAssistant Professor Marija Vavlukis,
\nMD, PhD, Regional Coordinator
\nof AAF-OMI for Macedonia
\nEducation
\nPhase 1: Screening, March
\n24 – April 28, 2010
\nThe screening phase of this eye camp started
\non March 24,2010 at the orphanage center in
\nGalkacyo. Screenings were given by two oph-
\nthalmic technicians from Al-Nur Eye Hos-
\npital in Mogadishu who were supported by
\nthe staff of Galkacyo South Hospital.The eye
\ncamp was advertised through the local media
\nand by text messaging using the local tele-
\ncommunication network so that a maximum
\nnumber of patients could benefit from it.
\nPatients were examined and those in need
\nof medicines or glasses were treated. Blind
\npatients in need of surgery were scheduled
\nfor treatment during the surgical phase
\n(phase 2) and advised on the date of their
\nsurgery.
\nA total of 3037 patients benefitted from
\nphase1 by receiving free medications and\/or
\nglasses and 725 more patients were sched-
\nuled for surgery.
\nPhase 2: Surgery April 22-29, 2010
\nThis phase started on April 22, 2010 and
\nwas completed on April 29,2010.The surgi-
\ncal team was comprised of three ophthalmic
\nsurgeons and six ophthalmic technicians.
\nGallkacyo South Hospital\u2019s operating the-
\natre was used to perform the eye surgeries.
\nWe used the two-table technique to speed-
\nup surgical times,maximizing the volume of
\nsurgeries able to be performed.
\n725 patients were booked for surgery dur-
\ning this phase, and 626 surgeries were com-
\npleted successfully. 48 patients did not keep
\ntheir appointment, 33 patients\u2019 surgeries
\nwere cancelled due to underlying eye dis-
\neases which might have affected the out-
\ncome of surgery, and 18 patients had medi-
\ncal conditions that prevented them from
\nundergoing anesthesia
\nPost-operative Care: All surgical patients
\nwere examined by an ophthalmologist for
\npossible complications on the second day
\nafter their surgery, and were given eye drops,
\nantibiotics and sunglasses to protect their eyes.
\nThey were also given advice and instructions
\non mobility, food and work.The Somali oph-
\nthalmic technicians remained at the hospital
\nSomali Medical Association
\nMSF- GALKACYO EYE CAMP
\nGalkacyo South Hospital Somalia
\nTable 1:
\nRegional distribution of OPD patients:
\nRegion
\nNo of
\nPatients
\n%
\nMudug 2608 85.87
\nSouth Somalia 125 4.1
\nEthiopia 118 3.9
\nRest of Puntland 93 3.06
\nGalgudud 55 1.81
\nSomaliland 23 0.77
\nHiran 15 0.49
\nTotal 3037 100
\nTable 2:
\nDetails of eye surgeries in Galkacyo eye camp
\n2010:
\nDate Female Male Total
\n22-Apr 56 36 92
\n23-Apr 48 55 103
\n24-Apr 53 52 105
\n25-Apr 51 46 97
\n26-Apr 46 48 94
\n27-Apr 41 43 84
\n28-Apr 18 17 35
\n29-Apr 8 8 16
\nTotal 321 305 626
\n% 51.3 48.7 100
\nChart 1: Number of surgeries\/Day:
\n204
\nfor an additional week to treat any post-oper-
\native complications and give advice to surgical
\npatients.There was one case of post-operative
\ninfection,the source of which was determined
\nto be a personal hygiene issue. The infection
\nwas treated aggressively with local and general
\nantibiotics and mydriatics which helped us
\nsave the sight of the patient.This represents an
\ninfection rate of 0.016% which is well below
\nthe WHO accepted level of < 2%.\nChallenges:\nDuring our presence at Galkacyo Eye Hos-\npital, I gave a presentation on the manage-\nment of ophthalmic emergencies to the\nentire hospital staff, each of whom also re-\nceived an eye screening.The Galkacyo Hos-\npital management and staff members were\nvery cooperative and no major challenges\nwere encountered during this eye camp.\nRecommendations:\nAs this eye camp has demonstrated the high\nprevalence of blindness in Somalia and the\nlack of eye services available to the general\npopulation, I would like to recommend to\nMSF the following:\nTo hold similar eye camps twice every\u2022\t\nyear, as they have been clearly demon-\nstrated to be a valuable service to the\ncommunity.\nImproved planning for the logistics,\u2022\t\nmedicines and consumables needed for\nthe eye camp.\nInvolvement of an MSF management\u2022\t\nteam in the planning and implementation\nof the eye camp.\nI would like to take this opportunity to thank\nthe management and staff of MSF for their\nsupport throughout this eye camp. I am also\ngrateful to the team of surgeons and techni-\ncians that supported me throughout this eye\ncamp for their tireless efforts and their high\nwork ethic. Last, but not least, I would like\nto acknowledge the support and encourage-\nment I have received from the chairman\nand operational team of Right to Sight.\nEye camp team: 3 Surgeons, 1 Camp man-\nager, 5 Ophthalmic technicians, 1 Anesthe-\nsia technician,2 Screening Nurses and MSF\nGalkayo South hospital team\u2019s support\nDr. Abdirisak Dalmar\nPresident, Somali Medical Association\nConsultant Ophthalmologist &\nHead of Training and Research\nRight to Sight, London, UK\nRegional and NMA news\nThis is Ayan Ali. At just ten years old, she was\nthe youngest person we treated. Congenital\ncataracts in both her eyes meant she had been\nblind since birth.\nWe only operate on one eye at a time.Here we\u2019ve\nmade sure Ayan\u2019s left eye is covered to protect it\nfrom infection.\nAs you can see, we use only the simplest equip-\nment.A microscope and light \u2013 Ayan\u2019s surgery is\ndone by hand. It takes a lot of skill and a steady\nhand. Not many doctors in the UK know how\nto do this operation manually any more.\nJust 24 hours later, Ayan returned to the eye\ncamp for a check up. Already, she could see with\nher left eye. When I held up my fingers, she told\nme she didn\u2019t know how to count very well,\nso we spent the next few minutes learning to\ncount the numbers from one to ten \u2013 using her\nsight for the very first time.\nThe surgery is more difficult for children to cope\nwith, so we gave Ayan a general anaesthetic.\nAfter a short 15-minute surgery, Ayan is car-\nried to the recovery room by one of the many lo-\ncal members of the team here, where her mother\nwas waiting.\n205\nRegional and NMA news\nSe\u00e1n Tierney\nThe Irish Medical Organisation (IMO)\nwas founded in 1984 following the amal-\ngamation of the Irish Medical Union and\nthe Irish Medical Association that brought\ntogether the union and professional repre-\nsentative groupings of doctors in Ireland.\nThrough this process, the IMO became the\nsole negotiating body on behalf of all doc-\ntors in Ireland. The role of the IMO is to\nrepresent doctors in Ireland to provide them\nwith all relevant services. It is further com-\nmitted to the development of caring, effi-\ncient and effective Health Services.\nStructure\nCouncil of the IMO is the overall govern-\ning body of the Organisation for policy\ndirection and implementation. In addition\nto Council there is the Management Com-\nmittee who meet eight times a year and\nmonitors the performance of the secretariat,\nreceives monthly accounts and ensures that\npolicy is being implemented.\nThe IMO also has four Specialty Groups\nthat address specific issues affecting the\nrelevant groups. Members of the Speciality\nGroups are elected annually. Each Specialty\nGroup contains regional and specialty rep-\nresentatives.\nThe Specialty Groups within the IMO are:\nThe Consultant Committee\u2022\t\nThe General Practitioner Committee\u2022\t\nThe Non-Consultant Hospital Doctor\u2022\t\nCommittee\nThe Public Health Doctor Committee.\u2022\t\nThere are two Standing Committees, Inter-\nnational Affairs and Ethics Committees:\nThe International Affairs Committee has\nresponsibility of representing the IMO at\ninternational meetings. The IMO is cur-\nrently active members of CPME, EANA,\nPWG, UEMO, UEMS and the WMA.\nMajor Issues\nGiven the economic climate globally \u2013 and\nparticularly in Ireland \u2013 there are issues that\nhave come to affect the medical profession,\nregardless of specialty or location.\nThe IMO is continuously engaging in talks\nwith government over a number of issues,\nparticularlyregardingtheimplementationof\npolicies that have seen a pronounced impact\non our membership. The IMO has worked\nhard to alert the HSE, the Department of\nHealth and Children and the broader Gov-\nernment to the dangers of pursuing cost\ncuts now that end up costing more money\nin the long run. It is vital at this time of un-\ncertainty that the IMO remains focused on\nprotecting the essential fabric of our health\nservices for our health professionals seeking\nto deliver quality services to their patients.\nResearch and Policy\nAs the representative body for the medical\nprofession in Ireland, one of the key activi-\nties of the IMO is advocacy. Through the\nResearch and Policy Unit, the IMO pub-\nlishes key position papers during the year\nalong with submissions on policy initiatives\nthat represent the views of the member-\nship.\nThe most recent position paper was pub-\nlished in April on Universal Health Cov-\nerage, which looks at the principles that\nshould underpin any Universal Health Care\nSystem.\nSuch papers, along with submissions on\nvarious government and non-government\nconsultations, are hoped to influence and\ninform Government proposals, and to rec-\nognise the unique and important role that\ndoctors play within the delivery of health\nservices.\nRole of the Doctor\nOne of the key roles of the IMO is to pro-\ntect and promote the Role of the Doctor in\nIreland. Through the active representation\nof Irish doctors both domestically and in-\nternationally, we hope to ensure the medi-\ncal profession is strong and will continue to\nadvocate for the development of a caring,\nefficient and effective Health Service.\nChief Executive: Mr George McNeice\nPresident: Professor Se\u00e1n Tierney\nVice President & Chair of the GP\nCommittee: Dr Ronan Boland\nTreasurer: Dr Anthony O\u2019Connor\nHonorary Secretary: Dr Bridin Cannon\nChair of the NCHD Committee:\nDr Matthew Sadlier\nChair of the Public Health\nCommittee: Dr Paul McKeown\nChair of the Consultant Committee:\nDr Trevor Duffy\nWebsite: www.imo.ie\nThe Irish Medical Organisation\n206\nIn October, 2008, the Ukrainian Medical\nAssociation (UMA) became a constitu-\nent member of the WMA during the 59th\nWorld Medical Assembly in Seoul, South\nKorea. On November 4, 2008 a press con-\nference was held in Kyiv to announce the\nmembership of the UMA in the WMA.\nThe President of the UMA,Oleg Musii,the\nChairman of the Board of the UMA, Stan-\nislav Nechaiv, and UMA board member\nand Ukraine Parliament member, Volod-\nymyr Karpuk,were present at the press con-\nference to answer questions from Ukrainian\nand foreign journalists.This marked the be-\nginning of a productive year for the UMA,\nsummarized as followed:\n1. In the spirit of co-operation, the UMA\u2019s\nfirst priority as a new WMA member was\nto arrange the Ukrainian translation and\npublication of the WMA\u2019s \u201cMedical Ethics\nManual\u201d\n2. On December 23, 2008, Law (\u21163539)\n\u201cAbout Medical Self-Government\u201d was\npresented to the Ukrainian parliament.\nDrafted by the UMA to develop the idea\nof independence of the medical profession,\nLaw 3539 had long been under consider-\nation by the Advisory Council of the Com-\nmittee of Health of the Verkhovna Rada\n(the Parliament) of the Ukraine.\n3. From May 19-22, 2009, the Ukrainian\nMedical Association took part in the 112th\nCongress of the German Medical Associa-\ntion in Germany.\n4. On June 5, 2009, the UMA presented its\nUkrainian translation of the second edition\nof the WMA\u2019s \"Medical Ethics Manual\"\nCarried out jointly by the UMA, the Ger-\nman Medical Association and the Finnish\nMedical Association, the largest contri-\nbutions to the quality of the translation\nare credited to: Yuriy Kundiyev (National\nAcademy of Science of the Ukraine and the\nAcademy of Medical Science of Ukraine),\nVitaliy Radchuk (Associate Professor of\nthe Taras Shevchenko National Univer-\nsity), Stanislav Nechaiv (Master of Health\nManagement), Dr. Oleg Musii (Master of\nHealth Management),and Dr.Nina Krush-\ninsky (Master of Health Management) with\ngeneral editorial credit given to Lubomyr\nPyrih (AMS of the Ukraine).\n5. On September 18, 2009, the UMA be-\ncame a member of the Forum of Medical\nOrganizations in Central and Eastern Eu-\nrope (ZEVA) during its 16th\nSymposium\nheld in the Serbian capital of Belgrade.\n6. The \"Ethical Code of Physicians of the\nUkraine\" was accepted during the 10th\nCon-\ngress of the Ukrainian Medical Association\nheld in Evpatoria From September 24-27,\n2009.\n7. From October 15-18, 2009, the UMA\ntook part in the 60th\nWMA General As-\nsembly in New Delhi, India.\nOn December 16, 2009 the President of the\nUkraine issued Decree \u2116 1055\/2009 \u201cCel-\nebrating 100 years of the Ukrainian Medi-\ncal Association\u201d and on February 24, 2010\nthe Cabinet of Ministers of Ukraine issued\nOrder \u2116 364-r \"About the preparation\nfor celebrating 100 years of the Ukrainian\nMedical Association\" Celebrations for the\noccasion were scheduled for September-\nOctober of 2010 and invitations were ex-\ntended to representatives of state and local\ngovernments, NGOs, leading medical ex-\nperts and veterans affairs, students of edu-\ncational institutions, scientists, and public\nfigures. Events planned for the celebration\ninclude scientific, medical and other health\ncare conferences, round tables devoted to\nthe value of the UMA, and the issuance of\nan engraved commemorative coin, postage\nstamp and envelope dedicated to the 100-\nyear anniversary of the UMA.The Ukraini-\nan Medical Association has worked many\nyears for the benefit of Ukrainian doctors,\nand in support of private medical practice.\nDr. Oleg MUSII, the President of the UMA\nDr. Stanislav NECHAIV, Chairman\nof Board of the UMA\nRegional and NMA news\nThe Ukrainian Medical Association after\nEntering to the WMA\nOleg Musii Stanislav Nechaiv\n207\nEducation\nThose working in the UK National Health\nService are accustomed to seemingly end-\nless reforms and changes in the NHS. Over\nthe past 15 years there have been many, es-\npecially in this century. Barely have the lat-\nest changes had time to be put in place. let\nalone given time for firm conclusions as to\noutcome, than further changes seem to ap-\npear.\nWithin weeks of the formation of the new\nCoalition Government following the June\nelection in the UK, the new government\npublished on the 12th July a White Paper\nbroadly setting out the most radical changes\nproposed since the foundation of the NHS.\nThe aims of the White Paper are indicated\nto be \u201cto\nput patients at the heart of everything the\u2022\t\nNHS does;\nfocus on continuously improving those\u2022\t\nthings that really matter to the patient-\nthe outcomes of healthcare;\nempower and liberate clinicians to inno-\u2022\t\nvate, with freedom to focus on improving\nhealthcare services.\u201d\nThe most radical proposals are that Gen-\neral Practices through Consortia of GP\u2019s,\ncomposed of representatives of each Gen-\neral Practice in an area, should be charged\nwith the Commissioning of most Health-\ncare services.These Consortia are to replace\nthe Primary Care Trusts ( PCTs) currently\nresponsible for the Commissioning of ser-\nvices. PCTs are to be phased out over the\nnext three years.\nThe GP Consortia are to be supported by\nguidance from a National autonomous\nCommissioning Board which will provide\nleadership for quality guidelines, aimed at\nstandardising good practice in promoting\nquality and equity, and promoting patient\nand carer involvement and choice.This pro-\nposal represents a radical change in placing\npower at the level of the provision of prima-\nry care,where,as general practice has always\nmaintained, the direct continuing interface\nwith patients permits a broad knowledge of\ntheir needs.\nIn proposals to increase the freedoms of\nFoundation Trusts (often referred to as\nHospital Trusts), they will be licensed by\nMonitor (currently responsible for regulat-\ning Foundation Trusts) in the same way as\nother Providers whether from the private or\nvoluntary sector, thus increasing Founda-\ntion Trusts\u2019 autonomy.\nThe White Paper includes many other pro-\nposals including the introduction of a Na-\ntional Public Health Service, the employ-\nment by Local Authorities (who will be\nresponsible for health promotion and im-\nprovement) of Directors of Public Health.\nand also provisions aimed at increasing local\ncoordination of relevant activities between\nthe NHS , Local Authorities and local pop-\nulations, including empowering patient\u2019s\ninput into local services and patients\u2019choice\nwhich are part of the democratisation of the\nNHS at the root of the proposals. A paper\non these proposals is promised in the near\nfuture.\nThe White Paper is open to consultation\nuntil the 6th of October following which,in\nNovember, legislation will be presented to\nthe parliament. No hint of any such radical\nproposal for change was suggested by any\npolitical party during the run-up to the re-\ncent election.\nA number of more detailed consultation pa-\npers have been published in the weeks fol-\nlowing the White paper.They provide more\ndetail of the various proposals and a detailed\ntimetable leading to full implementation in\nthree years. These papers are the subject of\nconsultation with continuing discussions\nand submissions by designated dates.\nDr Hamish Mel drum, Chairman of Coun-\ncil of the British Medical Association in a\nletter to all members concerning the White\nPaper said \u201cTaken together, these propos-\nals represent very significant changes to the\norganisation of health services in England.\nThe proposals include increased respon-\nsibilities for doctors, the phasing out of\nPCT\u2019s and SHA\u2019s ( Statutory Health Au-\nthorities at Regional level) and a greater fo-\ncus on outcomes,as well as perceived threats\nto education and terms of service. There are\nalso very significant proposals for the future\nof Public Health, with closer working with\nlocal authorities and ring-fenced budget in-\ntended to ensure the provision of a wider\npublic health agenda.\u201d He stressed the key\nproposal to devolve more involvement and\nfinancial control in commissioning to Gen-\neral Practitioners and that to be successful,\nthis would require the fullest engagement\nwith secondary care colleagues and also\nwith the public. High quality management\nsupport would be needed and the new GP\nConsortia would need to engage with expe-\nrienced NHS managers\u201d\nWhile the aims and proposals offer great\nopportunities and a challenging agenda, es-\npecially given the timescale, overall the pro-\nposals are not without risks -as a number of\nexpert commentators have commented.\n(i)\u201cEquity and Excellence \u2013 Liberating the\nNHS\u201d Crown copyright\nISBN 9780101788120\nRadical changes proposed in the NHS\n(England) Government White Paper on\nthe National Health Service \u2013 \u201cEquity and\nExcellence - Liberating the Health Service\u201d.(i)\n208\nWMA news\nComing to Vancouver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167\nWMA Supports Physicians in Refusing\nPunishment Request. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167\nFinal Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168\nImpact of Economic Crises on\nNational Health Care Systems \u2013 Experience and Strategies . . 168\nGlobal and local financial crisis \u2013\na challenge to the national health system. Example of Latvia . 173\nWhat are the Minimal Services to be\nProvided by the Healthcare System? . . . . . . . . . . . . . . . . . . . . 176\nHow can Health Care Systems be structured and\nmanaged to be less sensitive to crisis and play\na stabilizing role in economy?. . . . . . . . . . . . . . . . . . . . . . . . . . 177\nImpact of Economic Growth and Financial Crisis\non Estonia\u2019s Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179\nThe Institutional Factors that help Health Care System\nto hold up against Financial Crisis . . . . . . . . . . . . . . . . . . . . . 181\nSingapore Statement on Research Integrity . . . . . . . . . . . . . . . 185\nThe Impact of the Economic Recession on\nNurses and Nursing in Iceland . . . . . . . . . . . . . . . . . . . . . . . . 186\nLifestyle Practices of Medical Students\nattending an International Student Conference . . . . . . . . . . . . 193\nThe Norwegian Medical Association . . . . . . . . . . . . . . . . . . . . 195\nBangladesh Medical Association (BMA). . . . . . . . . . . . . . . . . 196\nHungarian Medical Chamber in the Last Twenty Years . . . . . 197\nMOTESZ \u2013 Association of Hungarian Medical Societies . . . 199\nAmerican \u2013 Austrian Foundation in Macedonia . . . . . . . . . . . 200\nThe Somali Medical Association . . . . . . . . . . . . . . . . . . . . . . . 203\nThe Irish Medical Organisation . . . . . . . . . . . . . . . . . . . . . . . . 205\nThe Ukrainian Medical Association . . . . . . . . . . . . . . . . . . . . . 206\nRadical changes proposed in the NHS (England)\nGovernment White Paper on the National Health Service \u2013\n\u201cEquity and Excellence - Liberating the Health Service\u201d. . . . . 207\nContents\nEFMA (European Federation of Medical Associations) \/\nWHO meeting in St. Peterburg 19\u201321 September 2010\n\n<\/p>\n"},"caption":{"rendered":"

wmj29 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, Inc G20438 Nr. 5, October 2010 Economic Crises on National Health Care\u2022 Systems \u2013 Experience and Strategies The Impact of the Economic Recession on Nurses\u2022 and Nursing in Iceland Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj29.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3606"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3606"}]}}