WMJ 05 2011

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, Inc
G20438
Nr. 5, October 2010
Economic Crises on National Health Care•
Systems – Experience and Strategies
The Impact of the Economic Recession on Nurses•
and Nursing in Iceland
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Dr. Edward HILL
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WMA Secretary General
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167
An exiting year lies behind us since the General Assembly in New
Delhi. Council and General Assembly will consider new policy and
potentially adopt new bylaws.The work groups will come back with
new proposals and Council will start rolling out a new strategic plan
for the coming years.
By far the heaviest paper before Council (and if Council adopts
it – the General Assembly) will be a consolidated set of bylaws and
Procedures and Operating Policies which should bring logically
together what has developed as rules of the organization over the
past decades,but was scattered over different documents,sometimes
with conflicting, often outdated wording.
Our rules weren’t bad at all, but they were from a time when mail
took weeks, fax machines could only be found in the offices of the
big newspapers and the Internet was unknown. The changes that
were made merely adapted the old rules, but were added in sec-
ondary documents, sometimes in contradiction to the still valid old
wording of the by- laws or, at least, leaving some ambiguities.
The consolidation before Council does not bring new rules to be
applied, but it provides clarity and stringency returns to our bylaws.
As in the past, the General Assembly will charge the Council with
the operational policies and procedures,which then will form a clear
set of rules, hopefully leaving no questions open.
Our association has been in a difficult situation with our President-
Elect, Dr. Ketan Desai, arrested on April 22nd this year. First, under
charges of bribery, and as he was not indicted for that, thereafter
under charges of “disproportionate assets”. He has been kept in cus-
tody.Months have gone by,but no “charge sheet”,as indictments are
called in India, has been filed against him. At the end of Septem-
ber he was released from custody and we are anxious to hear from
him in Vancouver. His friends have always stated that the arrest
was politically motivated. It was aimed to take him out of power as
the government finally tried to dismantle physician self-governance
with a new act on the Medical Council of India (MCI).
Indeed the new parliament hurried up and a few days after passing
the law that is designed to turn the largest self-governed physician
body of the world into a government watch dog Ketan Desai was
released. For nearly ten years he had combated the government’s
attempts to get rid of the self-governed MCI, including protests
and a countrywide strike. The charismatic and powerful leader had
become a state-enemy.
There are more questions open now than answers are available. But
the real answer may lie in what the famous André Wynen told us
when he resigned from office: “A medical leader should be intelli-
gent, but in the first place a leader should be courageous.” He knew
what he was talking about, as a member of the Belgian Resistance
he spent the winter 1944 to 1945 as prisoner at the Concentra-
tion Camp in Buchenwald. We will have to be courageous and
intelligent.
Dr. Otmar Kloiber
WMA Secretary General
Coming to Vancouver
The World Medical Association supports
physicians in Saudi Arabia in refusing to
carry out a punishment as suggested by a
court that would be a severe breach of med-
ical ethics.
This follows the recent request to hospitals
by a Saudi Arabian judge to damage a man’s
spinal cord as a punishment for his attack-
ing and paralyzing another man.
Dr. Dana Hanson, President of the WMA,
said: “This is an appalling request and one
which every physician must resist. As the
WMA’s Declaration of Tokyo clearly states
no physician should participate in the prac-
tice of torture or any other forms of cruel,
inhuman or degrading procedures,whatever
the offence of which the victim of such pro-
cedures is suspected, accused or guilty of.
The Declaration also includes a prohibition
of participation in the planning or advising
for such a procedure.
“Physicians must at all times preserve their
ethical independence. The Declaration of
Geneva states that, ‘The health of my pa-
tient will be my first consideration,’ and the
International Code of Medical Ethics de-
clares that, ‘A physician shall act only in the
patient’s interest when providing medical
care which might have the effect of weaken-
ing the physical and mental condition of the
patient.’
“This refers to all patients whatever their
status”.
For further information please contact:
Dr. Otmar Kloiber
WMA Secretary General
+33 4 50 42 6757
Nigel Duncan
WMA Public Relations Consultant
+44 (0) 20 8997 3653
WMA Supports Physicians in Refusing
Punishment Request
Press release, 24 August 2010
168
WMA news
The most widely used indicator of an eco-
nomic crisis is the decline of the Gross
Domestic Product (GDP), which measures
the economic activity in a country. When
GDP declines for at least two consecutive
quarters, an economy is typically declared
to be in recession. A GDP decline which is
substantial (e.g., – 10%) and sustained (e.g.,
lasting two or more years) is often called an
economic depression.
While recessions are part of the business
cycle of economies and are nothing new,the
most recent recession was unprecedented
in its scope. Reflecting the growing inter-
dependency of economies, it was the first
global recession, as shown in Figure 1.
There are reasons to expect that the recent
economic crisis may result in a health cri-
sis. Because of the economic crisis, health
expenditure may be cut. Absent compen-
sating efficiency improvements, such a cut
may lead to a deterioration in a population’s
The global economic crisis has made a sig-
nificant negative impact on public health
and health care systems all over the world.
The impact has been particularly detrimen-
tal for the health of low-income population
groups, as well as for women and children.
Growing unemployment and poverty, as
well as crisis-inflated payments for health-
care services have frequently prevented
people from turning to timely health-care.
Though countries have had varied success in
handling the impact of the crisis on health-
care systems, progress has been better in
those countries where the respective gov-
ernments have managed to maintain their
health budgets and have seen the crisis as an
opportunity for taking strong decisions on
the reforms to be carried out, making long-
term contributions to the management of
the health-care system, prioritising on in-
vestments in human capital, improvement
of its productivity and better use.
Economic crisis is a time for deeper con-
templation. Governments together with
medical associations and health-care pro-
fessionals have to reconsider correlations
between economics and health-care policies
with a clear understanding that investments
in health are investments in a country’s hu-
man resources which are at the basis for the
economic development of any country.
The time of economic crisis is a time for op-
portunities. It is the right time for modi-
fying health-care systems, abandoning
what has been superfluous and excessive,
at the same time sustaining the resources
for health-care. The emphasis should be on
adequate availability of services, through
providing for evidence-based patient needs.
Decisions have to be taken by way of chan-
nelling new resources towards prevention,
health promotion and primary health care.
It has to be acknowledged that in most
countries allocations for prevention are dis-
proportionately small and they should not
be further reduced during a time of crisis;
on the contrary – we should look at addi-
tional and more focused investment in or-
der to reduce the long-term impact of the
crisis on public health.
Economic crisis is a time for taking respon-
sibility, with the public and private sectors
having particularly important roles to play
in placing health issues high on the public
and political agenda.Health budgets should
be safeguarded and used rationally. Health
is hardly the sector to be reduced when
governments have a problem in coping with
balancing the budget.
Lessons learned from this conference in-
clude the vital importance of setting a high-
er priority on health-care and health-care
spending during times of economic down-
turn, while understanding and encouraging
counter-cyclical health expenditure strate-
gies.Both the private and public health-care
sectors must understand that investment in
health-care, especially investment in human
capital, continuing education and primary
care, as well as research is critical for the
wellbeing and sustainability of health-care
and the economy for present and future
generations.
Final Conclusions
WMA conference on “Financial crisis and its implications
for health care”, Riga, September 10-11th
2010
Impact of Economic Crises on National Health
Care Systems – Experience and Strategies
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
Reinhard Angelmar
169
WMA news
health status. An increase in the need for health care resulting from
the negative effects of economic distress on health could further ag-
gravate this deterioration.
I will concentrate here on the impact of an economic crisis on health
expenditure. Two main questions will be addressed: (1) Does a de-
cline in GDP always lead to a decline in health expenditure or, less
damaging, to a slow-down in the growth of health expenditure? (2)
Do public and private health expenditure respond in the same way
to a decline in GDP?
Does a decline in GDP always lead to a decline in health expen-
diture?
A decline in GDP generally leads to a decline in the financial re-
sources of households, firms, and governments due to rising un-
employment, reduced profits, and lower tax revenues. When an
economic crisis is accompanied by a financial crisis, the declining
value of stocks, houses and other assets further reduces the ability
to finance expenditures for health care and other items through the
sale of these assets. And when a crisis is global, remittances from
abroad and foreign aid are likely to diminish as well. Unless health
expenditure is seen as a high priority compared with other types of
expenditures, one would expect health expenditure to decline in a
recession along with GDP.
The expectation that a GDP decline leads to a decline in health
expenditure is consistent with the many studies that have shown
a positive relationship between the growth of GDP and of health
expenditure [1]. If health expenditure goes up when GDP goes up,
it should also go down when GDP goes down.One would therefore
expect that the number of years of declining health expenditure over
time matches the number of recession years in a country.
Figure 2 plots the percent of years with negative GDP growth
against the percent of years with negative health expenditure growth
for the 34 countries included in the OECD (Organization for Eco-
nomic Cooperation and Development) Health Data 2010 database.
Both GDP and health expenditure growth are in real terms, that is,
removing the effect of inflation, and on a per capita basis. For each
country, the analysis uses all available years since 1980.
The diagonal line in Figure 2 represents the expectation that the
number of years with a decline in health expenditure (negative health
expenditure growth) is equal to the number of recession years (years
with negative GDP growth). Figure 2 shows that there is indeed a
number of countries which fit this expectation (e.g., Italy, Germany,
Spain, Chile, Korea) or come close to it (e.g., Israel, Denmark, Ire-
land). However, there are also three countries which, despite having
experienced recessions, have not seen a cut in health expenditure
(USA, France, Australia). In the opposite direction, one finds coun-
tries in which a decline in health expenditure has occurred more
frequently than a decline in GDP (e.g., Hungary and Norway).
Economic crises and health expenditure crises therefore are not as
tightly connected as one would expect, at least in the OECD coun-
tries. A decline in GDP is neither a necessary (e.g., Hungary) nor
a sufficient (e.g., USA) condition for health expenditure to decline.
Whether an economic crisis leads to a cut in health expenditure
varies from one country to the next.
What explains the country differences in the link between economic
and health expenditure crises? Figure 3 indicates that a country’s
income plays a significant role. The greater a country’s GDP per
capita (at US$ purchasing power parity), the lower the frequency
Figure 1. Real Annual GDP Growth
-4
-2
0
2
4
6
8
10
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
RealGDPGrowth(%)
World Advanced economies Emerging and developing economies
Source : International Monetary Fund, World Economic Outlook
Database, April 2010
Figure 2. Frequency of Health Expenditure Decline and of GDP
Decline
USA (1980-2008)
UK (1980-2008)
TUR (1983-2007)
CHE (1980-2008)
SWE (1980-2008)
ESP (1980-2008)
SVN (1996-2008)
SVK (1998-2008)
PRT (1980-2006)
POL (1991-2008)
NOR (1980-2008)
NZL (1980-2008)
NLD (1980-2008)
MEX (1991-2008)
LUX (1996-2006)
KOR (1981-2008)
JPN (1980-2007)
ITA (1989-2008)
ISR (1980-2008)
IRL (1980-2008)
ISL (1980-2008)
HUN (1992-2008)
GRC (1988-2007)
DEU (1980-2008)
FRA (1991-2008)
FIN (1980-2008)
EST (2000-2008)
DNK (1980-2007)
CZE (1991-2008)
CHL (1996-2008)
CAN (1980-2008)
BEL (1980-2008)
AUT (1980-2008)
AUS (1980-2007)
0%
5%
10%
15%
20%
25%
30%
35%
0% 5% 10% 15% 20% 25% 30% 35%
Percentof years withGDPdecline
(onaverageevery7.1years)
Percentof years with
healthexpenditure
decline
(onaverageevery8.1
years)
Source: OECD Health Data 2010
170
WMA news
of a decline in health expenditure compared with the frequency of
a decline in GDP. In high-income countries, health expenditure is
more protected in recession times than in lower-income countries.
Does a decline in GDP always lead to a slow-down in the growth
of health expenditure?
The preceding discussion has shown that the worst case outcome
of an economic crisis, namely a decline in health expenditure, does
not always occur. But should one not at least see a slow-down in the
growth of health expenditure during a recession?
When one analyzes the evolution of GDP growth and health ex-
penditure growth over time, one sees a diverse pattern of health
expenditure response to a recession, both within one country, and
across countries. This diversity is illustrated in the following figures
from the U.S., the country with the highest per capita health ex-
penditure (2008), and from Turkey, the country with the lowest per
capita health expenditure (2007) in the OECD health data.
Figure 4 shows the evolution of the growth of real per capita GDP
and health expenditure in the U.S. between 1979 and 2008. U.S.
GDP growth displays significant fluctuations,called business cycles,
punctuated by recessions in 1980 and 1982 (a “double-dip” reces-
sion), 1991, 2001 and 2008.Three different types of health expendi-
ture response to a recession are apparent:
Acyclical behavior, in which health expenditure growth is unrelated
to GDP growth (no correlation between GDP growth and health
expenditure growth): in 1982,GDP declined significantly,yet health
expenditure growth changed very little; furthermore, while GDP
growth fluctuated widely between 1981 and 1985, health expendi-
ture growth showed little variation during the same period.
Pro-cyclical behavior, in which health expenditure growth increases
when GDP growth increases, and slows down when GDP growth
slows down (positive correlation between GDP growth and health
expenditure growth): during the 1991 and 2008 recessions, health
expenditure growth slowed down considerably.
Counter-cyclical behavior, in which health expenditure growth in-
creases when GDP growth slows down, and goes down when GDP
growth goes up (negative correlation between GDP growth and
health expenditure growth): during the 1980 and 2001 recessions,
health expenditure growth actually increased; the years 2003 and
2004 also demonstrate counter-cyclical behavior: GDP growth in-
creased whereas health expenditure growth declined.
The diverse response pattern apparent in the U.S. stands in stark
contrast to the consistent pro-cyclical behavior one sees in Turkey
(see Figure 5). In all recession years for which health expenditure
data are available (1985, 1989, 1991, 1994, 2001), health expendi-
ture behaved in a pro-cyclical manner, either declining (1985, 1994,
2001) or experiencing a growth slow-down (1989 and 1991). Pro-
cyclical behavior is also present in most non-recession years, with
health expenditure growth rising and falling in parallel with GDP
growth.
Only a pro-cyclical behavior of health expenditure is consistent
with the many studies that have found a positive relationship be-
tween GDP growth and health expenditure growth. Acyclical and
counter-cyclical responses, such as the ones that one observes in the
U.S., are not. The solution to this puzzle may well lie in the meth-
ods used in these studies. In a recent study of OECD countries,
one econometric method found only positive relationships between
Figure 3. Years with Health Expenditure Decline / Years with GDP
Decline and GDP per capita (US$ PPP)
TUR
CHE
ESP
USA
UK
SVK PRT
POL
NZL
NLD
MEX
KOR
JPN
ITAISR
IRL
ISL
HUN
GRC
DEU
FRA
FIN
EST
DNK
CZE
CHL
CAN
BEL AUT
AUS
NOR
LUX
R2 = 0.24
(excluding LUX & NOR)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0 10,000 20,000 30,000 40,000 50,000 60,000 70,000
GDP per capita US$ PPP
Years with health
expenditure decline /
Years with GDP decline
Source: OECD Health Data 2010
Figure 4. GDP Growth and Health Expenditure Growth in the US
-4%
-2%
0%
2%
4%
6%
8%
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
AnnualGrowth
Growth of real per capita GDP Growth of real per capita health expenditure
Source: OECD Health Data 2010
171
WMA news
GDP growth and health expenditure growth, indicating procycli-
cal behavior of health expenditure in all countries. However, using
another method, the authors found no or negative relationships for
some countries, indicating acyclical or counter-cyclical health ex-
penditure behavior in these countries [3]. Again, the link between
the evolution of GDP and health expenditure appears to vary great-
ly across different countries.
Do public and private health expenditure respond in a similar way
to a GDP decline?
The question of how health expenditure behaves over the business cy-
cle is particularly relevant for public health expenditure. Government
policy makers might seek to stabilize health expenditure through a
counter-cyclical public health expenditure policy, compensating pro-
cyclical private health expenditure. In addition, such a policy could
also be an instrument for macroeconomic stabilization. Pro-cyclical
public health spending, by contrast, might reflect a passive, hands-off
approach to health expenditure and economic fluctuations.
Panel A of Figure 6 shows the evolution of GDP growth and public
expenditure growth in the U.S. between 1979 and 2008. In four
out of the five recessions during this period, public health expendi-
ture increased, in addition to displaying counter-cyclical behavior in
many non-recession years as well. In stark contrast to the counter-
cyclical behavior in the U.S., Panel B of Figure 6 shows that public
health expenditure in Turkey was highly pro-cyclical. Health ex-
penditure growth slowed down in all five recession years for which
health expenditure data are available. Throughout, health expendi-
ture growth generally moved up and down in parallel with GDP
growth. The counter-cyclical behavior of public health expenditure
in the U.S. and its pro-cyclical behavior in Turkey observed here is
consistent with the results obtained by Hercowitz and Strawczynski
[2] in their analysis of the cyclicality of total government expendi-
ture in these two countries over the 1975-1998 period.
Figure 7 allows to compare the cyclical behavior of public and pri-
vate health expenditure. Panel A shows that the growth of public
and private health expenditure in the U.S. evolved in opposite di-
rections during three out of the five recession years, with growth
in non-recession years also often showing opposite behavior. This
indicates that public and private health expenditure in the U.S. were
to some extent substitutes,with private health expenditure compen-
sating for a slowdown in public health expenditure and vice versa.
Similar to what one saw in the previous comparisons,the pattern for
Turkey in Panel B of Figure 7 is different from that for the U.S. In
Turkey, both public and private expenditure growth display pro-cy-
clical behavior, slowing down together in recession years. However,
whereas private health expenditure declined or stopped growing in
Figure 5. GDP Growth and Health Expenditure Growth in Turkey
-40%
-30%
-20%
-10%
0%
10%
20%
30%
40%
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Annualgrowth(%)
Growth of real per capita GDP Growth of real per capita health expenditure
Source: OECD Health Data 2010
Figure 6. GDP Growth and Public Health Expenditure Growth in the
US and Turkey
A. US
-4%
-2%
0%
2%
4%
6%
8%
10%
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
AnnualGrowth
Growthof realper capitaGDP Growthof realper capitapublic healthexpenditure
B. Turkey
-20%
-10%
0%
10%
20%
30%
40%
50%
60%
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
AnnualGrowth
Growth of real per capita GDP Growth of real per capita public health expenditure
Source: OECD Health Data 2010
172
WMA news
all recession years, public health expenditure kept growing, albeit at
a slower rate,in three of these years (1999,1991,2001) and declined
significantly less than private expenditure during the two other re-
cession years (1985 and 1994). Public health expenditure in Turkey
thus was much less negatively impacted in recession years than pri-
vate health expenditure, thereby softening the negative impact on
health expenditure of the latter.
Beyond their differences, there is therefore an important common-
ality between the U.S. and Turkey. In both countries, private health
expenditure responded more negatively to recessions than public
health expenditure, and the latter contributed to reducing the fluc-
tuation in health expenditure over the business cycle.
Conclusion
It is often thought that economic crises induce a reduction in the
level or growth of health expenditure. However, the data from
OECD countries examined here indicate that the impact of eco-
nomic crises on health expenditure is more varied than expected.
Some countries have never cut health expenditure in recent decades
despite going through several recessions, others have experienced
significantly more years with expenditure cuts than years with re-
cessions, and many fall between the two extremes. And whereas in
many countries as expected the growth of health expenditure slows
down or becomes negative in response to a recession, one also finds
countries where health expenditure growth displays a counter-cy-
clical behavior, going up when GDP declines, and slowing down
as GDP growth rises. Public health expenditure in particular may
show such counter-cyclical behavior, or at least experience less of a
growth slow-down compared with private health expenditure.
Health expenditure enjoys greater immunity against recession-in-
duced cuts in high-income than in lower-income countries. Future
research should identify other determinants and discover what ex-
plains counter-cyclical or pro-cyclical behavior of overall,public and
private health expenditure.
This article has addressed only the question of how economic crises
impact health expenditure. Considering their respective impact on
health during an economic crisis, a counter-cyclical health expendi-
ture policy seems to be preferable to a pro-cyclical policy. However,
the impact of health expenditure on health also depends on how
the money is spent. An economic crisis may well be an opportunity
for improving the efficiency and equity of health expenditure. One
would hope that countries that cut health expenditure during a cri-
sis do so in a way that enhances both of these outcomes.
References
Gerdtham UG, Jönsson B. International comparisons of health expendi-1.
ture: theory, data and econometric analysis. In: Culyer AJ, Newhouse JP,
editors. Handbook of Health Economics. Vol. 1. 2000. p. 11-53.
Hercowitz Z, Strawczynski M. Cyclical ratcheting in government spend-2.
ing: evidence from the OECD. The Review of Economics and Statistics.
2004; 86(1): 353-61.
Baltagi BH, Moscone F. Health care expenditure and income in the3.
OECD reconsidered: evidence from panel data. Economic Modelling.
2010; 27: 804-11.
Reinhard Angelmar
Professor of Marketing
The Salmon and Rameau Fellow in Healthcare Management
Figure 7. GDP Growth, Public and Private Health Expenditure
Growth in the US and Turkey
A. US
-4%
-2%
0%
2%
4%
6%
8%
10%
12%
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
AnnualGrowth
Growthof realper capitaGDP Growthof realper capitapublic healthexpenditure
Growthof realper capitaprivatehealthexpenditure
B. Turkey
-60%
-40%
-20%
0%
20%
40%
60%
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
AnnualGrowth
Growth of real per capita GDP Growth of real per capita public health expenditure
Growth of per capita private health expenditure
Source: OECD Health Data 2010
173
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Girts Brigis
Background
Latvia is one of the so-called Baltic coun-
tries with a population of 2.3 million and
a territory of about 64,600 sq. kilometers.
It joined the European Union in 2004. Al-
ready before that Latvia experienced steep
economic growth and continued it within
the EU.The maximum increase was reached
during the period between 2005 and 2008.
Analysts of economy at that time called
this process an “overheating of economy”
and warned about possible problems in the
future. This period was characterized by an
annual increase in GDP by 11% (Figure 1),
with the annual consumer price inflation up
to 17% and high and uncritical crediting by
banks leading to a real estate bubble.Despite
this growth, the state budget remained with
a fiscal deficit.This was different in compar-
ison with the neighboring country Estonia,
where the budget reserve was accumulated
during the economic growth. It should be
mentioned that a very important economic
sector in Latvia was banking which was ac-
tive in providing international services.
After the breaking down of the Soviet Union
Latvia inherited the tax-based health care
system. Despite some political willingness to
turn to social insurance system, due to prag-
matic financial (e.g., relatively low income
and essential proportion of “grey” economy)
and demographic reasons (e.g., large propor-
tion of the elderly) Latvia found this system
feasible and efficient up to the present mo-
ment. However, Latvia experienced a period
with a marked proportion out of payroll tax
for health care in the late nineties.The reason
to abandon this approach was the low popu-
lation income and the necessity to subsidize
health system from other taxes by state. Also
in the mid nineties Latvia introduced pri-
mary health care system with family physi-
cians, did a partial privatization of services,
and started successfully to introduce health
promotion [1].
However, health care has never been con-
sidered as a priority by the Latvian parlia-
ment (Saeima) and government. Public
expenditure for health has never exceeded
4% of GDP, which is one of the lowest pro-
portions in Europe. Despite that, in gen-
eral, there was a trend of increase in public
spending for health during the years of eco-
nomic growth (Figure 2).
At the beginning of this century, the Lat-
vian government took a World Bank’s loan
to design and implement health sector re-
forms. One very important plan concerned
the structural reforms of Latvian health
care,because,from the Soviet times,the sys-
tem was oriented to inpatient care with too
many hospitals,hospital beds in comparison
with the Western European countries, and
correspondingly with an inefficient finan-
cial spending. Unfortunately the starting of
this plan was delayed and it was not started
during the so-called good years of economic
growth.
Effect of the global financial crisis on
the financing of Latvia’s health system
When the global financial crisis started
in 2008, many Latvian people did not pay
much attention to the events taking place in
the American and British banks. Therefore
it was quite a shock to the Latvian people to
suddenly hear about the bankruptcy of one
of the biggest banks in Latvia – Parex Bank.
Most of the biggest banks in Latvia are
owned by foreign (Scandinavian, German)
companies. Parex Bank was exceptionally
owned by local investors. After some hesi-
tation the Latvian government decided to
save this bank. Buy the way, today this hesi-
tation is considered as a mistake with quite
big losses. About one billion Latvian Lats
(about 1.4 billion Euros) were taken from
state budget for a deposit in that bank.Tak-
ing into account that the GDP in 2008 was
about 15 billion Lats (in absolute prices),
this decision lead to an immediate fiscal
crisis with a following economic crisis. The
Latvian government of that time decided
to apply to the international community,
in particular to the International Monetary
Fund, World Bank and European Commu-
nity, for a loan.The loan was given on a very
strict condition that the state budget deficit
was reduced. The essential budget consoli-
dation immediately influenced all the pub-
lic sector. The number of employees in the
public sector reduced, salaries decreased, in-
stitutions closed, and taxis increased.This in
turn led to a further slowdown of the econ-
omy of Latvia by aggravating the economic
crisis with progressing unemployment and
other social consequences. During the year
after the beginning of crisis GDP decreased
by 18% (Figure 1).
Global and local financial crisis – a challenge
to the national health system.
Example of Latvia
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
174
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State health budget was cut seriously. Figure 3 shows that during
the following 2 years public health spending reduced by 25 % [2].
The same can be seen in Figure 2: per capita expenditure decreased
from 253.9 Lats (362.7 EUR) in 2008 to 192.4 Lats (274.9 EUR)
in 2010 (budget plan). Already in 2008 out-of-pocket spending was
quite high in Latvia – about 39% according to WHO calculations [3].
There is no updated evidence about the current situation, but every-
day experience shows that the decrease in public expenditure has led
to a dramatic increase in out-of-pocket spending leading to serious
problems of access to health care of Latvian population. The Health
Minister of Latvia resigned in 2009 just after the categorical request
of the President of Ministers to do the next cut of health budget not
believing in the possibility to run the system with such a cut budget.
At the beginning of 2010 the Minister of Finance and the President
of Ministers recommended the Minister of Health to create an expert
working group to make an investigation into the possibilities for a
change in the health financing system in Latvia. The idea was to in-
troduce a private health insurance system with an aim to attract addi-
tional financial resources for health care and reduce the responsibility
of the government sector. The health financing models in the USA,
Netherlands, Austria and Estonia were analyzed. Despite disagree-
ments between the experts of health sector and financial sector (Bank
of Latvia) the final conclusion was to deny the idea as this involved
unavoidable increase in payroll tax and was unacceptable to employers
[4]. However, the discussion about health insurance is ongoing up to
the present moment, and outcome will depend on the results of the
Parliamentary Election (October 2010).There is a threat that the fi-
nancial and economic crisis in Latvia can lead to mistakes and unjus-
tified reforms with longstanding consequences for the health system.
Figure 1. GDP of Latvia (in comparative prices by 2000)
Source: Database of the Central Statistical Bureau of Latvia.
Figure 2.Expenditure from health budget per capita and as % from GDP
Source: Ministry of Health of Latvia, 2010 Figure 3. Health budget of
Latvia (mill. LVL)
Figure 3. Health budget of Latvia (mill. LVL)
Source: Ministry of Health; Report to the Saeima about the current situ-
ation in 2010.
Figure 4. Number of hospitals in Latvia
Source: Ministry of Health; Report to the Saeima about the current situ-
ation in 2010.
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Effects of expenditure cuts on the Latvian health care system
At the beginning of this decade the World Bank prepared a master
plan for the structural reforms of the health system of Latvia. Reduc-
tion of hospital beds was intended. The financial crisis and budget
cuts forced the Ministry of Health of Latvia to start immediate re-
forms. A number of hospitals were closed or transformed into social
care institutions in 2009. Figure 4 shows the decrease in the number
of hospitals. This resulted in the reduction in the proportion of the
health budget spent for hospital care from 61.4% in 2008 to 27.1%
in 2010. The relative spending for outpatient care in this situation
increased from 21.5% in 2008 to 30.7% in 2010.Unfortunately,there
was no increase for outpatient care in absolute numbers (Figure 5)
[2]. Also, it means that there was no other aim for reform but cuts.
This created additional burden for primary health care and emergency
care with no additional resources. Moreover, due to the financial di-
saster hospitals actually stopped all planned care financed with public
money.This raised additional demand for the delayed emergency and
acute care. Hospitals did not refuse acute care and found themselves
in serious debts. The Government, as an exclusion, allocated 26 mil-
lion Lats to partially cover these debts in the current year. It is nec-
essary to conclude that structural and probably other health system
reforms carriet out during the crisis with the only aim of financial cuts
are leading to system failure and social stress.
Probably the public health system (disease prevention,health promo-
tion, technology assessment, health information) suffered and is still
suffering most of all during the financial crisis in Latvia.Table 1 pro-
vides some selected comparative data on financial cuts. Public health
cuts during 2009 and 2010 reached 88.6%. Two leading institutions,
the Agency of Public Health and the Agency of Health Statistics and
Medical Technology, were closed leaving some minor functions to
the Health Economy Center, the Health Inspectorate, and the Cen-
ter of Infectology. An additional reason for that was pressure from
mass media and business to reconsider the functions of government
sector including health care and public health institutions. Poor un-
derstanding of the functions of public health led to the destruction
of the system which was successfully built for the last 15 years. Also,
public health represents a long-term vision for health with sustainable
achievements. Unfortunately, the financial crisis cancels any long-
term initiative.
At present there are some signs of financial stabilization in Latvia.Nev-
ertheless it is difficult to expect improvements in the near future. Be-
cause of the too high fiscal deficit, the International Monetary Fund, a
provider of the loan, requires further cuts in government spending.The
largest proportions of state expenditure perfain to social security, health
care and education. Also, the forthcoming election of the parliament
(Saeima) is providing a lot of populistic promises in the mass media and
delays serious budget planning. The nearest future will reveal the abil-
ity of the State of Latvia to fulfil the obligation under its Constitution:
Article 111 “The State shall protect human health and guarantee a basic
level of medical assistance for everyone”[5] .
References
Tragakes, E. et al. Latvia: Health system review. Health Systems in Transi-1.
tion.Vol.10.2008: European Observatory on Health Systems and Policies,
251.
Informative report “On the situation in health care” submitted to the Cab-2.
inet of Ministers on June 14, 2010. 2010, Ministry of Health of Latvia,
Riga.
European Health for All Database (HFA-DB). 2010, World Health Or-3.
ganization Regional Office for Europe.
Report on feasibility to introduce health insurance system in Latvia. 2010,4.
Ministry of Health of Latvia, Riga.
Constitution of Latvia. Available from: http://www.saeima.lv/LapasEng-5.
lish/Constitution_Saturs.htm
Girts Brigis, professor of Public Health and
Epidemiology at Riga Stradins University
Figure 5. Health budget distribution (in Lats); 2009 and 2010
Source: Ministry of Health; Report to the Saeima about the current situ-
ation in 2010.
Table 1. Budget cuts in the health care of Latvia (selected)
Func�on
Cuts in 2009
against 2008 (%)
Cuts in 2010
against 2008(%)
Treatment -10,2 -40,4
Public health -24,0 -88,6
Central administra�on -28,4 -58,6
Medical and health
educa�on at universty -27,1 -41,7
Administra�on of health
care financing -19,3 -67,7
Source: Ministry of Health and State’s Chancellery of the Cabinet of
Ministers.
176
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Konstanty Radziwill
Most of the European States have got con-
stitutional provisions stating that everyone
has the right for health. In most of them
public authorities must ensure equal access
to health care services financed from public
funds to all citizens, regardless of their fi-
nancial situation and a special health care is
provided to children, pregnant women, dis-
abled, chronicly ill and elderly persons.
Many European States specify conditions
and scope of healthcare benefits in high-
level rulings. There is a long list of areas of
health care to be covered: disease prevention
and early detection of diseases (including
vaccinations), primary health care, outpa-
tient specialist services, medical rehabilita-
tion,dental care,hospital care,psychological
care, long-term nursing and care (including
palliative and hospice care), spa treatment,
supply of medicinal products, and devices ,
transport , medical emergency services, etc.
Of course, the governments or parliaments
make decisions on the level of public spend-
ing on healthcare. However, in many Euro-
pean States decisions on public expenditures
on healthcare and the basket of healthcare
services guaranteed to citizens are made
independently. There is very little counting
how much the medical services guaranteed
cost. Public spendings most often are col-
lected from citizens’ contributions based
on their income, but they differ very much.
Public health spendings reached in Europe
an average level of 8.4% of GDP (ranging
from less than 3% in Cyprus to over 10%
in Sweden). It accounts for between 10 and
15% of total primary government spending
in most EU countries, although it is rang-
ing from 6.0% in Cyprus to 18% in Norway.
Of course, taking into account differences
in the GDP level, in real figures they differ
much, much more.
The share of healthcare spendings in all
public expenditures in Europe has been
growing, suggesting that in majority of the
European States health care budgets fared
better than other expenditure items during
periods of „fiscal consolidation”. Of course,
in some countries it has not.
Planning how much should be spent on
health care the real dilemma is to be faced:
how much responsibility for citizens’ health
belongs to the state and to which extent
individuals should feel it is their own busi-
ness?
The basic basket of medical services guar-
anteed to all the citizens of particular coun-
try may consist of medical rescue services,
prenatal care and newborn care, child care
(including assessment of health and devel-
opment and mandatory vaccinations), care
of women during pregnancy, childbirth, the
puerperium and of breast-feeding mothers,
long-term nursing and care (including pal-
liative and hospice care), hospital care and
outpatient specialist services for chronically
ill patients. If there are enough resources,
the list can be prolonged with disease pre-
vention and early detection of diseases (in-
cluding adults’vaccinations),primary health
care, medical rehabilitation, dental care,
psychological care, spa treatment, supply of
medicinal products and devices and medical
transport.
It seems that what is proved to be preven-
tive, urgent, necessary but expensive or
needed by the weakest and most vulnerable
patients should be considered as basic.
Preventive measures, often very simple and
relatively cheap, enable to save much in the
future. This is why health promotion and
information, preventive provisions (anti-
tobacco, anti-alcohol, anti-drugs, dietary,
sanitary, etc.) and necessary vaccinations
(also for adults) should be in the center of
public interest.
Urgent measures, such as medical rescue
services and emergent outpatient and hos-
pital care must be given to all in need with-
out any difficulties. It should be given also
with no limits to refugees, homeless unem-
ployed, etc.
Necessary (from the evidence based medical
point of view) but expensive hospital care
and one-day inpatient diagnostic/therapeu-
tic procedures should be also in the basket.
Procedures needed by the weakest and
most vulnerable patients, such as prenatal
care and newborn care, child care, care of
women during pregnancy, childbirth, the
puerperium and of breast-feeding mothers
and long-term nursing and care (particu-
larly palliative and hospice care) should be
also guaranteed.
Summarizing, the division of the responsi-
bilities between the state and citizens should
What are the Minimal Services to be
Provided by the Healthcare System?
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
177
WMA news
be designed.The state must feel responsible
for the health promotion, urgent, necessary
and expensive medical services and medi-
cal care over the weakest and most vulner-
able citizens. The individual citizens should
take care of health prevention matters and
all preventable and cheap procedures. In the
time of an aging population, rapid develop-
ment of medical sciences and public money
constrictions it is simply to be faced: “sub-
sidiarity of the state and not replacing all
people’s thinking is the must.”
Konstanty Radziwill, MD, President,
Standing Committee of European Doctors
Haino Burmester
From a theoretical point of view it might seem
simple to structure and manage health care
systems in a way that makes them less vul-
nerable to crises and, therefore, able to play a
stabilizing role in economy.Since the variables
involved in managing such health systems can
generally be ascertained or predicted by demo-
graphic an epidemiological studies, it should
be possible to factor them into a mathemati-
cal model to create a program that works. Of
course,this is not so! In practice things are far
more complicated and unpredictable then ex-
pected.So,let us explore the difficulties.
The problem with most health systems is
not only lack of proper funding but it is also
the amount of waste it is produced within
them. Problems in these systems (mostly
in developing countries) are therefore both
funding and management. Let’s be pro-
vocative. Either we agree with the following
assertion of Prof. Rosenthal or we do not:
“Health care is the economy and fixing it
would free up money for other priorities,
such as education and industrial innova-
tion.The health care system is dysfunctional
and full of waste — as much as 30% of all
spending. Unlike most other markets, con-
sumers rarely know which doctors, drugs
or treatments are best for them, don’t price
shop and, if they’re insured, don’t know the
full cost of care. And that all can lead to un-
necessary spending”. (Meredith Rosenthal,
a Harvard University professor of health
economics and policy).
It is also important to consider health prob-
lems beyond local, regional or national con-
texts only. As a report from the UN states:
“the paradigm of self-sufficiency has re-
cently been challenged.As part of the global
response to the HIV/AIDS epidemic, the
aim of national self-sufficiency was thrown
overboard by some activists. Wealthy na-
tions were pressured into contributing
their fair share by AIDS activists who ad-
opted human rights arguments to push for
expanded access to AIDS treatment, for
which the cost at the time greatly exceeded
the present and future financial capacity of
some of the most seriously affected coun-
tries. This new development aid approach
is based on the idea of building sustained
transnational redistributive fiscal transfers
and creating new within-country protective
mechanisms in poor nations.It appears to be
gaining ground. In April 2009, the Govern-
ment of Ethiopia signed a Joint Financial
Agreement with the World Bank, the U.K.
Department for International Develop-
ment, Ireland’s Irish Aid, and other donor
and U.N. agencies, which stated that Ethio-
pia needs an additional US$1.4 billion per
year, as a starting redistribution of capital,
to achieve the health-related Millennium
Development Goals. While this agreement
constitutes merely an acknowledgment of a
funding gap and a fundamental inequality
in resources, the fact that Ethiopia’s pres-
ent government health budget (including
present “on budget” development assis-
tance) stands at about US$400 million per
year indicates that an ambitious target has
been agreed to,one that can only be reached
through sustained transnational redistribu-
tive fiscal transfers a form of global social
health protection”.
In light of this global concern,there are some
policy questions that have to be answered to
sufficiently address the issue. These ques-
tions are related to the basic difficulties each
and every system must confront in order to
solve its problems: How are resources mo-
bilized and managed? Who pays for what
and how? Who provides goods/services and
what resources do they use? How are health
care funds distributed across different ser-
vices / interventions / activities produced
by the health system? Who benefits from
health care expenditure? In other words:
How can Health Care Systems be structured
and managed to be less sensitive to crisis and
play a stabilizing role in economy?
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
178
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how the system is planned and how it is
managed?
What are the challenges health care systems
must address under the stress of an econom-
ic crisis? At the fundamental level, it must
contribute to restoring confidence among
society as a whole by restoring/maintain-
ing the workers’ health as well as the health
of families and communities. In doing so,
it will ultimately be contributing to restora-
tion of the economic health of businesses,
which is a vital factor in returning the over-
all economy to normal.
Low income countries suffer when there is
reduced demand for their exports,which re-
duces access to capital. Foreign investments
decline as do remittances from people living
abroad. Unemployment comes and these
countries usually have no adequate safety
net to compensate for those in need. Pub-
lic sector services become the more favored
source of health care at the very time when
government revenues to finance these ser-
vices are under the greatest pressure.
High income countries also have their share of
health care problems.For example,the United
States has an incredible amount of resources
an unthinkable amount for most countries.
Americans spend more on health care than
the entire Brazilian GDP, including expendi-
turesforhealthcareprovidersalaries,hospitals,
outpatient centers, Veterans Affairs and other
clinics, doctor and dentist practices, physical
therapists, nursing homes, home health ser-
vices and on-site care at places such as schools
and work sites. It also includes retail sales of
prescription and nonprescription drugs, pre-
miums paid to health insurers and producers
of medical devices, surgical equipment and
durable medical equipment such as eyeglasses,
hearing aids and wheelchairs. It also accounts
for out-of-pocket payments by consumers
for health insurance premiums, deductibles
and co-payments. But, we will see that even
with such massive amounts of money spent
on health care, Americans also have problems
that,as we all know,are not due to any specific
financial crisis. Health insurance premiums
have skyrocketed, making it ever-tougher for
workers and employers to afford them. From
1999 through 2008, annual health insurance
premiums jumped 119%. The average family
premium paid by workers rose from $1,543 to
$3,354 per year, and employer payments per
worker jumped from $4,247 to $9,325. Dur-
ing that span, worker earnings rose only 34%
and overall inflation was just 29%. So worker
income has barely kept pace with inflation,
more of the paycheck is going to health costs,
and there is less income left over for things
like vacations, home improvements or a new
car — especially for low-wage workers and re-
tirees.This lack of disposable income for such
items represents a huge drag on the economic
growth, considering that consumer spending
powers about 70% of the American economy.
For employers, particularly small businesses,
rising insurance premiums mean far less
money for new equipment, better facilities,
research or expansion.That means fewer new
jobs,plus smaller raises and higher health pre-
miums for workers,further limiting consumer
spending.
High income countries take measures, in-
cluding complex and politically challeng-
ing reform, in anticipation of increases in
spending on health and pensions. But there
is also evidence that plans to set aside re-
sources and create the fiscal space to address
the future health needs of the elderly are
shelved as the crisis deepens.
It is critical for countries to protect life
and livelihood and to boost productivity by
maintaining levels of health and other so-
cial expenditures. If countries do not have
adequate reserves and revenues decline, the
shortfall will have to come from aid. And
this aid will need to be skillfully managed
for maximum impact. The critical point is
that commitments to maintain levels of aid
are not an extra element in the recovery
agenda, but integral to its success.
Under the circumstances of an economic cri-
sis, what can health systems do to help the
economy as a whole? First and foremost it is
important to gather quality, real-time infor-
mation to guide the response; there is no way
to act properly without solid data that allows
decision-makers, for example, to be able to
identify groups most at risk; to ensure that
safety net programs are well targeted so they
reach the most needy; to seek efficiencies in
spending where possible; to know where and
when external aid is required to ensure that it
effectively used.It is crucial to sustain spend-
ing on prevention (which is often the first ca-
sualty of spending cuts). And it is important
to recognize that crisis often offer opportu-
nities for reform; some of the best managed
health systems in the world verify the poten-
tial to improve under critical circumstances.
The former Canadian Minister of Health,
Marc Lalonde said in 1974 that the four
cornerstones of any health care system are:
human biology; the environment; lifestyle;
and health care organization. This theory is
as true today as it was in 1974. So, health
care organization demands a management
model that should be as effective in times of
crisis as in normal times.
Let us examine how the Brazilian health
system is structured and managed to be less
vulnerable to crisis and play a stabilizing
role in economy, not because it is neces-
sarily a model to be followed but because
it has survived the economic crisis without
major decreases in supply of health services.
In other words the system didn’t change its
normal level of effectiveness. It should be
noted that the system’s effectiveness may
still have a long way to go in order to achieve
excellence. But the system has a long his-
tory of trial and errors that brought it to its
present stage: far from maturity but with a
well-developed management model that is
constantly being improved little by little.
The principles of the Unified National
Health System (SUS) are the ideological ref-
erences on which the system is based. They
derive from the Constitution that states
health care as a right of the people and a duty
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WMA news
of the State to provide. At this moment, the
concept is being questioned as far as the re-
sponsibility of the individuals themselves for
their own health. Universality means that
every citizen has right to be cared for within
the system, but at this point we should also
introduce the duty of persons to care for their
own health with respect to other citizens.
Integral is related to the types of services
provides. The equity aspect is concerned
with fairness, equal rights, or equality (same
opportunity to all). Another important prin-
ciple is the socialcontrol over the system put
into practice by participation of the people
in the Health Councils. Administrative and
political decentralization is a cornerstone
of the system. The hierarchy principle di-
rects access to the services and must be done
according to the region where the person
resides and the acuteness of his or her con-
dition. Other principles that should be men-
tioned are: preservation of the autonomy of
patients facing diagnostic and therapeutic
procedures; total access to information con-
cerning care delivered; total knowledge of
the types of services provided by each facil-
ity; use of epidemiological data to determine
priorities; integration of health care delivery
with basic sanitation and environmental con-
cerns; coordinated use of federal, state and
municipal resources to avoid duplication of
public services provided at the same location
and for the same purpose; and resolution of
problems at the most appropriated level.
The basic structure of the health care orga-
nization in Brazil is based on its division of
responsibilities and attributions among the
three layers of power: federal, state and mu-
nicipal.When these three sources of financ-
ing act properly the system has a chance
to be successful. The three different levels
of financing according to the total budget
of each of these sectors of government are,
at a minimum: Federal Government 5%;
States 12%; and Municipal Governments
15%. Municipalities are responsible for
emergencies and primary care; the states are
responsible for secondary and tertiary care;
and the federal government is responsible
for general policy making and strategic de-
cisions plus the federal university hospitals
and medical schools.
SUS provides primary, secondary and ter-
tiary care delivered under contract or at
its own facilities; control and supervision
of procedures, products and substances of
interest to health and promoting the pro-
duction of medicines, equipment, immu-
nobiological products, blood products and
other inputs; performing actions of sanitary
and epidemiologic surveillance and workers’
health; training and development of human
resources; policy formulation and imple-
mentation of basic sanitation; scientific
and technological development; oversight
and control of foodstuffs, including con-
trol of their nutritional content and water
for human consumption; participation in
the supervision and control of production,
transportation, storage and use of psychoac-
tive substances and products, toxic and ra-
dioactive products; collaboration in protect-
ing the environment, including that of labor
conditions and workers’ health.
In conclusion, we must recognize that
health care is one of the pivotal factors that
countries can use to overcome an economic
crisis. In spite of all the problems we have
seen so far, the health care industry is still
one of the engines of the economy and it
helps countries to face the challenges of
economic crisis creating jobs and maintain-
ing consumption of goods and services. Of
course, there are always a need for improve-
ment, such as eliminating waste, improving
efficiency and increasing preventive care.
It is unlikely that health care provider jobs
will decline during economic crisis, since
demand and supply of health care services
are, or should be, basically inelastic.
Haino Burmester (reghaino.ops @ terra.com.
br), is Phisicyan and Business Administrator,
with a Masters Degree in Community
Medicine from the University of London;
Professor of Hospital Administration at the
São Paulo School of Business Administration
(Fundacão Getulio Vargas,Brazil), Chief of
Staff of the Superintendence of the University
Hospital, São Paulo Medical School;
Coordinator of the Program Commitment to
Health Quality (CQH) maintained by the
São Paulo Regional Council of Medicine and
the Paulista Medical Association; Advisor to
the World Health Organization; President
of the São Paulo Association for Preventive
Medicine and Health Administration.
Impact of Economic Growth and Financial
Crisis on Estonia’s Health Care
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
This is a case study from Estonia – a
country where the health system en-
joyed annual budget increase of 20% dur-
ing 2004 –2008 – and which now has to
maintain and to improve performance
in the reality of economic recession. In
this short paper some selective examples
will be provided on the availability of re-
sources and use of services over the last
couple of years as well as lessons learned
and challenges ahead.
During the years of economic growth,
the Estonian Health Insurance Fund col-
lected financial reserves that can keep the
health system public expenditure during
2010–2011 at the level of 2007. However,
the reserves will be exhausted in 2012 and if
new taxes are not introduced to cover pub-
lic health care costs, the current health sys-
180
WMA news
tem shall face drastic cuts that will decrease
availability and access to services and care.
Moreover, currently there is no political will
and leadership to rearrange the financing
and governance of health system and ser-
vices into one based on rational use of re-
sources for the decade of no-growth.
Prosperous years before the economic cri-
sis have allowed to invest heavily into new
technologies for both diagnosis and treat-
ment, and to double the salaries of doctors
and nurses during 2005–2008 without in-
crease in the volume of services.
Until now (2010) the number of health
services provided to the population have
decreased by 2–4% in both out-patient and
hospital care, as compared to 2008, when
the provision of services had reached its
ever highest level in Estonia. By 2008, the
major achievements can be summarised as
following:
– patient satisfaction with availability and
quality of care was very high;
– emigration of doctors and nurses had
stopped;
– availability of high-tech diagnostic
equipment and rate of use had reached
European top level;
– use of prescription medicines had dou-
bled in 8 years;
– availability and use of resource-inten-
sive services (hip replacement, invasive
cardiology) had doubled in recent years;
– a number of modern and expensive
treatments in nephrology, oncology
and rheumatology were included to the
public insurance basket of services.
During 2009 the economic crisis in Esto-
nia increased unemployment fourfold and it
reached 20% at highest. This has put pub-
lic sector finances under very serious con-
straints and the governmental spending in
2010 has dropped to the level of 2006. As
the need for social support has increased
severalfold, the prospects of health care to
regain its financial basis are not good at all.
Lessons learned:
– During recent years the economic growth
in Estonia allowed to introduce new tech-
nologies and to increase prices, which has
pushed the medical profession to become a
service provider for the medical and phar-
maceutical industries.
– Economic growth and availability of
new financial resources were not managed
and governed to increase the availability of
human resources and services in the most
underdeveloped health sector in Estonia –
nursing and rehabilitation – that lag behind
the needs of the ageing population.
Morale for the medical profession
Now, when the politicians are not willing or
able to adapt the health system according to
the economic reality,it is the opportunity for
the medical profession to use its knowledge,
skills and prestige and to take the wheel for
the benefit of patients and society.
Raul Kiivet, Professor of Health Care
Management, Department of Public
Health, University of Tartu, Estonia
Table 2. Change in selected economic indicators in Estonia (% as compared to previous year)
2007 2008 2009 2010 2011
Change in GDP 14.5% –3.6% –14.8% –2.8% 1.5%
Unemployment rate 4.9% 5.5% 14.4% 16.8% 16.6%
Social tax 25.4% 14.8% –10.3% –4.0% ??
Health Insurance Fund
spending
27.5% 20.5% –2.2% –4.7% ??
Doctors’ salaries 22% 39% –6% ?? ??
Table 1. Increase in the volume of diagnostic
tests and procedures
2001 2004 2008
Lab tests &
analysis (106
)
9.5
(100%)
10.8
(115%)
15.1
(159%)
incl biochemi-
stry (106
)
3.8
(100%)
5.1
(134%)
8.6
(226%)
Ultrasound
diagnostics
429
000
(100%)
474
000
(110%)
654
000
(152%)
Endoscopic
procedures
83 000
(100%)
79 000
(95%)
91 000
(109%)
CT and MRI
investigations
45 000
(100%)
96 000
(213%)
236 000
(536%)
Raul Kiivet
181
WMA news
Michael S. Chen
Taiwan’s national health insurance (NHI)
program has won its share of international
attention for its accomplishments in terms
of universal coverage, comprehensive bene-
fit, efficient administration, up-to-par qual-
ity of care, and affordability. In line of the
theme of the 2010 Conference of the World
Medical Association, I shall begin this ar-
ticle by giving an introduction of Taiwan’s
NHI, followed by the major challenges that
the NHI faces, and then, based on Taiwan’s
experience, summarize the institutional fac-
tors that would be inductive to the capacity
for the program to neutralize, to certain ex-
tent, the impact of economic fluctuations in
general, or financial crises in particular.
If any lessons can be learned from Taiwan’s
NHI, that would be: one must begin with
the “right” structure when considering a
healthcare system. The “right” structure will
give the program the capacity to hold up
against the economic crisis. As summarized
by this article, three most prominent factors
for the stability of the program are: a social
insurance program based on premiums, a
single-payer program, and the built-in bal-
ancing mechanism under a global budget-
ing scheme.
How did Taiwan’s NHI come
into what it is now?
Taiwan’s NHI was implemented in 1995 by
taking in the health components from the
then existing social insurance programs and
extending the coverage to all others, nation-
als as well as expatriates who stay in Tai-
wan with valid residence permits. And out
of historical legacy, ideological split did not
stand in the way; instead, the political lead-
ership, incumbent and the opposition, was
committed to providing universal health
coverage and a health program as massive
as NHI was able to come into being.
Initially, the medical profession posed a
hostile gesture out of fear, uncertainty, and
doubt, but soon realized that a health pro-
gram like this meant a wider clientele and
would bring in a stable and ample income
stream.The medical profession then became
cooperative partners with the NHI, and in
the process of working together closely,now
has become an integral part of the NHI es-
tablishment.
Insurance industry, which bedeviled the US
healthcare reform for many times over the
past decades, did not quite constitute a re-
sistance, because they were happy with the
lucrative business in life insurance and were
not quite interested in extending their busi-
ness to health insurance for the troublesome
administrative loading. Surprises to many,
the turf for commercial health insurance
has expanded, rather than shrunk after the
NHI, possibly because people started to ap-
preciate the value of insurance and desired
to seek better protection against hazards of
all kinds.
Competent authorities together took many
extra miles to put the program on its feet.As
time passes, even without anyone’s knowing
it, the program gradually got what it de-
serves: the satisfaction rates started to pick
up, and have been around 70% for quite
some time up to present, ranking among
the highest in the world. Delegations from
all around the world coming to Taiwan to
study the NHI, and more than one third of
them are from the US, especially the staffs
from the Capitol Hill. Taiwan has offered
training courses to high-ranking health ad-
ministrators from countries as important
as the Kingdom of Saudi Arabia, Thailand,
Mongolia, the Philippines, Korea, Indone-
sia, etc.The Public Broadcast System has, in
“Frontline – Sick Around the World”, cho-
sen along with other four countries as the
models that the US can emulate. Taiwan’s
NHI has won its reputation.
What are the main features
of Taiwan’s NHI?
The NHI is a compulsory program, which
requires mandatory and universal enroll-
ment, covering all nationals as well as expa-
triates with valid residence permits on equal
terms. It is a single-payer program run by
a governmental agency – Bureau of NHI.
Ability-to-pay is the fundamental financ-
ing principle, with payroll-based premiums
(currently 5.17%) shared by the employee,
the employer, and the government. NHI
offers comprehensive and uniform benefit
package for all. The policy of contracting
The Institutional Factors that help Health
Care System to hold up against Financial
Crisis
Lessons based on Taiwan’s experience
Presentation at the WMA conference on “Financial crisis and its implications for health
care”, Riga, September 10-11th
2010
182
WMA news
with the medical facilities is on the basis of
all-willing-providers, and more than 90% of
the providers are contracted with the pro-
gram. The payment system for the program
is run on a plural reimbursement schemes
(fee for service, case payment, pay for per-
formance, etc) under an overarching global
budget.
What are the major accomplishments
in Taiwan’s NHI?
The best way to characterize Taiwan’s NHI
is that the NHI is a program that defies
the “conventional wisdom”. In the standard
textbook of health economics,it is suggested
that you can choose some of the virtues for
your program; yet,you cannot expect to have
all the virtues in one program. These values
as indicated in the textbook are: universality,
comprehensiveness, freedom of choice, and
cost containment. Taiwan’s NHI, though
has problems of its own, embodies all those
virtues in one, and more.
Universality
Though Taiwan’s NHI is a compulsory pro-
gram,universality is not an action of the law.
Instead, it is the human action that brought
universality to the program, the human ac-
tion inspired by the belief that “I am my
brother’s keeper.” Soon after its implemen-
tation, the NHI has extended its coverage
from 59% to virtually all the population in
Taiwan. For those who could not pay the
premium, the NHI provides a pretty elabo-
rate safety net to make sure that everyone is
protected:
the premium is 100% subsidized for the•
households below the poverty line;
if you are unable to pay the premium for•
running into one of the vicissitudes in
your life, interest-free loans are available
or you can apply to pay on installments;
or, Bureau of NHI can refer you to many•
of the charitable organizations for help;
in the case when all these fail to work for•
you, you can simply take yourself to the
hospital should an emergency occur and
leave the financial problem to be taken
care of between the hospital and the
BNHI;
with this safety net in place, no single in-•
dividual on this land can ever be denied
health care for lack of means or anything;
there must be a way to get the help.
With NHI, bankruptcies out of medical
bills have become unheard of since; we don’t
often use the expression “health care as a
human right”, yet universality testifies to
that our program is an incarnation of the
very ideal.
Comprehensive and Uniform
Benefit Package
The benefit package provided by the NHI is
comprehensive; all medically necessary ser-
vices are covered. The package covers inpa-
tient, outpatient, dental services, traditional
Chinese medicine, and maintains a very
long list of nearly 20,000 items of prescrip-
tion drugs. Before the implementation of a
long-term care insurance, the program also
pays for home care, rehabilitative care, day
care, and hospice care, provided that certain
criteria are met.
Some of the target therapy drugs are cov-
ered; many of the expensive drugs for rare
diseases are covered too. To provide more
options for the insured, some of the high-
priced devices such as drug-eluting stents,
intraocular lenses with special functions, are
covered with extra billings.
The benefit package is rather “generous”
when you compare with, say, that of Medi-
care in the US. US Medicare requires the
beneficiary to pay for the first day of hos-
pitalization as deductible that could be as
much as $5,000 or even more, while our
program picks up the tab right from the
first dollar without any deductibles. For
new treatments or drugs, there is a prompt
procedure to get those items on the reim-
bursement list, provided that they are cost
effective.
The co-payments are very little, even sym-
bolic in some cases.There is a 10% co-insur-
ance for acute hospitalization,but the maxi-
mum amount of that co-payment is capped
by 10% of per-capita income. The benefits
are provided without any discrimination
whatsoever. For instance, anyone who needs
and demands a renal dialysis will get one,
without discretions on age or anything,
even discretionary measures are prevalent in
many countries.More importantly from the
standpoint of equity, the benefit package is
uniform for all: the President of the nation
and the people in the street are entitled to
exactly the same package of benefits.
Freedom of Choice and Accessibility
Taiwan’s NHI is a single-payer program
and therefore it offers no choice of the car-
rier; it,however,offers unlimited freedom of
choice when it comes to the choice of the
providers: you can choose your doctors and
hospitals from more than 18,000 contract-
ed facilities. Everyone is issued an NHI IC
card, with which you can just walk into any
of the facilities, oftentimes even without a
reservation.
There is no waiting line, or at least not any-
thing like those in some other countries
where you might have to wait for months or
even years for selective surgeries. You may
see people lying in the hallway around the
emergency room in some of the medical
centers.But that is because the medical cen-
ter won’t turn patients away to the commu-
nity hospital where there are many vacant
beds. And over 99% of those patients will
be admitted to the ICU or a regular ward
within 48 hours.
Since a referral system virtually does not
exist, you can see a doctor or be admitted
into a hospital any time if you are not too
particular in choosing the facility. Normally,
it would take just about a couple of weeks to
get a major surgery at the location of your
choice. For the people living in the moun-
tainous areas and off-shore islands,the NHI
pays extra dollars for the integrated delivery
system (IDS) to deliver primary care and
some of the specialty care.The co-payments
are waived in those areas. Care reaches ev-
ery corner. Care is even provided in the off-
183
WMA news
beaten recreational areas just to assure that
you have a care-free weekend.
Cost Containment and Affordability
Health care inTaiwan is quite affordable:to-
tal healthcare expenditure accounts only for
about 6.2% of GDP, lower than most of the
OECD countries, and slightly more than
half of it were spent on the NHI. A family
of four pays roughly US$100 per month as
the premium, which is about one tenth that
of the US families, accounting for about 2%
of the averaged household income.
It is more efficient to run the daily opera-
tions of a single-payer program than any
others; and a single-payer system with the
aid of information technology can even
be more efficient. Billions of transactions
in claims and reimbursements are handled
electronically. As results, the administrative
costs for NHI have been controlled below
2% of the medical expenses.
Quality of Care
Changes in life expectancy (currently 82
years for women, 76 years for men) testified
to the quality of care in Taiwan. According
to a newly released study,the life expectancy
for the ten-year period after the NHI grew
twice as fast as that of the ten-year period
before the NHI. Health disparities among
socio-economic groups and geographic ar-
eas had somehow narrowed, though not as
significant as one would like to see.
Another piece of information on the quality
of care is the performance of organ trans-
plants: although Taiwan has a long way to
go in the transplantation of the lung, the
records of the kidney, heart, and liver trans-
plantations are as good as that of the US.
What are the leading challenges
faced by the NHI?
Financial Shortfalls
There are several factors contributing to
the financial shortfalls. First is the inher-
ent nature in the structure of the financ-
ing scheme. The premium is based on the
payroll, and the increase rates in the pay-
roll always fall short of the increase in the
GDP, and the increase rates in GDP always
fall short of the increase rates in healthcare
expenditures. As a result, there is always a
gap between the growth rates of the revenue
and the expense. Another factor is the aging
population. The aging factor alone explains
a significant fraction of the increase rate
in the medical expenditure, and the global
budget is ratcheted up every year as the ag-
ing factor is a “non-negotiable” component
to determine the global budget.
What makes the financial situation worse
is the political intervention. As stipulated
by the NHI Act, the premium rate must be
raised whenever the reserve fund is lower
than one-month expenditure. In reality, out
of political reasons, premium raise is only
next to impossible.
Having said all this, the financial shortfall,
as much as tens of billions of NT dollars, is
not a problem that would cut into the eco-
nomic competitiveness on the world mar-
ket, as would the healthcare cost of the US,
because Taiwan can still afford to spend a
little more on health care.The deficit is basi-
cally a “why-me”problem and can be settled
with patient consensus-building process.
And the following are a couple of strategies
to keep the financial house in order:
Strategies to make both ends meet
Premium based on individual’s total in-
come
An amendment to the NHI Act has been•
proposed to put the premium on the in-
dividual’s total income rather than solely
on the payroll.
Incomes other than regular salary, if be-•
yond certain amount, will be levied by
a certain percentage for supplementary
premium.
The amendment also calls for lowering•
premiums paid by the union workers and
those who do not have regular incomes.
If enacted,the amendment can make both•
ends meet and has a positive implication
in social equity.
Supplementary revenues for NHI
Before the NHI Act can be amended, the•
Department of Health and BNHI have
gone out in search of all possible sources
trying to control the deficit: putting more
surtax on each pack of tobacco, raising
more revenues from lotteries, going after
those who could but failed to pay the pre-
mium, etc.
In addition to making up NHI’s deficit,•
the revenues from tobacco surtax will be
used to improve quality of care, provide
better care to those living in the remote
areas, assist the indigent to pay off the
overdue premium or pay the out-of-
pocket expenses, etc.
Ever-Rising Expectations
Health care is a non-satiable good. More
can be less, and you can easily fall victim of
your own success. You can never catch up in
quality improvement; you can never match
the demand on the benefit.
This kind of Catch-22 situation is actually
faced by all the public projects, and is espe-
cially troublesome in health care.To respond
to this situation, the BNHI constantly im-
proves on its service by adding new items
on the benefit package,by introducing more
indicators for quality assurance, by control-
ling the expenditure so as to defer the need
for premium raise, and by providing more
information on the website to make the op-
erations of the system more transparent.
What are the key institutional factors
leading to stability over financial crises?
Based on taiwan’s experience with the
NHI, I would like to summarize some of
the factors built in the design of the sys-
tem that are inductive to the capacity for
the program to somehow neutralize the
impact of economic fluctuations. And the
184
WMA news
lesson is that, when it comes to the stabil-
ity of the program, it is more important to
have the “structure” right, than to have the
“operation”or the “administration”right. In
other words, it takes a structural reform in
order to put thing right. In the following
section, I would just like to cite three of
those institutional factors: the premium-
based social insurance, the effectiveness of
the single-payer system, and the built-in
balancing mechanism centered around the
global budget.
Stability of Premium-Based
Social Insurance
There are a number of options for one to
choose as the financing basis for a health-
care system, such as government budget
from general tax, a surcharge on top of in-
come tax, and premium collected from in-
come or wealth.
As so vividly evidenced by the recent ex-
perience in Latvia, the system on govern-
ment budget can be very vulnerable during
economic downturns. A program based on
a surcharge on top of income tax can have
the similar instability, as those revenues can
be hard-hit by the economic recessions. As
a user’s fee, premium can, to some extent,
insulate the impact of a financial crisis, be-
cause it is independent from the real in-
come, which can vary according to the eco-
nomic situation.
I would like to point out that, under cer-
tain situations, a user’s fee can consti-
tute a burden for some people who just
encounter misfortune in the life. And
therefore, it is important to have a safety
net to come to rescue, as demonstrated in
Taiwan’s NHI.
Effectiveness of the Single-
Payer System
Taiwan’s NHI is a single-payer system that
has proved very effective in providing neces-
sary care to all, particularly to those in pov-
erty and other disadvantaged groups.This is
a cornerstone for solidarity, and enjoys the
maximal capacity to spread out the risks.
A single-payer system serves as a platform
not just to pull together all the risks,but also
to pull together dollars of various sources.
Pooling all the risks in a single pool makes
cross-subsidization among the different so-
cio-economic groups very easy and effective;
pooling together all the dollars from various
sources makes the money flow very efficient.
A single-payer system is flexible in that any
newly added needs or newly added budgets,
resulted from, say, economic recessions,
can be incorporated into the program with
ease, and the safety net can be continuously
strengthened without structural changes.
With a single-payer system, the state acts
as a monopsonist on the healthcare market,
and the state can wield tremendous levering
power to co-opt the medical profession to
work together for the good of the people.
Built-in Balancing Mechanism
Under Global Budget
The single most important instrument for
cost containment is the global budget sys-
tem, which puts a lid on the overall annual
NHI expenditure. The annual growth rates
of the global budget are negotiated every
year through the Medical Cost Negotiation
Committee, whose members comprise of
the representatives from the payer groups as
well as the provider groups.
With such an overarching global budget,
the payment for each service is defined in
terms of the number of points, rather than
the number of dollars: the value of one point
will be lower than one dollar, if the medical
profession together provided more services
than that expected by the Negotiation Com-
mittee. And therefore, when economic cri-
sis hits, the system will respond as a whole
by more stringent use of the resources. Of
course,the leadership of the medical profes-
sion must exercise its coordination power to
make sure that, while saving resources, ad-
equate services will still be provided.
In addition to the function of cost contain-
ment, the global budget system is meant
to give incentive to the medical associa-
tions to rein in their members and ensure
appropriate care. The global budget system
has worked pretty well, able to control the
increase rates between 4% and 5% annually,
without compromising the quality of care
over these years.
Lessons and Concluding Remarks
The success of Taiwan’s NHI, undoubt-
edly, should be, to an extent, attributed to
the “operation” of the program – the “extra
miles”that the BNHI staff has put in.How-
ever, it is the “structure”of the program that
conveys the resilience,flexibility,and tough-
ness to this program so that the program
can weather through the economic crises
without losing much capacity to uphold its
safety net, which is so crucial for the less
fortunate. Therefore, when a nation consid-
ers a healthcare system, the first thing com-
ing to the minds of the architects is that the
program must be placed on a well thought-
out structure which will help the program
to hold up against the economic crises.
Based on Taiwan’s experience with its NHI,
the program better be financed by premiums
which, to a greater extent, are independent
from the financial crisis. A single-payer
system has the virtue of being efficient in
administration, effective in cross-subsidiza-
tion, and therefore makes the safety net re-
silient and tough to meet the challenges of
a financial crisis.And finally,there must be a
built-in mechanism that will automatically
balance the books in bad economic times.
Michael S. Chen
Former VP & CFO, Bureau of National
Health Insurance, Taiwan Associate Professor,
Department of Social Welfare, National
Chung-Cheng University
e-mail: aping_chen@yahoo.com.tw
185
WMA news
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Preamble. The value and benefits of research are vitally dependent on the integrity of research. While there can be and are national and
disciplinary differences in the way research is organized and conducted, there are also principles and professional responsibilities that are
fundamental to the integrity of research wherever it is undertaken.
Principles
Honesty in all aspects of research
Accountability in the conduct of research
Professional courtesy and fairness in working with others
Good stewardship of research on behalf of others
The Singapore Statement on Research Integrity was developed as part of the 2nd
World Conference on Research Integrity, 21–24 July 2010,
in Singapore, as a global guide to the responsible conduct of research. It is not a regulatory document and does not represent the official
policies of the countries and organizations that funded and/or participated in the Conference.For official policies,guidance,and regulations
relating to research integrity, appropriate national bodies and organizations should be consulted.
186
Economic Recession on Nurses
Executive Summary
The worldwide economic crisis has hit Ice-
land particularly hard and will lead to severe
cutbacks in all areas of Icelandic society,
including the health care system. The state
budget for the year 2009 estimates that 115
billion Icelandic krona (ISK) will be spent
on Ministry of Health projects, or almost a
quarter of the entire state budget for the year
(equivalent to approximately €0.64 billion).1
It has been proposed that health services
must be cut back by ISK 8 billion (approxi-
mately €0.04 billion), or approximately 7%
this year (2009), and additional ISK 8 bil-
lion in 2010. Possible cutbacks for 2011 and
2012 have not yet been announced,however
the authorities have announced strict mea-
sures in order to curb public spending in
an effort to beat the recession. Health care
facilities have been merged to decrease ad-
ministrative costs, with reductions in over-
time and shift supplement payments,termi-
1 All currency conversions in this paper reflect ex-
change rates as at 17 August 2009, calculated using
currency converter at www.xe.com.
nations or cutbacks of contractual payments
to doctors, fewer paid study leaves, etc.
The recession and the proposed cutbacks
have already caused changes in Iceland’s
nursing workforce.A large number of nurs-
es have increased their number of normal
hours as the former demand for overtime
work has now vanished. Cutbacks, such as
reorganised shift routines and change in
skill mix, have also brought about a educ-
tion in the number of nurses needed. In-
creasing nursing hours and in some cases
delayed retirements are thus temporarily
hiding the shortage of nurses. The short-
age is however severe and will increase as
almost a quarter of Icelandic nurses are
between 55 and 64 years of age and will
therefore soon be reaching pensionable
age. The recession has also had dramatic
effect on the number of enrolled nursing
students which has doubled between the
years 2008 and 2009.
The Icelandic Nurses Association (INA)
has increased its activities to assist its mem-
bers in adapting to altered working condi-
tions. The general assembly and board of
the INA have passed resolutions on various
current issues, primarily emphasising the
safety and quality of health care services
and the importance of nursing. The INA
Board published its priorities and propos-
als concerning health sector cutbacks at the
end of June 2009. This is an official policy
declaration by the association emphasizing
the maintenance of quality and safety of
health care, the need to review the health
care system and payments for services, the
necessity to fix guidelines for prioritisation,
and the advantage of merging some health
care facilities.
Introduction
Iceland has been hit particularly hard by the
global economic crisis. The rapid develop-
ment and growth of the country’s banking
system rendered it vulnerable to the closing
of international credit markets.The govern-
ment takeover of Icelandic banks and the
ensuing debt guarantees demand related
to collapsed Icelandic banks in the United
Kingdom and Holland led to severe cut-
backs in all areas of Icelandic society, in-
cluding health care and education. The col-
lapse of the Icelandic krona (ISK) by around
50% in 2008 has restrained the purchasing
power of the general public and led to price
escalations as the domestic market is heav-
ily reliant on the importation of commer-
cial goods. In fact, the economic recession
in Iceland has had an impact on everything
and everybody – on the homes and jobs of
Icelanders, social services, price levels and
most aspects of daily life.
The purpose of this article is to throw
some light on the impact of the economic
recession as already felt in Iceland with a
special emphasis on nurses and nursing.
The article describes human resources in
nursing and the role and status of nurses
within the health care system. The article
also deals with already announced gov-
ernment measures and the foreseeable
impact of these measures on nurses, nurs-
The Impact of the Economic Recession on
Nurses and Nursing in Iceland
Elsa B. Friðfinnsdóttir Jón Aðalbjörn Jónsson
187
Economic Recession on Nurses
ing and health care services. A brief ac-
count is given of nursing education and
remuneration matters. Finally, the article
outlines the priorities and measures of the
Icelandic Nurses Association in the wake
of changes within the health care system
and the impact of these changes on nurses
and nursing.
Iceland’s Nursing Workforce
The current number of INA members is
around 3,600 and corresponds roughly to
90% of all registered nurses in Iceland. The
INA members’ portfolio shows that around
2,800 nurses receive salaries on the basis of
collective agreements made on their behalf
by the INA and 76% of them are employed
by public institutions. According to the
portfolio nearly half of all working nurses
(or 1,370) are employed by Landspitali,
which is the only university hospital in the
country and is located in the capital Reyk-
javik. The same INA data reveals that the
average work time ratio of nurses in pub-
lic employ is currently around 80% of a full
time equivalent. The privatisation of health
care services is negligible in Iceland and
very few nurses work for private institu-
tions.The public sector can thus be claimed
to be practically the sole employer of nurses
in Iceland, either in public institutions or
state-funded private institutions caring for
the elderly.
Nursing in Iceland enjoys a strong legal
status. Nurses were guaranteed Professional
autonomy by law in 1978 and this autono-
my was further enhanced by the entry into
effect of the new Health Service Act [1]
on 1 September 2007. The President of the
INA served on a committee preparing the
bill to propose a new legislation on health
services. The Health Service Act defines
the Icelandic health care system as resting
on two main pillars,nursing and medicine.
All health care facilities shall, in addition to
a director general,employ a nursing direc-
tor and a medical director. Nurses carry full
legal responsibility for nursing.
Health Sector Cutbacks
In Iceland, the health care system is ad-
ministered by the central government and
around 10% of GDP is allocated to it. The
system is financed from the state general
budget, of which 83% is state financed and
17% are user fees [2].
The state budget for the year 2009 [3] es-
timates that ISK 115 billion will be spent
on Ministry of Health projects, or almost
a quarter of the entire state budget for the
year. The largest single operational item on
the budget is Landspitali University Hospi-
tal, which stands to receive ISK 33 billion
(€0.18 billion) according to the budget for
2009. At the beginning of 2009,the author-
ities announced strict measures in order to
curb publicē spending in an effort to beat
the recession. It is likely that the health care
system will need to be cut back by ISK 8
billion (€0.04 billion) or approx 7% in 2009.
This corresponds to the total budgetary re-
sources allocated to the Akureyri Hospital,
the second largest hospital in the country
located in the north of Iceland, and to pri-
mary health care of the Capital Area which
serves around two-thirds of the country’s
population. Additional health service cuts
of ISK 8 billion are anticipated for the year
2010. The authorities have not, as yet, an-
nounced possible cutbacks for 2011 and
2012, but by 2013 the economy is expected
to begin to show signs of recovery.
Government Plans for Health
Service Cutbacks
Following the collapse of the Icelandic
banking system in early October 2008 it
became clear that dramatic cutbacks in
public sector spending were imperative and
these would also affect the health services.
At a press conference on 7 January 2009 the
Health Minister announced fundamental
changes to the health care system. Twenty-
two health care facilities outside the capital
area were to be merged into a total of six
facilities, a hospital in a municipality near
the capital was to be changed into a geri-
atric unit, small operating theatres in hos-
pitals near the capital would be closed, and
so on [4]. The aim of these mergers was to
cut down administration costs rather than
the patient care budget. Furthermore, user
fees for health services were increased and
moderate admittance charges introduced
for hospitals [5] in addition to plans to con-
siderably curtail drug costs.
A new government took over in Iceland on
1 February 2009. The new Health Minister
comes from a party to the extreme left in
Icelandic politics,while his predecessor rep-
resented the political right wing. Changes
within the Ministry of Health have had
dramatic effects. Two days after taking of-
fice, the new Health Minister revoked the
regulation on increased health service fees
and hospital admission charges[6].Over the
next few days the Minister withdrew most
of the changes that had been prepared and
announced by his predecessor [7].
On 25 March 2009 the Minister of Health
announced the principal features of ratio-
nalisation measures to be taken by hospitals
in the vicinity of Reykjavik [8].The focus of
the Minister’s proposals was for these health
care facilities to remain within the budget
and, in the long term, look to increase their
cooperation with Landspitali University
Hospital with the aim to decrease overall
costs without decreasing service rendered.
The Minister’s proposals anticipated re-
ductions in overtime and shift supplement
payments, terminations or cutbacks of con-
tractual payments to doctors, fewer admin-
istrative positions, fewer paid study leaves
and more [9].
Salaries make up around 75-80% of the
operating expenses of health care facilities.
In 2008, an additional 50% on average was
added to basic salaries for overtime and
shift supplement payments. Nurses receive
just under 25% of the total salaries paid
by health care facilities, whereas they fill
around 23% of total full-time positions. Av-
188
Economic Recession on Nurses
erage overtime work for nurses was 32% of
their total hours in 2008 [10].
The Health Minister’s overall approach
concerning health sector cutbacks for the
current year and the next years to come was
not available when this article was written
at the beginning of July 2009. The Minis-
ter has, however, announced the merger of
health care facilities in West Iceland [11]
as of 1 January 2010 as well as the merger
of two small facilities in the North [12]
that will take effect at the same time. The
Minister has also fixed the maximum price
for two common prescription drugs [13].
The Health Minister places great emphasis
on consulting the local population in the
different health care regions but has not
looked much to the INA for collaboration.
Press interviews with the Minister indicate
that detailed proposals for health sector
cutbacks for this year and the next are to
be expected within a few weeks [14]. The
uncertainty surrounding envisaged health
sector cutbacks makes all long-term plan-
ning difficult for the directors of health care
facilities.Lack of integration may mean that
rationalisation in one facility results in in-
creased costs at another. The delay in min-
isterial decisions and proposals also creates
uncertainty among nurses as to their work-
ing conditions and this environment of un-
certainty makes it difficult for the INA to
organise its support and work on behalf of
its members.
Impact of Recession on
Nursing Shortage
There has always been a nursing shortage
in Iceland. When the first educated nurse
came back home from her studies abroad
at the end of the 18th century people wel-
comed her but also stated that there really
should have been two of them!
In 2006 the INA conducted an extensive
survey into human resources in nursing.
The results of the survey were published in
a report entitled Nursing Shortage [15] in
March 2007.In the survey nursing direc-
tors of health care facilities nationwide were
asked the following questions:
1. How many full-time positions are au-
thorised for nurses at the facility?
2. How many full-time positions for nurs-
es are occupied at the facility?
3. How many full-time positions occupied
by nurses have individuals on leave due
to childbirth, further education or pro-
longed sickness?
4. How many nurses are required to fill the
full-time positions authorised at the fa-
cility?
5. How many full-time positions for nurs-
es do you think are required by the fa-
cility on the basis of estimated need for
nurses?
The results of the survey showed that in or-
der to fill the authorised nursing positions,
as well as those where individuals were on
maternity, study or sick leave, the num-
ber of nurses would need to be increased
by 15.75%. When taking into account the
number of full-time positions considered
necessary by nursing directors in order to
deliver optimum quality care, however, the
overall nursing shortage was estimated at
20.66%. In 2006 the average work-time ra-
tio of nurses was 76.45% and thus a total of
582 nurses were required in order to meet
the need. Based on available data, the INA
put together a nursing shortage projection
for the period 2006-2015 [16].
In March this year the INA conducted an
informal survey of nursing shortage [17] in
the same health care facilities as participat-
ed in the 2006 survey. Replies were received
from nursing directors at a total of 50 facili-
ties which together command around 65%
of all fulltime positions in the country. The
questions in this survey were comparable to
those used in the previous survey.
The results of the latest survey indicate that a
significant change has taken place. At pres-
ent, nursing directors’ professional assess-
ment is that the nursing shortage, based on
estimated needs to fulfil service demands, is
3.84% compared with 21.5% in 2007.
Recent social upheavals have thus contribut-
ed dramatically to reducing the shortage of
nurses. The change can partly be explained
by the INA collective agreement in 2008, in
which the aim was to reduce overtime and
increase normal hours worked by nurses
(see page 190). As a result a large number
Nursing Shortage Projection 2006-2015
0
100
200
300
400
500
600
700
800
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Number
Full-time positions Nurses needed for these positions
Source: Icelandic Nurses’ Association, 2007
189
Economic Recession on Nurses
of nurses have increased their work-time
ratios but, as already pointed out, health
care facilities have in the past relied heav-
ily on nurses working overtime. Directors
of health care facilities have welcomed this
trend as it helps reduce overtime costs. The
INA predicts that the average total salaries
of nurses will slightly decrease but the re-
duction is accompanied by better working
environment due to higher staffing levels,
more regular working hours and less over-
time. Nurses have, most likely, opted for
part-time work due to family obligations
and the stress entailed in working shifts and
therefore increased work-time ratios might
in the long run have detrimental effects on
their family lives. Various cutbacks, such as
reorganised shift routines,have also brought
about a reduction in funded nursing posi-
tions. Finally, nurses previously employed in
private sector enterprises are now increas-
ingly seeking positions in public sector fa-
cilities.
As of now the INA is lacking data whether
some individuals, who have nursing qualifi-
cations but were not working as nurses,have
come back in to nursing employment. It
should, however, be reiterated that this sur-
vey was an informal one and therefore the
figures cited may not be entirely reliable. It
should also be emphasised that this seem-
ingly favourable trend may not necessarily
last. While there is still uncertainty con-
cerning the measures intended by the au-
thorities and the Health Minister in order
to bring about the extensive rationalisation
necessary within the health service sector in
coming months, some health care facilities
may even resort to layoffs.
So far there have been no mass redundan-
cies, but the directors of many health care
facilities have stopped filling vacant posi-
tions when nurses either retire or go away
on leave. In some facilities there are now
fewer nursing positions than before and
this inevitably increases the strain on nurses
who are still at work. Organisational chang-
es and new shift routines have forced nurses
to move between places of work and even
change from regular daytime work to doing
shifts.
Emphasis in INA Collective
Agreements
Collective agreements between the INA
and its counterparties ceased to apply in the
early months of 2008 as planned. In light
of the downward trend in work-time ratios
and the apparent nursing shortage [18],
coupled with the relatively high proportion
of overtime in the gross pay of nurses [19],
the Association placed heavy emphasis on
increasing basic salaries.Following intensive
negotiations and an imminent overtime ban
for nurses,a collective agreement was signed
on 9 July 2008 which fixed the hourly rate
for overtime work at 0.95% of an individual
nurse’s basic monthly salary instead of the
earlier amount of 1.0385%. The average in-
crease in basic salaries thus came to around
14%. The collective agreement was valid for
nine months only, or from 1 July 2008 to 31
March 2009. Based on information gath-
ered from nursing directors at the largest
health care facilities, these salary changes
had a considerable impact on nurses raising
their work-time ratios and reducing over-
time work. As stated above, the recession
then had a further impact on staffing and
work-time ratios.
The INA’s collective agreement has now
been open for three months. The INA, as
member of the Association of Academics,
has participated in the formation of a sta-
bility pact between Icelandic employees, the
government and the business community.
The pact is part of the government’s strat-
egy in facing the economic crisis and aims
primarily at reaching some sort of stability
within the national economy and the em-
ployment market, the key element being
objectives regarding inflation levels, interest
rates, unemployment levels, exchange rates
of the Icelandic krona, etc. It is clear that
nurses will not receive any pay increases in
the coming months, but the INA will focus
on protecting the jobs of nurses as well as
the salaries and conditions that have already
been achieved.
Impact of Recession on
Nursing Education
All nursing education in Iceland has been at
university level since 1986. Nursing is cur-
rently taught at two universities: the Uni-
versity of Iceland in Reykjavik and the Uni-
versity of Akureyri. The study programme
takes four years and concludes with a BSc
degree in nursing. Graduate programmes
on offer in Iceland include midwifery, a
diploma programme in specialised nurs-
ing, MSc in nursing, interdisciplinary pro-
grammes in health informatics and public
health sciences, and a PhD in nursing.
According to the nursing shortage report of
2007 [20] a total of 145 nurses are expected
to graduate each year. During the period of
economic expansion and growth there was a
decline in the number of students enrolled
in the nursing programmes at the universi-
ties and in the last three years only around
100 students have graduated. This spring,
however, in a climate of recession, the num-
ber of applications for nursing studies has
more than doubled. In the spring of 2008
a total of 173 students applied to be en-
rolled in the nursing programmes at both
universities. This year has seen a total of
369 applications. Owing to a tight budget
and a lack of clinical placements only 170
students will, however, be allowed to con-
tinue with their studies on the strength of
their examination results at the end of the
first semester. The INA believes that 170
new nurses need to enter the profession an-
nually in order to maintain the status quo.
This estimate is based on the large number
of nurses reaching retirement age over the
next few years [21].
Almost a quarter of all nurses working in
the country are between 55 and 64 years
of age and will therefore soon be reaching
pensionable age.In recent years, nurses have
190
Economic Recession on Nurses
on average started drawing pension at the
age of 64, but given the current economic
conditions it is to be expected that many
will choose to delay their retirement by a
year or two. This ageing of the nurse popu-
lation is taken in to account in the former
outlined projection of nursing shortage till
the year 2015.
Despite the disappearance of the nursing
shortage in recent months it is important
to remain vigilant and to ensure that there
are sufficient numbers of newly-graduated
nurses to meet the needs of society, not least
when the nation has managed to weather
this economic storm. When such a time
comes, Iceland may again be faced with a
shortfall of qualified nurses.
Various changes within the health service as
well as in the Icelandic society require more
nurses to be employed. In the INA’s Policy
on Nursing and Health Care it is stated that
the needs of the public for nursing services
are the cornerstone of nurses work. Nurses
must, under all conditions, ensure they de-
liver high-quality nursing services while
having the best interests of their clients at
heart at all times [22]. More work needs to
be done in areas of prevention and health
promotion. Shorter hospitalisation periods
mean that health care is transferred to other
facilities as well as the homes of the patients
and this calls for increased nursing services.
At the same time, the age composition of
the population is changing. Improved treat-
ment possibilities increase longevity, but as
the population grows older the number of
serious and chronic health problems also in-
creases. In times of recession the population
may require different types of health service
and it is important that these needs are as-
sessed so that appropriate measures can be
taken.
INA Emphases and Actions
The 3,600 member association of Icelandic
nurses represents nearly 90% of all nurses li-
censed to practice in the country. Member-
ship is voluntary and annual dues amount to
1.5% of a nurse’s basic salary. The INA was
established in 1919 and acts on behalf of
its members in matters concerning profes-
sional issues, economic interests and work-
ing conditions. The Association is a profes-
sional body as well as a union of nurses. Its
purpose is to:
a) Be an advocacy for nursing and nurses
and safeguard their interests.
b) Protect the image and autonomy of
the nursing profession, encourage co-
operation between nurses and promote
professional and social awareness.
c) Negotiate with employers on pay and
conditions on behalf of its members as
well as other issues covered by its man-
date.
d) Promote the development of nursing as
an academic field of study.
e) Participate in international collabora-
tion among nurses for the benefit of the
profession.
f) Participate in the formulation of poli-
cies concerning health care.
Through new emphases in collective bar-
gaining, the INA has been successful in
improving the salaries and working hours
of nurses. As the recession forces health
care facilities into reorganising their work
schedules,i.e.by reducing overtime as much
as possible, it can be safely maintained that
the move made in the 2008 collective agree-
ment was both correct and timely.
Since the collapse of the financial system
in October 2008 the INA has focused
its activities on assisting its members in
adapting to altered working conditions, for
instance through active dissemination of
information. Already in January 2009 the
budget of the INA was amended so as to
allow for improved services to association
members. To make room for this change
it was decided to cut down on overseas
travel in connection with international
projects. There has been detailed coverage
of health sector changes in The Icelandic
Journal of Nursing which is published five
times a year and distributed by mail to all
INA members. Every two weeks the INA
publishes an electronic bulletin which is
sent out to 2120 members registered on
the association’s distribution list.The news
section on the website www.hjukrun.is is
also regularly updated. Advisory services to
individuals have been increasing, particu-
larly in matters relating to working hours,
statutory sick pay and rules on dismissal.
Age distribution of nurses, 5 years grouped together (June 2009)
Icelandic residents, 70 years of age and younger
0
100
200
300
400
500
600
700
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70
Age (years)
Number
Source: Directorate of Health, Register of Nurses, 2009
191
Economic Recession on Nurses
All changes give rise to a range of ques-
tions concerning employee rights and the
INA considers it to be its duty to assist
members in these matters.
The President of the INA and Associa-
tion employees have actively participated
in consultations with authorities, served
on committees, and attended meetings and
conferences. A good case in point is the re-
cent collaboration with the Directorate of
Health on a report concerning human re-
sources in nursing. The General Assembly
and Board of the INA have passed resolu-
tions on various current issues, primarily
emphasising the safety and quality of health
care services and the importance of nurs-
ing. All resolutions are forwarded to the
authorities, published on the INA website
and sent to the media, who have generally
been very positive in their coverage of the
Association’s activities.
The Board of the INA published its empha-
ses and proposals concerning health sector
cutbacks at the end of June [23]. This is an
official policy declaration by the Associa-
tion and was sent to the Minister of Health,
published on the INA website and for-
warded to the national media. The Board’s
emphases are fourfold:
• To maintain quality and safety
The INA emphasises that all decisions con-
cerning health sector cutbacks must take
the interests of the population as a whole
into account, there must be consistency in
the actions taken between institutions and
health care regions, and the importance of
securing the quality and safety of services
for all members of the community should
be used as a guiding principle at all times.
The INA Board stresses that care should be
taken not to make any changes to the health
care system that cannot be reversed when
the economic climate begins to change for
the better. No measures should force spe-
cially qualified health service personnel to
leave parts of the country or even the coun-
try itself, because the quality of the health
services provided rests primarily on the
knowledge and skill of the individuals who
work in the field.
• To review the healthcare system and pay-
ments for services
The Board of the INA urges the Health
Minister to spearhead a thorough review
of the health care system, to determine
what should be done and where, and what
should be financed from public funds. The
kind of services covered (as well as those
not covered) by health insurance as de-
fined in the Social Security Act needs to
be specified. Decisions must also be taken
as to whether health care personnel are
permitted to provide services that are not
covered by health insurance, since their cli-
ents would need to pay the entire cost of
such services.
• To fix guidelines for prioritisation
The INA Board emphasises the need for de-
fining the extent to which treatment should
be provided under specific conditions. Pa-
tients, relatives and the general public must
be aware that treatment limitations apply
equally to all individuals who are in a simi-
lar position, i.e. that such decisions are not
be taken as a result of limited human re-
sources or finances when and if the situation
might arise.
• To continue the merger of health care facili-
ties
There are at present 20 hospitals in Iceland
and it is natural to question whether this is,
in fact,necessary or sensible for such a small
population. The INA Board calls for a pre-
cise definition of what constitutes basic ser-
vices that should be provided in each com-
munity and then how many hospitals are
actually required and where they should be
located. The safety of the population must
of course be the focal point of any such de-
liberations.
Based on these emphases, the INS Board
has presented the following proposals to the
Minister of Health:
• That the Minister of Health establish a
five-person task force to work, full time, on
developing a health service plan for Iceland
up to 2015. The task force will be entrusted
with setting out proposals for health sector
cutbacks for the next three years by consid-
ering, for instance, areas where action needs
to be taken,how basic services should be de-
fined and where hospitals should be located
in the future. The group should also specify
what kind of services are to be covered by
health insurance and then to what extent,
either temporarily or permanently,as well as
patient contributions towards health service
costs, privatisation in the health care sector,
and the kind of services that should be per-
mitted outside the health insurance system.
The proposals should also suggest ways in
which to reconstruct the health care system
at the end of the recession. The INA Board
is prepared to nominate its representative
to serve on this task force and to assist the
group in any way possible.
• That the Minister of Health immediately
appoint a committee on the prioritisation of
health services which will be entrusted with
making proposals concerning the limita-
tion of treatment and how services should
be prioritised. Various other nations have
already specified such limitations. It is nec-
essary that this group becomes a permanent
advisory committee to the Minister and also
handles the introduction of new treatment
possibilities within the health service. The
INA Board suggests that this committee
should be comprised of an expert on eth-
ics,a health economist,a nurse,a doctor and
political appointees.
• That work continues on the merger of
health care facilities on the basis of the
Health Service Act and regulation on health
regions. Special attention needs, however, to
be paid to the safety of people in rural areas
in this respect. Ease of transportation and
192
Economic Recession on Nurses
the burden of cost for the local population
must also be considered when planning the
merger of facilities and organising basic ser-
vices and hospital locations. Decisions on
the mergers of health care facilities should
form part of the work of the special task
force mentioned in the first proposal above.
Conclusion
There is no doubt that Icelandic nurses, as
well as the entire population of the country,
are entering into hard times.The health care
system is one of the pillars of the community
and it is important that good standard that
Iceland has already achieved is maintained.
The knowledge and skills of nurses and oth-
er health care workers is the foundation on
which the health service is built.Therefore it
is now more important than ever to secure
a solid education for Icelandic nurses and
that sufficient numbers graduate each year,
that new knowledge is put to use within the
health care system and that every effort is
made to prevent a human capital flight of
nurses to neighbouring countries.
All the same, the recession brings opportu-
nities. A higher number of nurses are now
working more regular hours than before.
With more nurses on each shift it is easi-
er to plan nursing care, aiming to increase
the quality of nursing care for each patient.
There are endless opportunities to enhance
the quality of nursing and to prove the ef-
fectiveness of nursing treatments as well
as becoming more visible as profession-
als. Nurses can also take on various differ-
ent tasks within primary health care, such
as patient reception, health protection, etc.
Nurses can also enhance and improve gen-
eral and specialised home nursing. Nurses
in sparsely populated areas need to be given
the opportunity to work independently.
Nurses should take a more active part in the
medical surveillance of clients with chronic
illnesses, for instance by receiving them at
special nursing clinics, and press for licences
to issue prescriptions for common drugs.
But the recession also brings serious threats.
Although the immediate effects of the
recession can be valued as positive by in-
creasing nursing hours and in some cases
delaying some retirements and thus hiding
temporary the shortage of nurses,the short-
age is still underlying and serious and can-
not be ignored.The nursing community and
the health care authorities still need to focus
on replacing and increasing the number of
nurses in Iceland, to decrease the long term
shortage of nurses and to insure that the
health care needs of the population are met.
There is also regrettably always the threat
that the authorities will resort to measures
dealing with the economic crisis that might
have a lasting impact on the health service
and lead to a reduction in the number of
nurses.
The Icelandic Nurses Association will con-
tinue to keep up a reliable flow of informa-
tion to its members. In the upcoming pay
negotiations the Association will focus
on protecting the jobs of nurses. The As-
sociation will also step up its participation
in public debates on health care issues and
promote the fact that the knowledge and
skills of Icelandic nurses are the best tools to
secure an efficient and safe nursing service.
References
Health Service Act (2007). no. 40 www.eng.1.
heilbrigdisraduneyti.is/media/Laws%20
in%20english/Health_service_act.pdf
OECD (2007). Health at a Glance2.
2007.Statistics Iceland: www.statice.is/
Pages/444?NewsID=3333 accessed 6 August
2007
Alþingi (the Icelandic Parliament) (2008).3.
General Budget for 2009.
Heilbrigðisráðuneytið (7 January 2009).4. Skip-
ulagsbreytingar heilbrigðisþjónustunnar í land-
inu. Organisational changes within the health
care system.ww.heilbrigdisraduneyti.is/frettir/
nr/2957accessed 6 August 2007.
Heilbrigðisráðuneytið (29 December 2008).5.
Reglugerð um hlutdeild sjúkratryggðra í kost-
naði vegna heilbrigðisþjónustu. Regulation on
patient participation in health service costs.
www.heilbrigdisraduneyti.is/frettir/nr/2955
accessed 2 July 2009.
Heilbrigðisráðuneytið (2 February 2009).6.
Innritunargjöld á sjúkrahús og heilbrigðisstof-
nanir felld niður. Hospital admission charges
revoked. www.heilbrigdisraduneyti.is/frettir/
nr/2988 accessed 2 July 2009.
Heilbrigðisráðuneytið (19 February 2009).7.
St. Jósefspítali samhæfður starfsemi Landspíta-
la. St.Jósefspítali Hospital harmonised with
Landspitali University Hospital. www.heil-
brigdisraduneyti.is/frettir/nr/2991 accessed 2
July 2009.
Heilbrigðisráðuneytið (25 March 2009).8. Spar-
naður og skert kjör í stað stórfelldra uppsagna
starfsmanna.Cutbacks and lower pay instead of
mass redundancies. www.heilbrigdisraduneyti.
is/frettir/nr/3015 accessed 2 July 2009.
Heilbrigðisráðuneytið (25 March 2009).9. Spar-
naður og skert kjör í stað stórfelldra uppsagna
starfsmanna. Ibid.
Heilbrigðisráðuneytið (25 March 2009).10. Spar-
naður og skert kjör í stað stórfelldra uppsagna
starfsmanna. Ibid.
Heilbrigðisráðuneytið (12 May 2009).11. Átta
heilbrigðisstofnanir sameinast um áramótin
Eight healthcare facilities to merge at year-
end. www.heilbrigdisraduneyti.is/frettir/
nr/3040 accessed 2 July 2009.
Heilbrigðisráðuneytið (12 June 2009).12. Stof-
nanir í Fjallabyggða sameinaðar. Institutions
in the Fjallabyggð region to merge).www.heil-
brigdisraduneyti.is/frettir/nr/3060 accessed 2
July 2009.
Heilbrigðisráðuneytið (3 March 2009).13. Ný
lyfjaverðskrá tekur gildi. New price levels for
prescription drugs. www.heilbrigdisraduneyti.
is/frettir/nr/2999 accessed 2 July 2009:
Morgunbladid Daily Newspaper (25 June14.
2009). Ögmundi stillt upp við vegg. Health
Minister faces barrage www.mbl.is/mm/fret-
tir/innlent/2009/06/25/ogmundi_stillt_upp_
vid_vegg/ accessed 2 July 2009:
Icelandic Nurses Association (March 2007).15.
Mannekla í hjúkrun (Nursing Shortage).
Icelandic Nurses Association (March 2007)16.
Ibid.
Talnabrunnur (2009).17. Miklar breytingar á
mönnun í hjúkrun (Dramatic staffing changes
in nursing), Directorate of Health Bulletin on
Health Statistics 3(6).www.landlaeknir.is/lis-
alib/getfile.aspx?itemid=4021 accessed 3 July
2009.
Icelandic Nurses Association (March 2007).18.
Op. cit.
Heilbrigðisráðuneytið (25 March 2009).19. Spar-
naður og skert kjör í stað stórfelldra uppsagna
starfsmanna. Op. cit.
Icelandic Nurses Association (March 2007).20.
Op. cit.
Talnabrunnur (2009). Op. cit.21.
193
Medical Education
Icelandic Nurses Association (May 1997).22.
Policy on Nursing and Health Care. www.
hjukrun.is/lisalib/getfile.aspx?itemid=34 ac-
cessed 3 July 2009.
Icelandic Nurses Association (29 June 2009).23.
Emphases and proposals of INA’s Administrative
Board in connection with health sector cutbacks.
www.hjukrun.is/?PageID=33&NewsID=3749
accessed 3 July 2009.
Elsa B. Friðfinnsdóttir RN, MSN,
President of the Icelandic Nurses´ Association.
e-mail SElsa@hjukrun.is
Jón Aðalbjörn Jónsson
International Secretary and Project Manager
at the Icelandic Nurses‘ Association
e-mail Jon@hjukrun.is
For free access to full this document and
other original research on nursing human
resources, please visit the ICN’s Interna-
tional Centre for Human Resources in
Nursing at www.ichrn.org.
Introduction
Medical students and doctors experience
high rates of psychological morbidity due to
their work and study environment. Medi-
cal students are initially similar to general
student populations prior to commenc-
ing their medical course. As their training
commences, however, the reductions in
psychological well-being have been dem-
onstrated to increase [1][2]. Stress may be
a contributing factor for unhealthy behav-
iors and co-morbidities. Previous research
has estimated that up to half of the medical
students reportedly abuse alcohol as well as
illicit substances such as marijuana. Other
aspects of student health and lifestyle, such
as reduced physical activity and poor diet,
also suffer with increased workloads [6].
With increases in obesity levels,fast-food con-
sumption, smoking rates, alcohol consump-
tion, and illicit drug use, it is uncertain what
the increase of these factors will cause over the
next couple of decades. It is inevitable, how-
ever, that the diseases which progress from
poor lifestyle choices such as regular smoking,
poor nutrition and poor exercise will be expe-
rienced by the doctors of the future.
Methodology and Results
The International Federation of Medical
Students Association (IFMSA) represents
1.2 million medical students from over
ninety countries worldwide. IFMSA holds
biannual general assemblies, hosted by
elected member countries.These assemblies
gather around 700 medical students,making
it an excellent forum for discussion, team
building, and cultural acceptance and sen-
sitivity. With such a large number of medi-
cal students attending these meetings, pri-
marily to advocate for improved health, the
events provide an excellent opportunity to
conduct surveys regarding healthy lifestyles.
Therefore, a cross-sectional study was con-
ducted at IFMSA’s general assembly held
in Macedonia in August, 2009. The socio-
demographic data was collected on lifestyle
choices, tobacco consumption (cigarette,
pipe tobacco and tobacco use in any other
form), exercise that lasts for 30 minutes or
longer, dietary habits (including fruit, veg-
etable and fast food consumption), alcohol
consumption and sexual activity [6].
A quarter of the students exercised regularly
with no difference between the genders.The
majority of respondents consumed fruit and
vegetables on a daily basis. A third of the
students also reported regular consumption
of fast food.Female students were reported-
ly healthier in their nutritional choices with
higher consumption of fruit and vegetables
that their male counterparts. Less than a
quarter of the medical students smoked on
a regular basis. When comparing genders;
males were significantly more likely to be
smokers than females.Living in Europe,the
Americas or in the Eastern Mediterranean
region also predisposed students to smok-
ing. Sixty percent of the medical students
consumed alcoholic beverages on a regular
basis. There was no difference in alcohol
consumption between the genders.
With regard to sexual health; the mean age of
first intercourse was 17.7 years.Regarding sex-
ual orientation; an absolute majority reported
being heterosexual with a small fraction (5%)
reporting their orientation as homosexual or
bisexual. An overwhelming majority stated
regular contraceptive use; the most popular
methods of contraception being the condom
or the contraceptive pill.Over half of the sexu-
ally active respondents reported having just
one sexual partner over the previous year.Male
students reported having twice as many sexual
partners as female students. Students from
European or American countries reported the
highest proportion of sexual activity.
Regardless of predisposing factors, lifestyle
choices have a great influence on morbidity
and mortality in life. Due to the cumula-
tive effect of adverse factors throughout the
life of individuals, it is important to adopt a
healthy diet and lifestyle practice.This study
assessed the dietary habits and lifestyle
choices made by medical students, who are
a significant community of future health-
care practitioners. Correct lifestyle choices
made early on during the medical education
period will produce physicians practising as
well as promoting a healthy lifestyle. There
is a visible need for improvement in some of
the lifestyle choices made by medical stu-
dents. The response rate of the study may
have been limited by the sensitive nature of
some of the questions and also due to pos-
sible language barriers.
Lifestyle Practices of Medical Students
attending an International Student
Conference
194
Medical Education
Similar studies conducted in Pakistan and the
United Arab Emirates have shown similar
findings with poor lifestyle choices made by
medical students [7][8]. Nisar et al. found a
very low smoking prevalence which correlates
with our study’s regional results described for
smoking [9]. A number of American stud-
ies also found a relatively low prevalence of
smoking amongst medical students [10]. It
is a well known fact that health providers
(including medical students) smoke and in
2005 the WHO Centre for Disease Preven-
tion and the Canadian Public Health Asso-
ciation developed the Global Health Profes-
sionals Survey to survey smoking habits of
medical, nursing, dental and pharmacy stu-
dents in a variety of WHO member states.
The results were published in 2005 [11].
Although a large number of medical stu-
dents smoke regularly there is also evidence
to support the fact that the same subset of
healthcare students know and understand
the health risks of smoking and are ready to
promote smoking cessation to their patients.
In a recent review of smoking in medical
students the rates of smoking were described
to increase incrementally with each year of
study and it was also suggested that smoking
cessation strategies should be put in place by
the medical schools themselves [12].
Poor diet has been documented in medi-
cal students with nutritional intake being
documented to worsen closer to exam pe-
riods [13]. British and Greek studies found
similar results when reviewing the amount
of fruit consumed by medical students with
the majority eating fruit regularly but with
very few actually consuming the five por-
tions of fruit per day advised by health au-
thorities [14].
Studies on sexual activity in medical students
have found similar results as found in our sur-
vey with similar mean ages for first intercourse
as well as similar preferences of contraceptive
methods [15]. The results of the international
survey show a high prevalence of sexual activ-
ity and an equally high prevalence of contra-
ceptive use with a proportion of the subjects
reportedly using two or more forms of contra-
ception; the male condom and the oral con-
traceptive pill being the most common forms.
Same-sex behaviour described in the literature
correlates well with the low levels of homosex-
ual or bisexual activity elicited in the medical
student international community [16].
Conclusion
The self-reported lifestyle choices and hab-
its of international medical students dis-
played choices of a healthy and unhealthy
nature with a predominance of high con-
sumption of tobacco, fast food and alco-
hol. The healthy choices made by the study
group however indicate that some aspects
of health promotion may permeate into the
lifestyle choices made by medical students,
as is shown in the positive prevalence of
contraceptive use.The high rates of exercise
as well as the clearly demonstrated levels of
fruit and vegetable consumption were also
some of the positive behaviors elicited.
It is possible that some lifestyle choices made
by medical students may be inevitable due to
the educational schedule,many of whom live
far away from home. It is possible that more
directed dietary and tobacco advice may be
required as a preventive strategy for this
study group.The findings of our study,as well
as other studies held in the past, suggest the
need for a larger study across more countries
so that adequate arrangements can be made
for student healthcare [17].
References
Stewart SM, Betson C, Marshall I, Wong1.
CM, Lee PW and Lam TH. Stress and vul-
nerability in medical students. Medical educa-
tion (2006) 29(2), 119-127
Guthrie EA, Black D, Shaw CM, Hamilton J,2.
Creed FH and Tomenson B. Embarking upon
a medical career: Psychological morbidity in
first year medical students. Medical Educa-
tion. (1995) 29, 337-341
Danaei G, Ding EL, Mozaffarian D,Taylor B,3.
Rehm J, et al. (2009) The preventable causes of
death in the United States: Comparative risk
assessment of dietary, lifestyle, and metabolic
risk factors. PLoS Medicine 6(4): e1000058.
doi:10.1371/journal.pmed.1000058
Carter AO, Elzubeir M, Abdulrazzaq YM,4.
Revel AD, Townsend A. Health and lifestyle
needs assessment of medical students in the
United Arab Emirates. Med Teach 2003; 25:
492-6
Nisar N, Qadri MH, Fatima K, Perveen S. Di-5.
etary habits and life style among the students
of a private medical university Karachi. J Pak
Med Assoc 2009; 59: 98-101
Nisar N, Qadri MH, Fatima K, Perveen S. Di-6.
etary habits and life style among the students
of a private medical university Karachi. J Pak
Med Assoc 2009; 59: 98-101
Conard S,Hughes P,Baldwin DC,Achenbach7.
KE, Sheehan DV. Substance use by fourth-
year students at 13 U.S. medical schools. Jour-
nal of Medical Education (1988) 63:747-758
Centers for Disease Control and Prevention8.
(CDC). Tobacco use and cessation counsel-
ling – Global health professionals survey pi-
lot study, 10 countries, 2005. MMWR Morb
Mortal Wkly Rep 2005;54:505-9.
Smith DR, Leggat PA. An international re-9.
view of tobacco smoking among medical stu-
dents. J Postgrad Med (2007) 53:55-62
Wolf TM, Kissling GE. Changes in life-style10.
characteristics, health, and mood of freshman
medical students. Journal of Medical Educa-
tion. (1984) 59:806-814
Bertsias G, Linardakis M, Mammas I, Kafatos11.
A. Fruit and vegetables consumption in rela-
tion to health and diet of medical students in
Crete, Greece. International Journal for Vita-
min & Nutrition Research. (2005) 75(2):107-
17
Ortiz-Ortega A, García de la Torre G, Galván12.
F, Cravioto P, Paz F, Díaz-Olavarrieta C, El-
lertson C, and Cravioto A. Abortion, contra-
ceptive use, and adolescent pregnancy among
first-year medical students at a major public
university in Mexico City. Rev Panam Salud
Publica/Pan Am J Public Health (2003) 14(2):
125-130
McConaghy N, Armstrong MS, Birrell PC,13.
Buhrich N. The incidence of bisexual feel-
ings and opposite sex behaviour in medical
students. The Journal of Nervous and Mental
Disease. (1979) 167(11):685-8
Ashton CH, Kamali F. Personality, lifestyles,14.
alcohol and drug consumption in a sample of
British medical students. Medical Education.
(1995) 29(3):187-192. DOI:10.1111/j.1365-
2923.1995.tb02828.x
Dr. Jonathan Mamo MD MSc
e-mail: Chantal.Fenech@gmail.com
Dr. Chantal Fenech MD
e-mail: Jonathan.Mamo@yahoo.com
195
Regional and NMA news
Organisation and membership
The Norwegian Medical Association
(NMA) was founded in 1886 as a profes-
sional association and trade union for Nor-
wegian physicians.Membership is voluntary
and approximately 96% of the Norwegian
physicians are members. The main aims of
the NMA are to protect and develop the
professional, social and financial interests
of its members, to promote their interests
in matters concerning medical education,
professional development and scientific
activities, and to advance the quality of the
Norwegian health care system.
Main bodies of the Norwegian Medical
Association
The Annual Representative Meeting
(ARM) is the chief decision-making body
and elects the Central Board of 9 members,
including the president and vice-president.
The election period for the board is two
years. ARM also elects the Medical Ethics
Committee.
The NMA consists of 19 local branches (one
in each county),7 occupational branches,44
specialty branches, one for retired doctors
and one student organisation.
The seven occupational branches organise
members that share occupational interests:
junior doctors, consultants, general prac-
titioners, researchers, occupational health
doctors, private practicing specialists and
public health doctors. The occupational
branches have their main interests in sala-
ries and working conditions, while the spe-
cialty branches are engaged in scientific and
professional activities like education,quality
improvement, etc.
The secretariat
The secretariat has five departments: Dep. of
professional affairs, Dep. of information and
health policy, Dep. of finance and adminis-
tration, Dep. of negotiation and legal section
and The Norwegian Medical Journal. The
number of full-time staff members is 130.
The role of The Norwegian Medical As-
sociation
The Norwegian Medical Association is the
only medical association for doctors in Nor-
way. The NMA has two main responsibili-
ties:
negotiating salaries and working condi-•
tions for the members;
taking care of the members professional•
and scientific interests.
In addition the NMA is responsible for
much of the post-graduate specialist educa-
tion.
Prioritised areas
The Norwegian Medical Association will
for the next two years (2009–1011) particu-
larly work for:
1. Quality work and measurements, work-
ing environment and economy in hos-
pitals. Hospitals have too little focus on
quality and working conditions com-
pared to economy.
2. Permanent positions for all doctors in
hospitals. Almost all junior doctors to-
day have temporary engagements.
3. Improved interaction between various
levels of the health care system.
4. Further development of primary health
care, especially the list patient system.
5. Promotion of medical research and pro-
fessional development.
6. Recruiting, supporting and educating
representatives for the NMA (union of-
ficials).
Some data about Norway
Norway has a population of 4,850,000 and
is situated in the northern part of Europe,
being bordered by Sweden, Finland and
Russia.
Healthcare and health services are financed
by taxation and are designed to be equally
accessible to all residents, independent of
social status. With its 220,000 employees,
the health sector is one of the largest sectors
in Norway.
The healthcare system is under the jurisdic-
tion of the Ministry of Health and Care
The Norwegian Medical Association
Geir Riise Torunn Janbu
196
Regional and NMA news
Sharfuddin Ahmed
Background
The Bangladesh Medical Association
(BMA) is the national association of doc-
tors of Bangladesh. It represents 46,000
physicians nationwide and has 67 district
branches working all over the country. The
BMA looks after the healthcare system of
the country, the interests of the doctors, and
the overall well-being of the medical com-
munity.A 47 member central executive runs
the association. The BMA is working hard
to ensure good health for every citizen of
Bangladesh.
Overview of the country’s
healthcare system
A wide range of therapeutic choices are
available in Bangladesh, ranging from self-
care to traditional and western medicine.
The public sector is largely used for in-
patient and preventative care while the pri-
vate sector is used for curative care. Primary
Health Care (PHC) has been chosen by the
government of Bangladesh as the strategy to
achieve their goal of “Health for all”, which
is now being implemented as Revitalized
Primary Health Care.
Public sector healthcare services
Primary care in the public sector is organ-
ized around the Upazila Health Complex
(UHC) at a sub-district level, which works
Bangladesh Medical Association (BMA)
services, which is responsible for planning
and monitoring national health policy. Re-
sponsibility for provision of services is de-
centralised to the municipal and regional
level. The municipalities are in charge of
providing primary health services, while the
four Health regions provide the specialised
medical services, mainly hospital care.
General practice is organised through a list
patient system. The list patient system is a
national system organised and run through
agreements between the NMA and the
health authorities where the general practi-
tioners are mainly self-employed.
There are some specialist practices working
under agreements with the Health regions.
Norway only has a small number of author-
ised private hospitals and health services in
addition to the public facilities.
The number of doctors, including students
and retired doctors, are about 27 000. In
relation to inhabitants we have one of the
largest numbers of doctors in Europe, in
2007 the ratio was one doctor per 244 in-
habitants.
The Committee on Human Rights
Since the early 1990s, the NMA has run
human rights programmes in Turkey, the
former Yugoslavia and now in China.These
activities are funded mainly by The Nor-
wegian Ministry of Foreign Affaires. In
cooperation with WMA, the International
Red Cross and Amnesty International the
association has published, on the web, free
of charge, a course for prison doctors.
The Journal of the Norwegian Medical
Association is issued every second week.
Post-graduate medical education
There are 44 recognised medical specialties
in Norway of which eight are subspecial-
ties under internal medicine and five are
subspecialties under general surgery. The
majority of the specialties relate to health
services in institutions (hospitals). Special-
ties in primary health care are family medi-
cine,community medicine and occupational
medicine.
Health politics
The NMA is involved in many of the activi-
ties run by the health authorities through
meetings, working groups and political
work. The NMA also appoints members
to participate in different task groups and
meetings with the political parties in the
Parliament.
Officers
President Dr. Torunn Janbu, Ph. D., Vice-
president Dr.Arne L.Refsum and Secretary
General Dr. Geir Riise.
The Medical Ethics Committee: chairper-
son Dr.Trond Markestad, Ph. D.
Contact information:
The Norwegian Medical Association
P.O. Box 1152 Sentrum
NO-0107 Oslo
Phone +47 23 10 90 00
Telefax +47 23 10 90 10
www.legeforeningen.no
Dr. Torunn Janbu, President
Dr. Geir Riise, Secretary General
197
Regional and NMA news
as a health-care hub.These Units have both
in-patient and out-patient services and fa-
cilities. Most have in-patient care support
with a 31 bed capacity, while some UHC’s
have over 50 beds. Many UHC Units have
a package service called “comprehensive
emergency obstetric care services” (EOC)
available, with an expert gynecologist, an
anaesthetist and skilled support nurses on
duty around-the-clock as well as in-house
basic laboratory facilities.At a lower tier,the
Union Health and Family Welfare Centres
(UHFWC) are operational, consisting of
two or three sub-centers at the lowest ad-
ministrative level, and a network of field-
based functionaries. Above the sub-district
are the district hospitals (100-250 beds) and
medical colleges (serving a group of districts
with approximately 650 beds), providing
secondary care, and national tertiary level
care facilities.
Private sector healthcare services
In the private sector, there are traditional
healers, homeopathic practitioners, village
doctors, community health workers, and,
finally, retail drugstores that sell allopathic
medicine on demand. In addition to dis-
pensing medicine, sellers at these mostly
unlicensed and unregulated retail outlets
also diagnose and treat illnesses despite
having no formal professional training.
Traditional medical practices
Grouped under “traditional medicine” are
most of the medical practices that fall out-
side the realm of ‘scientific’ medicine. Thus
Kabiraj, totka, herbalists, practitioners of
‘Folk Medicine’ and faith healers of differ-
ent shades fall under this broad umbrella.
Many of these healers (e.g. faith healers)
provide a much narrower range of services
for a more limited set of conditions.
The BMA supports the country’s strategic
health profile through different activities,
which include involving the healthcare sec-
tor in decision making, raising its voice to
guide the country’s heath policy,and arrang-
ing meetings, seminars, and symposiums to
create awareness of the country’s key health
issues.The BMA also involves itself directly
in professional matters such as:
1. The promotion of public doctors
2. The provision of legal support to doc-
tors, if needed
3. Support for an effective primary, sec-
ondary and tertiary referral system
4. Acting as a legal body to oversee physi-
cians’ problems
5. The improvement of medical education
6. Solutions for different national issues
7. The training of private doctors as well as
healthcare providers
8. Liaising with different international
organizations including International
Physicians for the Prevention of Nucle-
ar War (IPPNW), the Commonwealth
Medical Association (CMA),the World
Medical Association (WMA) and other
national medical associations.
Professor Dr. Md. Sharfuddin Ahmed
Chairman,
Department of Ophthalmology,
Bangabandhu Sheikh Mujib Medical
University,
Secretary General,
Bangladesh Medical Association
Eger Istvan
The history and function of the Hungarian
Medical Chamber are closely tied to Hun-
gary’s political history. After the 2nd World
War, Hungary’s communist political regime
ordered the HMC inactive. A trade union
of common health care professionals was
created in its place and strictly controlled by
the government with no possibility for self-
governance by Hungarian doctors during
the 40 years of the communist regime. The
healthcare system was financed by the state
and no provisions were made for a health
insurance system. During this time, Doc-
tors salaries were low, paid by the govern-
ment who (unofficially) encouraged “under
the table” payments from patients.
During the early 1990s Eastern Central
Europe, including Hungary, underwent
major fundamental structural changes. Not
only did the political system transform, but
a new healthcare system was developed
and agreed upon as well. Public healthcare
costs were financed through a health insur-
ance company that was paid by the state
and whose budget was provided mainly by
taxes. Physicians who had previously been
government employees gradually became
independent practitioners that contracted
directly with the health insurance compa-
nies,however doctors who worked in hospi-
tals and outpatient care facilities remained
government employees. Despite the many
changes that occurred within Hungary’s
healthcare system, healthcare providers sal-
aries remained quite low.
Hungarian Medical Chamber in the Last
Twenty Years
198
Regional and NMA news
In 1989, doctors began to anticipate the up-
coming changes and possibilities that were
facing their nation and a few enthusiastic
members of the physician workforce re-es-
tablished the Hungarian Medical Chamber.
In the first period membership was volun-
tary. The HMC’s top priority was creating a
new ethical structure, writing an ethical code
and organizing committees (e.g. professional,
educational, legal, etc ). Moreover they con-
tinually sought to connect with stakeholders
and decision-makers in an effort to establish
their influence and ensure their input regard-
ing important questions of healthcare practice
and policy. In 1994,five years after the HMC
was re-established, the Hungarian Parlia-
ment drafted and voted into law legislation
that made the HMC (and the pharmaceutical
chamber) part of the public sector.
The most important change as a result of the
new law was that membership in the HMC
became mandatory. Mandatory membership
gave the chamber a powerful regulatory posi-
tionwithinthehealthcaresystemsincedoctors
memberships could be cancelled or suspended
for ethical violations, which would prohibit
them from continuing to treat patients. In
addition, the HMC was charged with tasks
regarding ethical issues, including the regis-
tration of doctors, organizing and control-
ling continual medical education and creating
recommendations regarding medical practice.
They were also given the right to voice their
opinion regarding proposed healthcare laws.
Most importantly, the HMC had a right of
concordance (it had a negative voice) regard-
ing the main points of contribution with the
health insurance company. The HMC has
limited financial resources to broaden their
affiliation with international organizations
but has been able to represent Hungary in the
Standing Committee of European Doctors
(CPME) since 2003.
In the second half of the nineties and par-
ticularly after 2000, the financial state and
functionality of Hungary’s healthcare sys-
tem was in a continual decline. In response,
the HMC changed its focus in an effort to
provide constructive criticism that would
benefit the best interests of the healthcare
system. The percentage of GDP dedicated
to the healthcare sector decreased year by
year (nowadays it is significantly lower than
5%!),as did the quality of care offered to pa-
tients. The shortage of medical profession-
als continued to rise due to low salaries and
poor working conditions, and became so
severe that by 2004 the media was reporting
on the difficulty of the situation. Although
the previous government searched for an-
swers and solutions to the crisis,their meth-
ods were ineffective and unsuccessful.
After Hungary joined the European Union
in 2004, Hungary’s healthcare crisis wors-
ened considerably as its doctors and nurses
sought better working conditions and wages
elsewhere in the EU.The Hungarian govern-
ment seemed uninterested in restoring the
failing healthcare system. They refused to
hear and understand the HMC’s many rec-
ommendations for the troubled healthcare
system and resented the HMC’s strong voice
of opinion. In 2007 the government tried
to destroy the HMC (and the pharmaceu-
tical and nurses chambers) by reversing the
law requiring mandatory membership to the
chambers. To further weaken the chambers,
the law refused to recognize any member-
ship obtained during the mandatory mem-
bership period and as of April 1, 2007 not
one official member remained in any cham-
ber. The amount of administrative work in
re-establishing membership in the interest
of preserving the community of doctors was
overwhelming,but in the end the HMC was
able to restore 80% of their membership vol-
untarily. It was a great success for the HMC
and the two other chambers (which had also
successfully recovered their members) and a
big defeat for the government. The political
parties in parliament that were in opposition
with the majority at that time promised to
reinstitute the government’s earlier position
on mandatory membership if at all possible.
The HMC’s greatest success in the last few
years has been the successful protection of
the existing public health insurance system
from a dangerous decision by the previ-
ous regime to organize a public health in-
surance system based on a business model
comprised of several competing health in-
surance companies. In 2008 there was a ref-
erendum about these proposed changes and
as a result of the voting, parliament had to
withdraw the law to create the new health
insurance system. During this whole pro-
cess the Hungarian Medical Chamber had
very important role, and we are very proud
of our activity regarding this issue.
In the spring of 2010 a new government was
elected in Hungary. The previous opposi-
tion became the new majority in the gov-
ernment. The Hungarian Medical Cham-
ber prepared a new proposal to change the
law about the chambers within the health-
care system. This will be discussed at the
autumn session of parliament and we are
hopeful that membership within the HMC
will be mandatory again by January 1, 2011.
The public body of Hungarian physicians
would like to become more influential in
the development of Hungary’s healthcare
system in the future.
Dr. Eger Istvan, Hungarian
Medical Chamber, President
Building of the Hungarian Medical Chamber
199
Regional and NMA news
Béla Szalma
MOTESZ, the most widespread organiza-
tion of Hungarian medical doctors based on
voluntary membership, had the opportunity
to introduce itself in the WMA’s periodical
publication in 2006. Below is an overview
of our organization and what we have been
doing the past several years.
MOTESZ was established in 1966 with 36
member societies. Since that time, numer-
ous health care organizations have joined
our association. At the moment we have
129 member societies, meaning that some
30,000 medical doctors,dentists,researchers
and scientists are connected to MOTESZ.
For almost four and a half decades we have
been making efforts to carry out our main
tasks: to coordinate the activities and coop-
eration of the member societies at the as-
sociation level, and to promote the solution
of common problems.
National activities
MOTESZ has been making significant ef-
forts to facilitate the addressing of interests
of member societies in health care-related
legislation and enforcement. As a perma-
nent invited body, MOTESZ observes leg-
islation in the Health Care Committee of
the Parliament and gives its opinion con-
cerning significant issues directly affecting
the medical profession.
On request, MOTESZ, through its profes-
sional committees, regularly provides opin-
ions on health care-related bills forwarded
by the Ministry of Health, as well as dis-
cussing and formulating, topics affecting all
stakeholders in Hungarian health care.
In February 2008 the Ministry of Health
requested that we prepare coordinated and
reconciled professional proposals. To fulfil
this duty,we created the ETSZ-MADOFE
Program (Program on Regulating Health
Care Activity), a program plan to regulate
the handling of operational data, documen-
tation, financing and controlling activity in
health care, in order to improve the system
of health care services.
As to its principles and essence, the MA-
DOFE program is consistent with the pro-
gram plan of the Hungarian government,
(“Safety and Partnership: tasks in health
care until 2010”), which was submitted to
widespread social discussion. Our associa-
tion, based on the request of the Ministry,
has organized a sectoral consensus confer-
ence to summarize the material that was
submitted for discussion.
We continued the National Program on
Prevention and Cure of Heart and Circula-
tory Diseases that was elaborated, accepted
and announced by MOTESZ and profes-
sionally relevant member societies in 2006.
The results of the program were revealed in
2008 to the Health Care Committee of the
Parliament, and in 2009, lectures were held
on the status of the program and on further
tasks of realization at different scientific
professional forums.
Meeting legislative requirements, the min-
ister of health entrusted us to organize and
execute the election of the professional
boards, the minister’s consultative body.
MOTESZ successfully carried out this task
this year as well.
The association formed an agreement of
cooperation with the Ministry of Health,
which entailed cooperating with profession-
als to evaluate bills on the minimum require-
ments expected from health care providers.
In addition, we formulated a professional
proposal on the modernization of the present
structure of health care services. Professional
documents consisted of complex solution
programs to develop both basic and emer-
gency health care services and out-patient
and in-patient professional care.
The organizing activities of MOTESZ,
which are conducted by its Congress and
Travel Agency, also play a significant role in
the organization. Besides promoting inter-
national recognition of the knowledge and
results of Hungarian medical doctors at both
national congresses with international par-
ticipants and international conferences,these
events are indispensable pillars of continuing
education within the profession nationwide.
In addition to overseeing the events them-
selves,the Travel Agency deals with organiz-
ing travel, accommodation, and program-
ming for medical doctors, researchers and
theoreticians.
Our scientific, political, and informative
periodical, MOTESZ Magazin, which has
been reaching readers for 18 years, appeared
with new design and content in 2009. To
further vivify our professional dialogue with
our readers, the website of MOTESZ in-
cludes an interactive correspondence col-
umn and a forum are linked to all columns
of the periodical, facilitating the sharing of
opinions on all themes appearing in the pe-
riodical.
MOTESZ – Association of Hungarian
Medical Societies
200
Regional and NMA news
Our homepage provides up-to-date infor-
mation on professional political events and
on the progress of the association’s work; we
also provide a place for the announcements
of our member societies.
Our international activities
We consider it a priority that our organiza-
tion’s activities fit that of the national and
international organizations of the medical
profession. Our relations with the follow-
ing organizations are of major importance:
Standing Committee of European Doc-
tors (CPME), World Medical Association
(WMA), European Forum of Medical As-
sociations (EFMA), World Health Organi-
sation (WHO), European Union of Medi-
cal Specialists (UEMS),European Union of
General Practitioners (UEMO), European
working group of practitioners and special-
ists in free practice (EANA).
Though our financial resources make it dif-
ficult for us to take part in sessions of in-
ternational organizations regularly, we can
report several positive results from sessions
attended.A great point of pride is that at the
general meeting of UEMS in Copenhagen
held in October 2008, Dr. Zoltán Magyari,
member of the international committee of
MOTESZ, was the only vice-president, to
be reelected, indicating the level of recog-
nition of his work and an appreciation of
Hungary’s role. Dr. Magyari continues to
play an active role,primarily in accreditation
of international congresses.
It is also significant that at the 2009 general
assembly of UEMO,held in Budapest,Prof.
Dr. Ferenc Hajnal was elected as president,
Dr. Renáta Papp as secretary-general, and
Dr. Sándor Balogh as treasurer, starting in
2011. They are all members of the inter-
national committee of MOTESZ. In the
operative work of the UEMO Presidency
we work in collaboration with other profes-
sional organizations.
As to our bilateral relations, our coopera-
tion with the German Medical Association
(Bundesärztekammer) is very active; we
participate on a regular basis in the annual
German Medical Assembly. We also main-
tain relations with the American Medical
Association, the French Medical Associa-
tion (Conseil National de L’Ordre des Mé-
decins), the Chinese Medical Association,
and the Chinese Medical University in
Heilongjiang.
We evaluate the results of relations with
the Chinese Medical Association each year.
Since 2004, we have alternated sending the
MOTESZ delegation to visit their Chinese
counterparts one year and hosting a Chinese
delegation the following year. In autumn of
2009, in collaboration with Semmelweis
University’s Faculty of Health Sciences, we
hosted two Chinese delegations in Hungary,
from both the Chinese Association of Tra-
ditional Chinese Medicine and the Chinese
Medical Association. Our association was
instrumental in integrating the teaching of
traditional Chinese medicine (TCM) into
the system of Hungarian medical educa-
tion, and in securing recognition of Chinese
TCM diplomas in Hungary.
Our association returned the visit on 24-25
April 2010,when a delegation was invited to
the 24th National Congress of the Chinese
Medical Association, held in Beijing. Our
delegation held talks with the leaders of the
Medical Center of the Beijing University in
order to facilitate the establishment of a re-
lationship with the Semmelweis University
of Budapest and the University of Pécs, as
well as to form an agreement of cooperation
with the Chinese.
The major duty of our association is repre-
senting the interests of our member societ-
ies, and through them, the interests of the
medical profession. All our member orga-
nizations are informed about our national
and international activities on a regular ba-
sis through the quarterly meetings of the
Association Council, the body consisting
of the presidents of the member societies of
MOTESZ.
Dr. Béla Szalma, the Secretary
General of the MOTESZ
What are we doing?
Continuing medical education is a never-
ending story for doctors who want to be up
to date and to give their patients the best
care possible. What follows is a short intro-
duction to our organization, whose primary
goal is to offer theoretical as well as practical
education for doctors from more than 100
countries.
THE AMERICAN AUSTRIAN FOUN-
DATION (http://www.aaf-online.org) is a
non-profit, non-governmental organization
that seeks to prevent brain drain and foster
brain gain in countries of transition through
exchanges in medicine, communications,
science and the arts.
Background:
In 1984,a group of Americans and Austrians
interested in fostering closer relations be-
tween the United States and Austria estab-
lished The American Austrian Foundation
(AAF). In the years since, the foundation
has grown from a bilateral to a multilateral,
international institution partnering with
American – Austrian Foundation in
Macedonia
201
non-governmental organizations (NGOs),
governments, and individuals.
Mission:
The American Austrian Foundation
seeks to bridge the knowledge gap by
providing qualified individuals with fel-
lowships to pursue postgraduate educa-
tion in medicine, media and the arts.
The AAF’s fellowship programs, ini-
tially offered to Americans and Austri-
ans, now include participants from more
than 100 countries worldwide.The AAF
conducts its own programs and joint
programs with American, Austrian and
international organizations. To facilitate
the operation of programs in Austria, the
friends of the American Austrian Foun-
dation founded The Salzburg Stafing in
1995, and the Vienna Chapter in 2002.
In 2005 the AAF, the Open Society In-
stitute, and the Austrian Ministry of
Science and Education established the
Open Medical Institute (OMI) to con-
solidate the Salzburg Medical Seminars
International and the Observerships
under one name. Later, The Vienna
Open Medical Institute (Vienna OMI)
(http://www.aaf-online.org/vienna-
omi) was established as a joint initia-
tive of the Vienna Hospital Association
(VHA) (www.wien.gv.at), the American
Austrian Foundation (AAF), the Vien-
nese Society of Physicians, the Austrian
Academy of Sciences and the Vienna
School of Clinical Research (VSCR)
(www.vscr.at), to provide scientific and
clinical postgraduate education in med-
icine using Vienna’s excellent resources.
So far, more than 10,000 physicians
from countries in transition (fellows)
have attended seminars; of these, 1500
have also participated in one-month ob-
serverships at Austrian hospitals.
Medical Programs
The medical educational process is orga-
nized through three steps:
Step One: KnowledgeTransfer – Salzburg
Medical Seminars
First established in 1993, today there are
around thirty seminars per year.These semi-
nars are postgraduate medical educational
programs provided by physicians from
leading American medical schools and hos-
pitals, including New York-Presbyterian
Hospital,The Children’s Hospital of Phila-
delphia, Memorial Sloan-Kettering Cancer
Center, The Hospital for Special Surgery,
Duke University Medical Center, Cleve-
land Clinic,and Methodist Hospital,as well
as leading European centers. These physi-
cians spend one week in Salzburg working
pro bono to teach their English-speaking
colleagues from countries in transition.
The seminars provide personal contacts
and small working groups for fellows, who
are admitted through a highly competitive
selection process. More than 500 seminars
have been organized with 35-40 partici-
pants attending each one.
Step Two: Experience Exchange –
Omi Observerships
The aim of the OMI-Medical Observer-
ship Program is to integrate seminar alumni
into the international medical community
by inviting them to spend up to 3 months,
in one-month periods, at Austrian hospitals
to improve their clinical skills. Organizing
the Vienna OMI has enabled an increas-
ing number of participants in Observership
programs in the last few years. All Vienna
hospitals are open to fellows, who conduct
their Observership programs in many dif-
ferent areas.
Step Three: Capacity Building –
Distance Learning
The Foundation brings distinguished lec-
turers into different countries by organizing
satellite symposia and visiting professor-
ships. Two-day OMI satellite symposia are
held in the region with the aim of reaching
a larger audience of physicians and health
care workers. At the same time, they are an
important opportunity to learn about local
conditions and foster relationships among
senior physicians in the region and Ameri-
can and Austrian faculty members. Satellite
symposia typically include six lectures, a
hospital visit, and a round-table discussion
on a topic agreed by local and international
faculty. One-day visiting professorship pro-
grams typically include three to four lec-
Regional and NMA news
Marija Vavlukis
Graphic 1.
202
Education
tures, case reports, and an optional hospital
visit.
Omi Alumni Network
The OMI Alumni Network is organized
as an open network for all fellows, provid-
ing open access to state-of-the-art medical
information via Medical Handbook Online
and video conferences. This network also
helps in the support and improvement of
local healthcare systems by providing the
possibility of a second opinion in patient
care, local knowledge transfer, and a chance
to attract new medical talent.
Activity Report from Macedonia
As a local coordinator, my routine activities
include:
Continuous management of the fellows’•
data in the AAF/OMI database in order
to facilitate their selection, travel arrange-
ments, etc;
English testing, screening of the appli-•
cants and fellows, and recommendations
to the Program Director;
Maintaining relationships with local•
OMI alumni fellows;
Maintaining relationships with other lo-•
cal coordinators in order to collaborate in
the organisation of local activities;
Promoting the benefits and opportunities•
of such collaborations with AAF/OMI in
order to facilitate the development of the
regional health care systems and scientific
research;
Establishing partnerships with local•
medical and educational institutions;
Submitting regular progress reports to the•
Network Coordinator to ensure progress
milestones, or to identify issues and prob-
lems that may necessitate assistance from
AAF/OMI;
Working collaboratively with the Net-•
work Coordinator and members of the
AAF/OMI team;
Organisation and administration of satel-•
lite symposia and visiting professorships.
Most Significant Accomplishments
The most significant accomplishments of
the past two years include:
1.Organisation and administration of OMC-
MACEDONIA as a virtual space for pro-
moting the AAF-OMI programs and com-
munication of the Macedonian fellows with
one another and with the OMI alumni net-
work. The OMI Alumni Network – OMC
Macedonia (http://www.webdoctor .com.
mk; http: //www.webdoctor.com.mk/index.
aspx?IDPage=273) currently functions as a
virtual network where graduates of the OMI-
Salzburg Medical Seminars International
(SMSI) can come together, share experi-
ences, and acquire new medical information
together with the Macedonian doctors. Open
Medical Club activities currently include an-
nouncing the Salzburg Medical Seminars and
publishing reports of the Macedonian fellows
that attend Salzburg Medical Seminars.These
reports include their activities and impressions
from the seminar,topics and faculty.
2. Increasing the number of Macedonian
applicants for Salzburg Medical Seminars
from 24 in 2006 to 52 in 2007, 75 in 2009,
and over 100 in 2010.
In the graphic below, we can see the chang-
es in applications and attendance of the
Salzburg Seminars and Observerships since
1994, when the first Macedonian fellow
participated at a Salzburg Medical Semi-
nar. Currently, we have 4-6 applications
per seminar, which improves the selection
process and guarantees the quality of the
selected doctors.There are about 600 Mace-
donian doctors affiliated with the program.
Since 1994 there have been 460 applications
for Salzburg seminars, 160 of which were
made during the past two years (during the
author’s tenure as coordinator). Of 230 total
seminar attendees, more than 40 occurred
in the past two years. We have more than
100 Observership applications, 77 of them
realized since 1995,and that is the area with
the greatest need for improvement. At the
moment, about 25 Macedonian fellows are
on the Observership waiting list.
This is the greatest indication of my prima-
ry goal – the promotion of the programs of
AAF-OMI and the entry of more Macedo-
nian fellows therein.
Partnerships and Alliances
One of my activities as coordinator is es-
tablishing partnerships and alliances with
medical institutions and organisations with-
in Macedonia. At present, we have signed
Memorandums of Understanding between
the Open Medical Institute (a program of
the “Association of Friends of the American
Austrian Foundation”) as well as the Medi-
cal Faculty, University St. Cyril and Metho-
dius, Skopje, and the Clinical Center Trifun
Talevski, Bitola.
We have also established contacts with lo-
cal medical and educational institutions,
including the Macedonian Medical Cham-
ber,University Clinic for Pediatric Diseases,
University Clinic for Gynecology and Ob-
stetrics, and Psychiatric Hospital Skopje.
Goal Achieved in 2010:
Organisation of the Very First Omi
Visiting Profesorship Program
in Cardiology in Macedonia
The first Macedonian visiting professorship
program in cardiology was organized un-
der the auspices of the American-Austrian
Foundation, the Open Society Institute and
the Medical University Graz,Austria,in co-
ordination with the medical faculty of the
University St. Cyril and Methodius, Skopje,
the University Clinic of Cardiology, and the
Macedonian Society for Cardiology. It was
organized as precongress activity within the
fourth Macedonian Cardiology Congress,
which was held from June 2-5, 2010, in
Ohrid.
Our first guest was Professor Rainer Rien-
müller, who is Professor of Radiology and
203
head of the department of General Diag-
nostic Radiology in the University Hospital
of Graz, as well as a professor at the Medi-
cal University of Graz Austria and at the
University of Munich, Germany. The sym-
posium consisted of four hour-long lectures
given by the professor, followed by a session
of six case reports from our daily clinical
practice, accompanied by interactive discus-
sions throughout the day. Of course, it was
a great pleasure for the regional coordinator
of the AAF for Macedonia finally to see the
first such symposium in the country become
reality. Preparations are underway to orga-
nize the second one during this calendar
year in the area of neurology in strategic
partnership with Clinical Hospital “Trifun
Panovski” from Bitola.
Spreading knowledge among doctors is
challenging and dynamic work; though it
differs greatly from the everyday work of a
practicing physician, it nonetheless comple-
ments and supports the primary goal of
improving ourselves in order to improve pa-
tient care.
Assistant Professor Marija Vavlukis,
MD, PhD, Regional Coordinator
of AAF-OMI for Macedonia
Education
Phase 1: Screening, March
24 – April 28, 2010
The screening phase of this eye camp started
on March 24,2010 at the orphanage center in
Galkacyo. Screenings were given by two oph-
thalmic technicians from Al-Nur Eye Hos-
pital in Mogadishu who were supported by
the staff of Galkacyo South Hospital.The eye
camp was advertised through the local media
and by text messaging using the local tele-
communication network so that a maximum
number of patients could benefit from it.
Patients were examined and those in need
of medicines or glasses were treated. Blind
patients in need of surgery were scheduled
for treatment during the surgical phase
(phase 2) and advised on the date of their
surgery.
A total of 3037 patients benefitted from
phase1 by receiving free medications and/or
glasses and 725 more patients were sched-
uled for surgery.
Phase 2: Surgery April 22-29, 2010
This phase started on April 22, 2010 and
was completed on April 29,2010.The surgi-
cal team was comprised of three ophthalmic
surgeons and six ophthalmic technicians.
Gallkacyo South Hospital’s operating the-
atre was used to perform the eye surgeries.
We used the two-table technique to speed-
up surgical times,maximizing the volume of
surgeries able to be performed.
725 patients were booked for surgery dur-
ing this phase, and 626 surgeries were com-
pleted successfully. 48 patients did not keep
their appointment, 33 patients’ surgeries
were cancelled due to underlying eye dis-
eases which might have affected the out-
come of surgery, and 18 patients had medi-
cal conditions that prevented them from
undergoing anesthesia
Post-operative Care: All surgical patients
were examined by an ophthalmologist for
possible complications on the second day
after their surgery, and were given eye drops,
antibiotics and sunglasses to protect their eyes.
They were also given advice and instructions
on mobility, food and work.The Somali oph-
thalmic technicians remained at the hospital
Somali Medical Association
MSF- GALKACYO EYE CAMP
Galkacyo South Hospital Somalia
Table 1:
Regional distribution of OPD patients:
Region
No of
Patients
%
Mudug 2608 85.87
South Somalia 125 4.1
Ethiopia 118 3.9
Rest of Puntland 93 3.06
Galgudud 55 1.81
Somaliland 23 0.77
Hiran 15 0.49
Total 3037 100
Table 2:
Details of eye surgeries in Galkacyo eye camp
2010:
Date Female Male Total
22-Apr 56 36 92
23-Apr 48 55 103
24-Apr 53 52 105
25-Apr 51 46 97
26-Apr 46 48 94
27-Apr 41 43 84
28-Apr 18 17 35
29-Apr 8 8 16
Total 321 305 626
% 51.3 48.7 100
Chart 1: Number of surgeries/Day:
204
for an additional week to treat any post-oper-
ative complications and give advice to surgical
patients.There was one case of post-operative
infection,the source of which was determined
to be a personal hygiene issue. The infection
was treated aggressively with local and general
antibiotics and mydriatics which helped us
save the sight of the patient.This represents an
infection rate of 0.016% which is well below
the WHO accepted level of < 2%. Challenges: During our presence at Galkacyo Eye Hos- pital, I gave a presentation on the manage- ment of ophthalmic emergencies to the entire hospital staff, each of whom also re- ceived an eye screening.The Galkacyo Hos- pital management and staff members were very cooperative and no major challenges were encountered during this eye camp. Recommendations: As this eye camp has demonstrated the high prevalence of blindness in Somalia and the lack of eye services available to the general population, I would like to recommend to MSF the following: To hold similar eye camps twice every• year, as they have been clearly demon- strated to be a valuable service to the community. Improved planning for the logistics,• medicines and consumables needed for the eye camp. Involvement of an MSF management• team in the planning and implementation of the eye camp. I would like to take this opportunity to thank the management and staff of MSF for their support throughout this eye camp. I am also grateful to the team of surgeons and techni- cians that supported me throughout this eye camp for their tireless efforts and their high work ethic. Last, but not least, I would like to acknowledge the support and encourage- ment I have received from the chairman and operational team of Right to Sight. Eye camp team: 3 Surgeons, 1 Camp man- ager, 5 Ophthalmic technicians, 1 Anesthe- sia technician,2 Screening Nurses and MSF Galkayo South hospital team’s support Dr. Abdirisak Dalmar President, Somali Medical Association Consultant Ophthalmologist & Head of Training and Research Right to Sight, London, UK Regional and NMA news This is Ayan Ali. At just ten years old, she was the youngest person we treated. Congenital cataracts in both her eyes meant she had been blind since birth. We only operate on one eye at a time.Here we’ve made sure Ayan’s left eye is covered to protect it from infection. As you can see, we use only the simplest equip- ment.A microscope and light – Ayan’s surgery is done by hand. It takes a lot of skill and a steady hand. Not many doctors in the UK know how to do this operation manually any more. Just 24 hours later, Ayan returned to the eye camp for a check up. Already, she could see with her left eye. When I held up my fingers, she told me she didn’t know how to count very well, so we spent the next few minutes learning to count the numbers from one to ten – using her sight for the very first time. The surgery is more difficult for children to cope with, so we gave Ayan a general anaesthetic. After a short 15-minute surgery, Ayan is car- ried to the recovery room by one of the many lo- cal members of the team here, where her mother was waiting. 205 Regional and NMA news Seán Tierney The Irish Medical Organisation (IMO) was founded in 1984 following the amal- gamation of the Irish Medical Union and the Irish Medical Association that brought together the union and professional repre- sentative groupings of doctors in Ireland. Through this process, the IMO became the sole negotiating body on behalf of all doc- tors in Ireland. The role of the IMO is to represent doctors in Ireland to provide them with all relevant services. It is further com- mitted to the development of caring, effi- cient and effective Health Services. Structure Council of the IMO is the overall govern- ing body of the Organisation for policy direction and implementation. In addition to Council there is the Management Com- mittee who meet eight times a year and monitors the performance of the secretariat, receives monthly accounts and ensures that policy is being implemented. The IMO also has four Specialty Groups that address specific issues affecting the relevant groups. Members of the Speciality Groups are elected annually. Each Specialty Group contains regional and specialty rep- resentatives. The Specialty Groups within the IMO are: The Consultant Committee• The General Practitioner Committee• The Non-Consultant Hospital Doctor• Committee The Public Health Doctor Committee.• There are two Standing Committees, Inter- national Affairs and Ethics Committees: The International Affairs Committee has responsibility of representing the IMO at international meetings. The IMO is cur- rently active members of CPME, EANA, PWG, UEMO, UEMS and the WMA. Major Issues Given the economic climate globally – and particularly in Ireland – there are issues that have come to affect the medical profession, regardless of specialty or location. The IMO is continuously engaging in talks with government over a number of issues, particularlyregardingtheimplementationof policies that have seen a pronounced impact on our membership. The IMO has worked hard to alert the HSE, the Department of Health and Children and the broader Gov- ernment to the dangers of pursuing cost cuts now that end up costing more money in the long run. It is vital at this time of un- certainty that the IMO remains focused on protecting the essential fabric of our health services for our health professionals seeking to deliver quality services to their patients. Research and Policy As the representative body for the medical profession in Ireland, one of the key activi- ties of the IMO is advocacy. Through the Research and Policy Unit, the IMO pub- lishes key position papers during the year along with submissions on policy initiatives that represent the views of the member- ship. The most recent position paper was pub- lished in April on Universal Health Cov- erage, which looks at the principles that should underpin any Universal Health Care System. Such papers, along with submissions on various government and non-government consultations, are hoped to influence and inform Government proposals, and to rec- ognise the unique and important role that doctors play within the delivery of health services. Role of the Doctor One of the key roles of the IMO is to pro- tect and promote the Role of the Doctor in Ireland. Through the active representation of Irish doctors both domestically and in- ternationally, we hope to ensure the medi- cal profession is strong and will continue to advocate for the development of a caring, efficient and effective Health Service. Chief Executive: Mr George McNeice President: Professor Seán Tierney Vice President & Chair of the GP Committee: Dr Ronan Boland Treasurer: Dr Anthony O’Connor Honorary Secretary: Dr Bridin Cannon Chair of the NCHD Committee: Dr Matthew Sadlier Chair of the Public Health Committee: Dr Paul McKeown Chair of the Consultant Committee: Dr Trevor Duffy Website: www.imo.ie The Irish Medical Organisation 206 In October, 2008, the Ukrainian Medical Association (UMA) became a constitu- ent member of the WMA during the 59th World Medical Assembly in Seoul, South Korea. On November 4, 2008 a press con- ference was held in Kyiv to announce the membership of the UMA in the WMA. The President of the UMA,Oleg Musii,the Chairman of the Board of the UMA, Stan- islav Nechaiv, and UMA board member and Ukraine Parliament member, Volod- ymyr Karpuk,were present at the press con- ference to answer questions from Ukrainian and foreign journalists.This marked the be- ginning of a productive year for the UMA, summarized as followed: 1. In the spirit of co-operation, the UMA’s first priority as a new WMA member was to arrange the Ukrainian translation and publication of the WMA’s “Medical Ethics Manual” 2. On December 23, 2008, Law (№3539) “About Medical Self-Government” was presented to the Ukrainian parliament. Drafted by the UMA to develop the idea of independence of the medical profession, Law 3539 had long been under consider- ation by the Advisory Council of the Com- mittee of Health of the Verkhovna Rada (the Parliament) of the Ukraine. 3. From May 19-22, 2009, the Ukrainian Medical Association took part in the 112th Congress of the German Medical Associa- tion in Germany. 4. On June 5, 2009, the UMA presented its Ukrainian translation of the second edition of the WMA’s "Medical Ethics Manual" Carried out jointly by the UMA, the Ger- man Medical Association and the Finnish Medical Association, the largest contri- butions to the quality of the translation are credited to: Yuriy Kundiyev (National Academy of Science of the Ukraine and the Academy of Medical Science of Ukraine), Vitaliy Radchuk (Associate Professor of the Taras Shevchenko National Univer- sity), Stanislav Nechaiv (Master of Health Management), Dr. Oleg Musii (Master of Health Management),and Dr.Nina Krush- insky (Master of Health Management) with general editorial credit given to Lubomyr Pyrih (AMS of the Ukraine). 5. On September 18, 2009, the UMA be- came a member of the Forum of Medical Organizations in Central and Eastern Eu- rope (ZEVA) during its 16th Symposium held in the Serbian capital of Belgrade. 6. The "Ethical Code of Physicians of the Ukraine" was accepted during the 10th Con- gress of the Ukrainian Medical Association held in Evpatoria From September 24-27, 2009. 7. From October 15-18, 2009, the UMA took part in the 60th WMA General As- sembly in New Delhi, India. On December 16, 2009 the President of the Ukraine issued Decree № 1055/2009 “Cel- ebrating 100 years of the Ukrainian Medi- cal Association” and on February 24, 2010 the Cabinet of Ministers of Ukraine issued Order № 364-r "About the preparation for celebrating 100 years of the Ukrainian Medical Association" Celebrations for the occasion were scheduled for September- October of 2010 and invitations were ex- tended to representatives of state and local governments, NGOs, leading medical ex- perts and veterans affairs, students of edu- cational institutions, scientists, and public figures. Events planned for the celebration include scientific, medical and other health care conferences, round tables devoted to the value of the UMA, and the issuance of an engraved commemorative coin, postage stamp and envelope dedicated to the 100- year anniversary of the UMA.The Ukraini- an Medical Association has worked many years for the benefit of Ukrainian doctors, and in support of private medical practice. Dr. Oleg MUSII, the President of the UMA Dr. Stanislav NECHAIV, Chairman of Board of the UMA Regional and NMA news The Ukrainian Medical Association after Entering to the WMA Oleg Musii Stanislav Nechaiv 207 Education Those working in the UK National Health Service are accustomed to seemingly end- less reforms and changes in the NHS. Over the past 15 years there have been many, es- pecially in this century. Barely have the lat- est changes had time to be put in place. let alone given time for firm conclusions as to outcome, than further changes seem to ap- pear. Within weeks of the formation of the new Coalition Government following the June election in the UK, the new government published on the 12th July a White Paper broadly setting out the most radical changes proposed since the foundation of the NHS. The aims of the White Paper are indicated to be “to put patients at the heart of everything the• NHS does; focus on continuously improving those• things that really matter to the patient- the outcomes of healthcare; empower and liberate clinicians to inno-• vate, with freedom to focus on improving healthcare services.” The most radical proposals are that Gen- eral Practices through Consortia of GP’s, composed of representatives of each Gen- eral Practice in an area, should be charged with the Commissioning of most Health- care services.These Consortia are to replace the Primary Care Trusts ( PCTs) currently responsible for the Commissioning of ser- vices. PCTs are to be phased out over the next three years. The GP Consortia are to be supported by guidance from a National autonomous Commissioning Board which will provide leadership for quality guidelines, aimed at standardising good practice in promoting quality and equity, and promoting patient and carer involvement and choice.This pro- posal represents a radical change in placing power at the level of the provision of prima- ry care,where,as general practice has always maintained, the direct continuing interface with patients permits a broad knowledge of their needs. In proposals to increase the freedoms of Foundation Trusts (often referred to as Hospital Trusts), they will be licensed by Monitor (currently responsible for regulat- ing Foundation Trusts) in the same way as other Providers whether from the private or voluntary sector, thus increasing Founda- tion Trusts’ autonomy. The White Paper includes many other pro- posals including the introduction of a Na- tional Public Health Service, the employ- ment by Local Authorities (who will be responsible for health promotion and im- provement) of Directors of Public Health. and also provisions aimed at increasing local coordination of relevant activities between the NHS , Local Authorities and local pop- ulations, including empowering patient’s input into local services and patients’choice which are part of the democratisation of the NHS at the root of the proposals. A paper on these proposals is promised in the near future. The White Paper is open to consultation until the 6th of October following which,in November, legislation will be presented to the parliament. No hint of any such radical proposal for change was suggested by any political party during the run-up to the re- cent election. A number of more detailed consultation pa- pers have been published in the weeks fol- lowing the White paper.They provide more detail of the various proposals and a detailed timetable leading to full implementation in three years. These papers are the subject of consultation with continuing discussions and submissions by designated dates. Dr Hamish Mel drum, Chairman of Coun- cil of the British Medical Association in a letter to all members concerning the White Paper said “Taken together, these propos- als represent very significant changes to the organisation of health services in England. The proposals include increased respon- sibilities for doctors, the phasing out of PCT’s and SHA’s ( Statutory Health Au- thorities at Regional level) and a greater fo- cus on outcomes,as well as perceived threats to education and terms of service. There are also very significant proposals for the future of Public Health, with closer working with local authorities and ring-fenced budget in- tended to ensure the provision of a wider public health agenda.” He stressed the key proposal to devolve more involvement and financial control in commissioning to Gen- eral Practitioners and that to be successful, this would require the fullest engagement with secondary care colleagues and also with the public. High quality management support would be needed and the new GP Consortia would need to engage with expe- rienced NHS managers” While the aims and proposals offer great opportunities and a challenging agenda, es- pecially given the timescale, overall the pro- posals are not without risks -as a number of expert commentators have commented. (i)“Equity and Excellence – Liberating the NHS” Crown copyright ISBN 9780101788120 Radical changes proposed in the NHS (England) Government White Paper on the National Health Service – “Equity and Excellence - Liberating the Health Service”.(i) 208 WMA news Coming to Vancouver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 WMA Supports Physicians in Refusing Punishment Request. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Final Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Impact of Economic Crises on National Health Care Systems – Experience and Strategies . . 168 Global and local financial crisis – a challenge to the national health system. Example of Latvia . 173 What are the Minimal Services to be Provided by the Healthcare System? . . . . . . . . . . . . . . . . . . . . 176 How can Health Care Systems be structured and managed to be less sensitive to crisis and play a stabilizing role in economy?. . . . . . . . . . . . . . . . . . . . . . . . . . 177 Impact of Economic Growth and Financial Crisis on Estonia’s Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 The Institutional Factors that help Health Care System to hold up against Financial Crisis . . . . . . . . . . . . . . . . . . . . . 181 Singapore Statement on Research Integrity . . . . . . . . . . . . . . . 185 The Impact of the Economic Recession on Nurses and Nursing in Iceland . . . . . . . . . . . . . . . . . . . . . . . . 186 Lifestyle Practices of Medical Students attending an International Student Conference . . . . . . . . . . . . 193 The Norwegian Medical Association . . . . . . . . . . . . . . . . . . . . 195 Bangladesh Medical Association (BMA). . . . . . . . . . . . . . . . . 196 Hungarian Medical Chamber in the Last Twenty Years . . . . . 197 MOTESZ – Association of Hungarian Medical Societies . . . 199 American – Austrian Foundation in Macedonia . . . . . . . . . . . 200 The Somali Medical Association . . . . . . . . . . . . . . . . . . . . . . . 203 The Irish Medical Organisation . . . . . . . . . . . . . . . . . . . . . . . . 205 The Ukrainian Medical Association . . . . . . . . . . . . . . . . . . . . . 206 Radical changes proposed in the NHS (England) Government White Paper on the National Health Service – “Equity and Excellence - Liberating the Health Service”. . . . . 207 Contents EFMA (European Federation of Medical Associations) / WHO meeting in St. Peterburg 19–21 September 2010