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RESEARCH (cid:127) DEBATE (cid:127) POLICY (cid:127) NEWS
Volume 12 Number 3, 2006
French health system reform:
Implementation and future challenges
Interview with Xavier
Bertrand, French
Minister of Health
Pharmaceutical and
human resource
policies in France
Hospital reform:
a new era of
public/private
competition?
Germany: Is Bismarck going Beveridge? (cid:127) Climate change and health (cid:127) Sexually transmitted infections
Obesity control (cid:127) Mental health reform in Romania (cid:127) Stem cell politics (cid:127) Choice and deregulation in Sweden
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Plus ça change……?
Plus ça change, plus c’est la meme chose – the more
things change, the more they stay the same! All too
often this can be said of health care reform. It is apt
therefore, that much of this issue of Eurohealth is
devoted to the French health system. Zeynep Or,
Chantal Cases and colleagues at the Institute for
Research and Information on Health Economics
(IRDES) in Paris have brought together contributions
describing and reflecting on the consequences of major
reforms enacted in 2004. We are especially delighted to
feature an interview with Xavier Bertrand, French
Minister of Health.
Previously ranked by WHO as the best performer, the
French health system is not without problems. It has
traditionally operated with little regard to efficiency or
cost containment. It has the highest rate of pharma-
ceutical use in the EU, while, until recently at least, there
has been little attempt to incorporate cost effectiveness
into policy making. The health workforce is ageing;
geographical inequalities in access to services exist.
Moreover, promotion and prevention have not been
high priorities.
The 2004 reforms make use of economic incentives to
influence the behaviour of health professionals and the
public. These include a system of gate keeping for
primary care, activity-based payments and managerial
freedom in hospitals, incentives to use generic drugs,
support for general practice training and investment in
public health campaigns.
Will the reforms lead to sustainable change? Will the
French experience be of relevance elsewhere in Europe?
In truth, it is too early to say, but the initial signs are
encouraging. According to M. Bertrand, for the first
time in ten years the Statutory Health Insurance has
stayed within expenditure limits. The potential to realise
greater savings while still investing in high quality
innovative therapies remains strong. It is to be hoped in
a few years, when speaking of the reforms we might be
able to say plus ça change, plus c’est la difference!
David McDaid Editor
Sherry Merkur Deputy Editor
Eurohealth
LSE Health, London School of Economics and Political
Science, Houghton Street, London
WC2A 2AE, United Kingdom
fax: +44 (0)20 7955 6090
email: eurohealth@lse.ac.uk
www.lse.ac.uk/LSEHealth
Editorial Team
EDITOR:
David McDaid: +44 (0)20 7955 6381
email: d.mcdaid@lse.ac.uk
FOUNDING EDITOR:
Elias Mossialos: +44 (0)20 7955 7564
email: e.a.mossialos@lse.ac.uk
DEPUTY EDITOR:
Sherry Merkur: +44 (0)20 7955 6194
email: s.m.merkur@lse.ac.uk
EDITORIAL BOARD:
Reinhard Busse, Josep Figueras, Walter Holland,
Julian Le Grand, Martin McKee, Elias Mossialos
SENIOR EDITORIAL ADVISER:
Paul Belcher: +44 (0)7970 098 940
email: p.belcher@lse.ac.uk
DESIGN EDITOR:
Sarah Moncrieff: +44 (0)20 7834 3444
email: westminster.european@btinternet.com
SUBSCRIPTIONS MANAGER
Champa Heidbrink: +44 (0)20 7955 6840
email: eurohealth@lse.ac.uk
Advisory Board
Anders Anell; Rita Baeten; Nick Boyd; Johan Calltorp;
Antonio Correia de Campos; Mia Defever; Nick Fahy;
Giovanni Fattore; Armin Fidler; Unto Häkkinen; Maria
Höfmarcher; David Hunter; Egon Jonsson; Meri Koivusalo;
Allan Krasnik; John Lavis; Kevin McCarthy; Nata
Menabde; Bernard Merkel; Stipe Oreskovic; Josef Probst;
Tessa Richards; Richard Saltman; Igor Sheiman; Aris
Sissouras; Hans Stein; Jeffrey L Sturchio; Ken Thorpe;
Miriam Wiley
Article Submission Guidelines
see: www.lse.ac.uk/collections/LSEHealth/documents/
eurohealth.htm
Published by LSE Health and the European Observatory
on Health Systems and Policies, with the financial support
of Merck & Co and the European Observatory on Health
Systems and Policies.
Eurohealth is a quarterly publication that provides a forum
for researchers, experts and policymakers to express their
views on health policy issues and so contribute to a
constructive debate on health policy in Europe.
The views expressed in Eurohealth are those of the authors
alone and not necessarily those of LSE Health, Merck & Co
or the European Observatory on Health Systems and Poli-
cies.
The European Observatory on Health Systems and Policies
is a partnership between the World Health Organization
Regional Office for Europe, the Governments of Belgium,
Finland, Greece, Norway, Slovenia, Spain and Sweden, the
Veneto Region of Italy, the European Investment Bank, the
Open Society Institute, the World Bank, CRP-Santé Lux-
embourg, the London School of Economics and Political
Science, and the London School of Hygiene & Tropical
Medicine.
© LSE Health 2006. No part of this publication may be
copied, reproduced, stored in a retrieval system or transmitted
in any form without prior permission from LSE Health .
Design and Production: Westminster European
email: westminster.european@btinternet.com
Printing: Optichrome Ltd
ISSN 1356-1030
Contents
1 Can adaptation reduce the health effects from
Eurohealth Debate
climate change?
Robert Mendelsohn
Public Health Perspectives
3 Sexually transmitted infections in Europe
Michael W Adler
7 Obesity-control policies in Europe
Philipa Mladovsky and Caroline Rudisill
10 French health system reform: recent implementation and
Focus on France
future challenges
Chantal Cases
12 Interview with Xavier Bertrand, French Minister of Health
15 Pharmaceutical policy in France: a mosaic of reforms
Nathalie Grandfils and Catherine Sermet
18 Health targets in France: role of public health and social
health insurance reform laws
Isabelle Durand-Zaleski
21 French hospital reforms: a new era of public-private
competition?
Zeynep Or and Gérard de Pouvourville
24 Health care human resource policy in France
Yann Bourgueil and Yvon Berland
27 New governance arrangements for French health insurance
Carine Franc and Dominique Polton
European Snapshots
Anna Melke
30 A new policy agenda in Sweden: choice and deregulation
31 Health care reform in Germany: is Bismarck going Beveridge?
Melanie Lisac and Sophia Schlette
Eurohealth
Volume 12 Number 3
Michael W Adler is Professor Emeritus of
Genitourinary Medicine, Centre for Sexual
Health & HIV Research, Royal Free &
University College Medical School, University
College London, UK.
Yvon Berland is Professor of Medicine and
President of the French National Observatory
of Health Professions.
Xavier Bertrand is the Minister of Health,
France.
Yann Bourgueil is a Research Director, Institut
de Recherche et Documentation en Economie
de la Santé (IRDES), Paris, France.
Chantal Cases is Director, Institut de Recherche
et Documentation en Economie de la Santé
(IRDES), Paris, France.
Isabelle Durand-Zaleski is Head of Department
at the Department of Public Health, APHP
hôpital Henri Mondor, Paris, France.
Anne-Maree Farrell is Lecturer, School of Law,
University of Manchester, Manchester, UK.
Carine Franc is a Researcher at the Institut
National de la Santé et de Recherche Médicale
and the Institut de Recherche et Documentation
en Economie de la Santé (IRDES), Paris,
France.
Jack Friedman is a Post Doctoral Fellow,
Department of Comparative Human Devel-
opment, University of Chicago, Illinois, USA.
Nathalie Grandfils is a Research Fellow, Institut
de Recherche et Documentation en Economie
de la Santé (IRDES), Paris, France.
Melanie Lisac is Project Manager, International
Network Health Policy & Reform Coordinator,
Bertelsmann Stiftung, Gütersloh, Germany.
Anna Melke is a former journalist and
currently a PhD candidate, School of Public
Administration, University of Göteborg,
Sweden.
Robert Mendelsohn is Edwin Weyerhaeuser
Davis Professor, Professor of Economics, and
Professor in the School of Management, Yale
School of Forestry and Environmental Studies,
New Haven, Connecticut, USA.
Health Policy
33 Stem Cell Politics
Anne-Maree Farrell
36 The challenges facing mental health reform in Romania
Jack R Friedman
Evidence-informed Decision Making
40 “Risk in Perspective” Risk communication: a neglected tool in
protecting public health
43 “Bandolier” Delivering better health care 2
Monitor
46 Publications
47 Web Watch
48 News from around Europe
Philipa Mladovsky is a Research Assistant at
LSE Health, London School of Economics and
Political Science, UK.
Zeynep Or is Senior Economist, Institut de
Recherche et Documentation en Economie de la
Santé (IRDES), Paris, France.
Dominique Polton is Director of Strategic
Research and Development, Caisse Nationale
d’Assurance Maladie, Paris, France.
Gérard de Pouvourville is Research Director,
Centre National de la Recherche Scientifique
and also at Institut National de la Santé et de
Recherche Médicale, Paris, France.
Caroline Rudisill is a Research Assistant at LSE
Health, London School of Economics and
Political Science, UK.
Catherine Sermet is a Research Director, Institut
de Recherche et Documentation en Economie
de la Santé (IRDES), Paris, France.
Sophia Schlette is Project Director,
International Network Health Policy & Reform
Coordinator, Bertelsmann Stiftung, Gütersloh,
Germany.
Eurohealth in perspective
Objectives
Backed by experts
The aim of Eurohealth is to bridge the
gap between the scientific and policy-
making communities by providing an
opportunity for the publication of
evidence-based articles, debates and
discussions on contemporary health
system and health policy issues.
Features
(cid:127) Debates
The Editorial Team is based at LSE Health
and works with an Editorial Board. Euro-
health is also supported by an international
Advisory Board, which is comprised of a
distinguished list of academics and policy-
makers from leading health policy research
centres, national Ministries of Health and
international organisations, such as the World Health Organi-
zation and the European Parliament. Eurohealth is also able to
draw on the expertise of the European Observatory on Health
Systems and Policies, which brings together eminent
academics and research centres from across Europe.
(cid:127) Public Health Perspectives
(cid:127) Health Policy Developments
Feedback
(cid:127) Evidence-based decision making for
health care
(cid:127) Monitoring the latest EU and country-
level developments plus information
on new publications, health-related
websites and much more
We very much value your continued feedback and
suggestions on future topics and potential contributions.
These can be sent in the first instance to the Editor,
David McDaid at d.mcdaid@lse.ac.uk
Eurohealth is available electronically for download at:
www.euro.who.int/observatory/Publications/20020524_26
EUROHEALTH DEBATE
Debate:
Can adaptation reduce the health
effects from climate change?
Summary: This article argues that much of the available literature on the impact of
climate change on health has grossly overestimated the likely effects by persistently
ignoring the potential of adaptation to reduce actual negative health outcomes. Specific
examples are provided for malaria and heat stress. Spending resources on adapting to
climate change, helping individuals avoid diseases and providing medical protection
(such as vaccines) can all be effective measures in reducing the risk of climate change
related illness.
Key words: Climate change, Public health, Adaptation, Malaria, Heat stress,
Robert
Mendelsohn
There are many
predicted damages
associated with climate
change but one of the
most salient and difficult to weigh is the
potential loss of health.1 Scientists predict
that there are many mechanisms that
might lead to future mortality and
morbidity.2 Infectious diseases may
increase as warming increases the
territory of dangerous vectors such as
mosquitoes or tsetse flies. Heat waves
could kill unsuspecting citizens. Concen-
trations of ozone could increase. There
could be malnutrition, fish and shellfish
poisoning, stress from migration, and
more frequent or severe floods, droughts
and storms.
Although the numbers of potential deaths
and illnesses from climate change are
uncertain, estimates in the literature are
frequently large. For example, a 2.5˚C
warming is predicted to cause 137,000
potential deaths per year.3 A doubling of
carbon dioxide (CO2) may cause 360–520
million cases of malaria.4 Health damages
reported for the US alone range from $9
to $69 billion,1 out of total climate
change damages of between $61 and $139
billion. The literature gives the
Robert Mendelsohn is Edwin
Weyerhaeuser Davis Professor, Professor
of Economics, and Professor in the School
of Management, Yale School of Forestry
and Environmental Studies, New Haven,
Connecticut, USA.
Email: robert.mendelsohn@yale.edu
impression that human health is one of
the primary reasons to curb greenhouse
gas emissions.
This article argues that the climate health
literature has grossly overestimated the
likely health effects from climate change
by persistently ignoring the potential of
adaptation to reduce actual negative
health outcomes. Victims are likely to
take measures to avoid future risks, for
example by reducing exercise in the heat
of the day or by avoiding mosquito bites
with netting. Public health organisations
can take important measures to reduce
the spread of infectious diseases by
spraying mosquitoes or inoculating
people against potential diseases. The
result of all of these adaptations is that
the actual number of people that will die
or become ill from climate change may be
quite small. Greenhouse gases are not
likely to cause the large ‘potential’
increases in future morbidity and
mortality predicted by the literature.
Two important mechanisms where the
links between climate and health have
been quantified are reviewed: malaria and
heat stress. In both cases the potential
threat and plausible adaptation response
are discussed in detail and the article
concludes with a discussion of the policy
ramifications of these arguments.
Vector-borne diseases
There are many infectious diseases that
may be climate sensitive because they
depend on an ecological vector
(mosquitoes, flies, snails) to spread.2 If
climate conditions change, the geographic
domain of that vector may change as
well. The disease may be able to spread to
new territories where the local popu-
lation represent ‘potential’ new cases.
Two of the most prominent infectious
diseases that have a clear link with climate
are malaria and dengue fever.2 Both
diseases depend on mosquitoes which
have very specific climatic ranges. For
example, malaria is caused by the
pathogen Plasmodium falciparum and
Plasmodium vivax. These pathogens are
transmitted by the Anopheles mosquito,
which requires minimum temperatures of
20˚C for breeding. Furthermore, the
breeding season must be long enough to
allow the pathogen to come to maturity.
As temperatures warm, currently cool
wet places become potential new
infection zones. For a specific climate
scenario, researchers count the number of
people who live in these new zones in
order to estimate the number of potential
new cases. Using this approach, it was
estimated that climate change could cause
between 360 to 520 million new potential
malaria cases by 2100 depending on the
Do you disagree? Eurohealth would like to invite your responses to this article. If you
are interested in presenting an alternative perspective please send a brief outline of your
proposed argument to Sherry Merkur at s.m.merkur@lse.ac.uk
Eurohealth Vol 12 No 3
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