European health systems under siege
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* Lauren Vogel

The quick fixes that most European Union member states adopted in response to financial pressure placed on their health care systems during the global economic crisis have likely compromised the sustainability of their systems and the quality of the care they provide, a European nonprofit organization charges.

Rather than implementing measures to improve health care efficiency, most nations opted for the quick and dirty fix of slashing health care budgets, staff and services covered by national health plans, without a view to long-term sustainability or potential health consequences, HOPE, the European Hospital and Healthcare Federation asserts in a report, *The Crisis, Hospitals and Healthcare* ([www.hope.be/05eventsandpublications/docpublications/86\_crisis/86\_HOPE-The\_Crisis\_Hospitals\_Healthcare\_April\_2011.pdf](http://www.hope.be/05eventsandpublications/docpublications/86\_crisis/86\_HOPE-The\_Crisis\_Hospitals_Healthcare_April_2011.pdf)).

The long-term effects have been, and will be, significant, says Pascal Gare, the federation’s chief executive officer. “These were not evidence-based policies, and we’re only just beginning to see their ramifications.”

Worsening quality and reduced access to care, particularly in poorer nations, have already been seen as a consequence of cuts in the number of health personnel, and their wages, as well as reductions in financial support for providers of publicly insured health services.

“Most countries already had efficiency reforms of some kind or other in place when the crisis hit, policies that could have been sped up or expanded upon, but it doesn’t seem there was a link between those measures and the urgent measures adopted during the crisis,” Garel says.

The report, which seeks to identify what impact the global economic crisis had on the health systems of European nations, states that most members states responded to the ensuing reduction in their revenues by cutting health care spending or reducing the rate of growth in health budgets. In some of Europe’s poorest nations, such as Romania, the response was to slash the health budget by 25%. Other countries implemented short-term ceilings or indefinite budget freezes, or prohibited the use of monies to pay down debt within the system.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/183/10/E623/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/183/10/E623/F1)

Layoffs and hospital closures were the order of the day in Romania during the recent economic recession. The number of employed health care professionals, and workers’ salaries, were reduced by as much as 25% in 2010.

Image courtesy of © 2011 Thinkstock

All the while, demand for health services continued to rise, the report states, adding that the brunt of the blow, in many nations, fell on health human resources. Several countries imposed wage cuts on physicians, or introduced hiring freezes for all health professionals. In some countries, such as France, Denmark and Romania layoffs and hospital closures were the order of the day.

“If you take the example of Romania, where health care professionals, and workers’ salaries, were reduced by as much as 25% in 2010, we’ve already seen a negative impact on the morale of the workforce, wait times for care increasing, access to care decreasing and patient satisfaction with it,” says Garel. “If they were really after efficiency, they would have tied performance indicators to the wages of workers, but what they’ve done has gone in the opposite direction; it’s demoralizing, not motivating.”

The cuts resulted in an exodus of some 2500 physicians from Romania in 2010, a development that Garel says has also been witnessed, although to a lesser extent, in countries such as Spain, Latvia and Estonia, where wages for health professionals were reduced by 5%–10%.

The report says that cuts were imposed in all nations.

Cyprus, Portugal and the United Kingdom were among those that introduced hiring and salary freezes, while Luxembourg passed legislation that allows the government to cap the number of health professionals over the next five years.

Most states also imposed strictures on replacing retiring health professionals, allowing as few as one new recruit for every 10 retired professionals. Finland strongly encouraged physicians to take a year’s leave without pay.

Other countries, including Belgium and the Czech Republic, increased funding to train nurses to take over physicians’ duties but offered no additional monies to offset their increased workloads and responsibilities.

Governments also scaled back funding for hospital services. In Latvia, for example, some 67 hospitals have been shut down, while no additional monies have been provided to the nation’s 39 remaining hospitals to handle the influx of patients to their facilities resulting from the closure of others. The impact has been felt on all forms of care, including emergency services.

Some 40% of French hospitals faced deficits in 2010, while 12 hospitals in Hungary were “privatized, faced disruption and were then resocialized [brought back under public governance].”

The report indicates that hospital mortality rates are on the rise in many nations and that the costs of care are being shifted onto the shoulders of patients, thus “dramatically” reducing access to care.

Even countries such as Sweden, whose health care systems were exempt from budget cuts during the economic crisis, saw patients take blows in the form of increased out-of-pocket, direct and copayments, or reductions in sickness benefits, drug coverage, nursing care and other forms of specialized care. In France, reimbursements for drugs were reduced by 10 percentage points from 35% to 25% in 2010.

“In countries where there was already out-of-pocket or some sort of co-payment for services and drugs, I think it has now reached a level that we cannot go any further because we’ll lose so many people,” Garel says.

The full effects will not be realized for another year or two, Garel adds. “It’s in the interest of the trade unions and health care professionals to make the population aware of what’s happening. But we’ve yet to hear one strong voice for health care professionals on a national level, let alone the EU [European Union] level.”