Prevention and Health Promotion for the Excluded and the Destitute in Europe (Biomedical and Health Research, 56)

PREVENTION AND HEALTH PROMOTION FOR THE EXCLUDED AND THE DESTITUTE IN EUROPE

Biomedical and Health Research Volume 56 Earlier published in this series

Vol. 23. M. Hallen (Ed.), Human Genome Analysis Vol. 24. S.S. Baig (Ed.),Cancer Research Supported under BIOMED I Vol. 25. N.J. Gooderham (Ed.), Drug Metabolism: Towards the Next Millennium Vol. 26. P. Jenner (Ed.), A Molecular Biology Approach to Parkinson's Disease Vol. 27. P.A. Frey and D.B. Northrop (Eds.), Enzymatic Mechanisms Vol. 28. A.M.N. Gardner and R.H. Fox, The Venous System in Health and Disease Vol. 29. G. Pawelec (Ed.),EUCAMBIS: Immunology and Ageing in Europe Vol. 30. J.-F. Stoltz, M. Singh and P. Riha, Hemorheology in Practice Vol. 3 1 , B.J. Njio, A. Stenvik, R.S. Ireland and B. Prahl-Andersen (Eds.), EURO-QUAL Vol. 3 2 . B.J. Njio, B. Prahl-Andersen. G. ter Heege, A. Stenvik and R.S. Ireland (Eds.),Quality of Orthodontic Care - A Concept for Collaboration and Responsibilities Vol. 33. H.H. Goehel, S.E. Mole and B.D. Lake (Eds.),The Neuronal Ceroid Lipofuscinoses (Batten Disease) Vol. 34. G.J. Bellingan and G.J. Laurent (Eds.),Acute Lung Injury: From Inflammation to Repair Vol. 35. M. Schlaud (Ed.),Comparison and Harmonisation of Denominator Data for Primary Health Care Research in Countries of the European Community Vol. 36. F.F. Parl, Estrogens, Estrogen Receptor and Breast Cancer Vol. 37. J.M. Ntamhi (Ed.), Adipocyte Biology and Hormone Signaling Vol. 38. N. Yopnandan and F.A. Pintar (Eds.). Frontiers in Whiplash Trauma Val. 39. J.-M. Graf von der Schulenburg (Ed.). The Influence of Economic Evaluation Studies on Health Care Decision-Making Vol. 30. H. Leino-Kilpi, M. Valimaki, M. Arndt, T. Dassen, M. Gasull. C. Lemonidou, P.A. Scott. G. Bansemir. E. Cabrera, H. Papaevangelou and J. Mc Parland, Patient's Autonomy. Privacy and Informed Consent Vol. 4 I.T.M. Cress (Ed.). Molecular Pathogenesis of Pancreatic Cancer Vol. 42. J.-F. Stoltz (Ed.), Mechanobiology: Cartilage and Chondrocyte Vol. 33. B. Shaw, G. Semb. P. Nelson, V. Brattstriim, K. Mslsted and B. Prahl-Andersen. The Eurocleft Project 1996-2000 Vol. 44. R. Coppo and Dr. L. Peruzzi (Eds.), Moderately Proteinuric IgA Nephropathy in the Young Vol. 45. L. Turski, D.D. Schoepp and E.A. Cavalheiro (Eds.), Excitatory Amino Acids: Ten Years Later Vol. 46. I. Philp (Ed.), Family Care of Older People in Europe Voi. 47. H. Aldskogius and J. Fraher (Eds.). Glial Interfaces in the Nervous System - Role in Repair and PI ast i c' i t y Vol. 48. H. ten Have and R.Janssens (Eds.). Palliative Care in Europe - Concepts and Policies Vol. 49. T. Reilly (Ed.). Musculoskeletal Disorders in Health-Related Occupations Vol. 50. R. Bussc. M. Wismar and P.C. Berman (Eds.), The European Union and Health Services Vol. 5 I . G. Leheer (Ed.), Ethical Function in Hospital Ethics Committees Vol. 52. JLF. Stoltz (Ed.). Mechanobiology: Cartilage and Chondrocyte, Vol. 2 Vol. 53. C . Huttin (Ed.),Patient Charges and Decision Making Behaviours of Consumers and Physicians Vol. 54. 1.M. Shapiro. B.D. Boyan and H.C. Anderson (Eds.). The Growth Plate Vol. 5 5 . J Matsoukas and T. hlavromoustakos (Eds. 1, Drug Discovery and Design: Medical Aspects ISSN: 0929-6743

Prevention and Health Promotion for the Excluded and the Destitute in Europe Edited by

Pierre Chauvin National Institute of Health and Medical Research (INSERM U444) and Institut de l 'Humanitaire, Paris, France

and

The Europromed Working Group

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V

Foreword Social inequalities of health have persisted in Europe, or even increased for the last 15 years, despite the large amount of public funds spent on health and social protection. Health education, prevention, and promotion - if they specifically address the populations that most need them (the more vulnerable, the more underprivileged) - can be adequate and costeffective responses in the fight against health inequalities. Everywhere in Europe original initiatives have been developed to respond to the health needs of these people. This book presents the experiences of professionals from various institutional backgrounds (public, associative, academic, etc.) from 8 European countries, as well as their recommendations to improve the access of excluded people and populations to prevention and health promotion. Working Group Pierre Chauvin and the EUROPROMED

Editor Pierre Chauvin, Nutiorid Institute of Health und Medical Research (INSERM U444) und lnstitut de 1 'Hirinunituire, Puris, Frunce

Co-editors: the EUROPROMED Working Group Paolo Contu Department of Hygiene and Public Health, Universiv ~fCagliari, Italy Sophie Durieux Dqxirrmen t of' Communih Medicine, Geneva's Universih Hospitals, Switzerland Jacques Lebas Saint-Airtoine Hospitul (Assistance Pitblique - Hiipitaux de Paris) und lnstitut de I'Hirmunituire, Puris. Frunc.u

Rui Gentil Portugal Iiistitrrte of' Pre\witiile Medicine, Universin of' Lisbon, Portugal Theo Rosenberg MPc1ccin.s rlii Monde-Grkcr, Athens, Greece Amparo Sanchez Met1ic.o.s clel Mundo. Vulenciu, Spain

Anne Vincent Mkdecins suns Frontikres, Brussels, Belgium Heinz-Jochen Zenker Depcirtinent qf' Public Health, Bremen, Germany

Contributors Federico Argiolas Manola Bacchis Gabriella Caria Valentina Coroneo Maria-Luisa Dorado Garcia Pilar Estebanez Danila Ghiani Anabelle Gilg Mikael GuCzelot Jacques Hassin Thomas Kieselbach Farid Lamara Michele Ikvy-Soussan Louis Loutan .4le\sandra Mereu

Michde Mezard Nassera Mezatfa Zahra Mohammadzadeh Juan Monleon Garcia Francesca Murati Rossi Rita Muscas; Serafinangelo Ponti Josien Prompers Catherine Richard Pierre Ryckmans J d l l e Saunikre Axel Schroter Hans Stalder Clare Taylor Gabi Siebenmorgen

vii

Editorial coordination Sandrine Revet

Translation from French and Spanish Christina Black

Special thanks to Hen riette Chamoui llet Commission of the European Communities, DGV

This document is the result of a collaborative work started in 1997 in eight European countries. This work was carried out with financial support from the Commission of the European Communities, Directorate General V. Only the authors are responsible for the views and opinions expressed in this document, these do not necessary reflect those of the Commission or the national governments.

Contents Part 1. An Overview on Europeans’ Health Care Systems The Aggravation of Health Inequalities in Europe Demands New Responses Exclusion from Health in Different European Countries The European Health Care Systems: a Focus on Germany, Belgium, France, Spain. Greece, Italy. Portugal, and Switzerland.

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Part 2. Europeans’ Experiences Illegal Immigrants in Spain Tuberculosis in an Indian Community in Lisbon The Bremen Health Programme for Asylum Seekers and Refugees Evaluation of the Impact of Trauma and Torture on Asylum Seekers: the Geneva Experience Roma and Social Exclusion in Greece The Rom Population in Spain Homeless in the Paris Area: Health and Access to Care Situation of the Homeless in Spain The Medical Emergency Care Facility for Single Homeless in Bremen Substance Abuse in Spain The Advisory Service on Sexually Transmitted Diseases in Bremen

65 71 73

77

82 84

90 95 98 104 107

Part 3. Health Promotion Public Health and Health Promotion Definition of Target Groups for Health Promotion or Preventive Programmes: The Example of Migrants Prevention and Health Promotion among Populations in Precarious Conditions: A Critical Approach Integrating Prevention and Health Promotion Practices into Primary Care for Deprived Populations Framework for Describing the Process of Health Promotion Activities: The “Healthy School” Programme at Sant’Elia, Cagliari, Italy SMILE: A Tooth Decay Prevention Project among Children of Asylum Seekers in Geneva Influence of the Social Characteristics of Patients on the Behaviour of Physicians Regards Prevention within a Hospital Outpatients Consultation Establishing Health Promotion Programmes among Migrant Rom Populations Living in Precarious Conditions in Europe A Workshop for HIV+ African Women Living in Paris Trends in European Health Care Systems: Implications for Destitute Populations Prevention and Health Promotion for the Excluded and the Destitute in Europe: Recommendationsfor the Health Professionals and Health Institutions

113 121 125

128 142

150 a15

154 158 161 164 171

ix

Appendix Presentation of the Institutions Participating in the Europromed Project

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Part 1

An Overview on Europeans’ Healthcare Systems

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Part I . An Overview On Europeans' Health Care Systems

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The aggravation of health inequalities in Europe demands new responses Pierre Chauvin

The European health systems confronted with the need for equity Equal access to health care is a principle common to all the European States, cited in their founding texts, their constitutions, carried over to their public health codes and their medical codes of ethics. It is about an ethical principle, which cannot be disassociated from Human rights, these universal ethics that constitute our common European heritage, as regards the right to dignity: the first of the fundamental, inalienable (and indemonstrable) rights of man,. It is this right to dignity which is then conjugated in so many conditions indispensable to individual and collective well-being. As Jonathan Mann reminded us, ((humanrights raise the question of the social conditions essential to well-being in terms of what the governments or states should not do (such as discriminate, deny equality before the law, violate private life) and of what the states should ensure to all, such as basic education, social security, access to care, to housing and to adequate food)).It is precisely in these terms that the principle of an equitable access to care is raised: neither a right, nor a principle that cannot be questioned, but an indispensable condition to respect the fundamental rights of man. This principle of equity is not only ethical. Various international organisations - the WHO, of course, but also institutions not suspected of humanitarian utopia such as the World Bank - now stress both the considerable impact of health on development and the need (and economic importance) to invest in these domains. This principle is becoming a public health imperative when faced with emerging or re-emerging epidemics, such as AIDS or tuberculosis. Such epidemics cannot or will not be controlled if individuals or communities remain, de facto, excluded from the health systems and the prevention programmes proposed. This principle and these facts, that seem to be rediscovered today in the developing countries, are in fact just the same as those that led to the construction of the European Welfare States over the last 50 years. The political histories of these states are quite different (from bourgeois democracies to populist dictatorships) but the objectives were the same: to ensure economic development and a certain social cohesion (some speak of social control) of these nations. These political histories have bequeathed to us extremely varied health and social protection systems, to such a degree that on these points the subsidiary principle prevails in the European Union. However, if the professionals and decisionmakers are willing to look beyond their borders, we must be able to extricate from this diversity, now confronted with identical problems of inequity and exclusion, some teachings, some paths of action. In Europe, different types of national health systems coexist: in the United Kingdom and Ireland of Beveridgian inspiration; public insurance systems of Bismarckian inspiration (such as in Germany, Belgium or France) in which public Social Security organisations manage most of the public health expenditure; mixed systems in Southern Europe where the more recent establishment of national health systems followed the corporatist systems inherited from authoritarian regimes; private insurance systems in Holland (above a certain income level) and also in Switzerland. In terms of care offer, that proposed by the insurance systems is often more abundant than that of the national health systems. The primary and specialised care offer is nearly two times greater in Germany and in France that in the United Kingdom or in

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Part I . An Overview On Europeans’ Health Care Systems

Portugal (figure 1). Major gaps are also observed in terms of utilisation or consumption of care. Each year, the Germans and the Italians consult a physician twice as often, on average, than the French, the Spanish or the Portuguese (figure 2).

Figure 1. Care offer in different countries of the European Union

Figure 2. Care utiiisation in different countries of tbe European Union What can explain these differences? As morbidity is roughly the same among the populations, it is probably a question of habits of medical consumption. These habits, these behaviours of care consumption, are strongly determined by the mechanisms of public coverage of health expenses. This is in fact the lever that has been used, for the last 15 years, by the plans to constrain health expenditure that have succeeded each other in all countries, in particular in Northern Europe. Incomplete health protection

In Europe the health protection systems are extremely varied. The manner in which this protection is defined and managed has a direct impact on the proportion of persons covered by the system; on the difficulty in making use of rights; and on the level of benefits provided, i.e. the share of health expenses paid by individuals. In the national health systems, public health expenditure is managed directly by the state and financed by taxation. In insurance systems, such as in France, these expenses are managed by one or several Social Security organisations. They remain mainly financed b> contributions. therefore by income from work. from professional activities. These Social

Part 1. An Overview On Europeans’ Health Care Systems

5

Security organisations can be monopolies (e.g. the different schemes in France), or not. Thus, in Germany, the (very numerous) Social Security funds compete among themselves: an individual can choose a fund in another region, or in another branch of activity, depending on the level of benefits proposed. Finally, in certain countries, the private insurance funds participate in this basic scheme, either in totality (due to the virtual absence of a Social Security system) as in Switzerland, or in competition with Social Security organisations such as in Holland. The role of additional insurance funds - mutual benefit or private - also varies from one country to another and from one system to another. Globally, additional insurance funds are most necessary and therefore rife in the Social Security type insurance systems. In these systems they are often the only possibility for standard ambulatory expenses (and specifically badly covered expenses, such as dental care) being entirely covered. The conditions of access to the health protection vary according to the system’s general organisation. Without a doubt the national health systems are the easiest to join: the regular place of residence - i.e. place of residence as sole condition -is the only condition for an individual’s coverage by the national care system. In the insurance systems, of the Social Security type, the ((usual)) insured person remains the one who works and contributes. Little by little health coverage has been extended to dependants, then to the ever more numerous categories of population that don’t work: students, the unemployed, etc. Structures managed by the local authorities or the state have often completed the Social Security system for those persons with the least financial resources. This evolution had led to the systems that we know in most of the countries that chose the Social Security model. In this model 99% of the population are covered in theory, but in practice, outside of the standarf situations where rights are obtained automatically, obtaining these rights implies individual initiative to confront a bureaucracy so complex that the probability of success is often arbitrary. It depends on being well-informed, knowing how to obtain one’s rights, and knocking at the right door with the appropriate documents. The national health systems appear, in theory, the most favourable to the equity of care: each person has free access, without paying and being reimbursed, to a physician or to hospital care. However this exemption from payment is, in fact, incomplete in that outside of the United Kingdom and Holland less than 75% of the cost of medications is reimbursed (figure 3). There again, the insurance systems are those which reimburse the least: in Germany, in Belgium and in France, only 50% of the cost of medications is reimbursed. In France, ambulatory care - consultations and visits - is among the least well reimbursed of Europe. In most countries and most care systems, dental care, dental and hearing prosthesis and eyeglasses are equally poorly reimbursed.

h

Par? I . An Overview On Europeans ’ Health Care System

Figure 3. Average reimbursement rates in different countries of the European Union Increasing health inequalities despite increasing health expenditure

The situation that prevails in Europe on the whole is, globally, a very high level of health expenditure, between 8 and 10% of the GNP, of which 80% is public expenditure. There again, the insurance systems often come first (Germany, France, Belgium); that is those that have the greatest difficulty in mastering the major increase of their expenditure despite a constant pressure on services and reimbursement rates. Western Europe is thus,as a whole. the region of the world that spends the most public funds on health and social protection in general. However, despite these investments, it is obvious everywhere that - whereas globally the level of health has constantly improved for the last 40 years - health inequalities persist, or have even worsened in the last 10 or 15 years. Constant gradients, always oriented in the same direction, are observed, whatever the social variables considered (classic socio-professional category, employment status, income level, nationality and migration status, education level, importance of the social network and/or social support, etc.) and whatever the health indicators used (perceived states of health, mortality, morbidity, consumption of care, etc. Some figures of the social inequalities of health in Europe...

in France, at the age of 35, there is nearly 10 years difference in life expectancy between engineers and labourers in Germany, degraded states of health (perceived) are twice as frequent among the unemployed as among those working in Sweden, the mortality risk of the homeless under 40 years of age is 9 times higher than among the general population in Britain, a 20% excess mortality from cancer is observed among men from the richest and poorest categories of the population

in France, belated discovery of HIV positivity frequent among immigrants as among nationals

-

i.e. at the full blown AIDS stage

-

is twice as

Few or no standardised data exists enabling a European comparison of these inequalities also, these data often remain very piecemeal. Outside the United Kingdom and certain Northern European countries, few longitudinal data and lengthy chronological data sets exist regarding these subjects. However such data are interesting. For example. the comparison of standardised mortality rates between the two extreme income categories in England and Wales from 1921 to 1983 (fgure 4) clearly shows three statements: (i) a

Part 1. An Overview On Europeans’ Health Care Systems

7

general decline of mortality during the period, (ii) a constant gap between richest and poorest, (iii) smallest during the years of post-war reconstruction and (iv) maximum during the 1980s: even greater between 1979 and 1983 than during the 1920s!

Figure 4. Evolution of standardised mortality rates in the two extreme income classes in England and Wales; 1921-1983 Finally, when comparing the European countries in terms of total health expenditure per capita (in €, standardised according to purchasing power) and of life expectancy at birth (for example for women, in years), one notes that major differences in terms of expenditure- from 600 to 2 400 € per year per capita, i.e. a 1 to 4 relation between Greece and Switzerland - only appear as minor differences in terms of national health performance (figure 5 ) .

Figure 5. Life expectancy of women at birth and annual health expenditure per inhabitant in different European countries What can be learnt from these European differences and similarities?

First, that questions of health inequality are not limited to medical care, that investments made in the curative care sector cannot, on their own, reduce these inequalities, and that a health policy cannot therefore just organise and finance the curative care offer. Other

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Part I. An Overview On Europeans’ Health Care Svsrems

sectors are involved: education, the way national wealth is distributed among the population and therefore the national fiscal policies, justice, urban policies, etc. Second, that at the present level of public health expenditure in most countries, it is not so much a question of mobilising new resources but rather of redistributing those available towards health programmes other than curative care. Health education. prevention, health promotion - if they specifically address the more vulnerable, most underprivileged populations who are most in need of them - are probably better adapted and more cost-effective answers to these health inequalities. Third, that these inequalities can only decrease if access to these programmes (and also, of course, to curative care) is ensured for all. Gone is the time when we could believe that poverty would disappear by the sustained economic growth, and that these inequalities and the exclusion of the most marginalised people did not threaten the improvement of the population’s health as a whole. Who are the people at risk of exclusion?

Developing specific programmes or enabling the access of all to health programmes requires a prerequisite: that of identifymg those people excluded fiom care (in the widest possible sense). Whatever the health systems and in all countries, the excluded fall into two categories: groups, or even communities, and individuals at risk of exclusion. The groups, or communities, though not well cared for, are at present well identified and characterised: - those ((without)):without papers, without permanent housing, without rights. etc.. Those who have understandably been front-page news for the last 10 years because they reveal. in a visible and obvious way, the flaws of our health and social policies. - the “outlaws”: the states of (il1)health and the specific needs of drug abusers are now known. Other population groups, such as prisoners. sex workers. the clandestine, are not so well studied. For all these populations, health policies and, sometimes, the practices of health professionals - are far removed from the ethical imperatives which we mention in the introduction. - the wn-categorisedx all those whose situation, though identified, still does not fit into the framework of the social protection systems and the care systems: one can mention migrants, the Roma, but also refugees and asylum seekers, whose official status does not protect them fiom profound deficiencies in social and health care in many European countries. These populations constitute the tip of the iceberg of exclusion. but there are many other individuals at risk of exclusion, less visible and not represented in the public arena. These are all people in precarious situations, that is those individuals who accumulate exclusion factors that, for a while, are manageable by the individual and possibly reversible, but eventually lead to effective exclusion from the health programmes: whether these exclusion factors are financial, socio-cultural, domestic, etc. These people and these trajectories of precariousness remain difficult to identi@ both by social protection systems (since they are often just above the thresholds of social aid benefits) and by health programmes. Even when these people are excluded fiom the health system, they nevertheless do not consult at the specific structures for the poor. These situations are difficult to count. What is sure, is that added to the previous populations, these excluded persons no longer constitute, as a whole. a marginal and negligible fjaction of the population.

Part 1. An Overview On Europeans’ Health Care Systems

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The experience of health professionals confronted with these situations of exclusion: the EUROPROMED project Everywhere in Europe original initiatives have been developed, with the dual objective of responding to the health needs of the people or populations excluded from care, and of improving access to the existing programmes. Most of these initiatives have two points in common. They are often initiatives on the fringe of institutions. Associative, nongovernmental, charitable, private, they are also - and more and more frequently - public. However, in most cases, these are field actions that then challenge the institution, including from the inside. They are often initiatives taken by health or social professionals, which enable these professionals to renew their practices, and to detect new situations of social and health exclusion that have neither been described, foreseen, nor taken into account. Once evaluated, these initiatives also enable the professionals to challenge decision-makers as to the quantitative importance of the social phenomena detected and the existence of possible responses. This document presents the EUROPROMED project carried out in 1997-1998, under the auspices of the Institut de l’Humanitaire, with the financial support of the DGV of the Commission of the European Communities. The objectives of this project were to describe and to confront the existing health promotion actions, in the various structures providing care for people in precarious situations, in 8 European countries (Germany, Belgium, Spain, France, Greece, Italy, Portugal and Switzerland) and to propose recommendations for health professionals and decision-makers for health promotion and prevention for excluded populations in Europe. This project was inscribed in the objectives of the community action health promotion programme (1996-2000) adopted by the European Parliament and the European Council on March 29th, 1996: “to improve the knowledge (...) of the situation and the problem of health promotion in regard to certain risk factors and health determinants, and certain underprivileged social groups” and “promote inter-sectorial and multidisciplinary approaches to health promotion for vulnerable or underprivileged groups”. We deliberately brought together collaborators from diverse institutional horizons: NGOs, academic departments, hospitals, and municipal institutions. They all had the common denominator of being health professionals whose practice and field knowledge had led them to establish original structures for these excluded populations.

Recommendations of the Europromed working group Once the experience and the difficulties encountered in caring for the excluded had been shared and discussed, we formulated 13 recommendations to promote and to improve the access of excluded persons and populations to health promotion and to prevention, in particular by integrating these programmes both into primary health care and into social services. The legitimacy of these recommendations is that they come from health professionals who are confronted with inequalities and situations of exclusion in their provision of care or health promotion. They are addressed to other health professionals, to the national political decision-makers and to the European leaders and decision-makers. Their only ambition is to raise issues to be reflected and acted upon by these different addressees. We hope that they will be distributed as widely as possible, discussed,

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Part 1. An Overview On Europeans * Health Care Systems

completed, and adopted by others. These 13 recommendations figure at the end of the present report. There are straightaway 4 points, addressed in particular to European health policy makers, which we would like to stress. The first point is that the principle of equal access for all to health programmes should be at the very core of the health reforms undertaken in most European countries. Whether to master health expenditure, to improve the quality of care, or to clearly define our public health policies, equity in the access to care and health programmes is a prerequisite indispensable to all these objectives. The second point is that these actions to promote health and improve the access to care of excluded populations require the commitment of local political decision-makers. Health policies defined and led locally are better able to respond to the health needs of the excluded and to facilitate their access to care and prevention programmes. Furthermore the national leaders and decision-makers must ensure that national health policies bridge the gaps observed in all countries, fiom one region to another, due to regional differences both in the resources available and in the local commitment. The third point is that these topics underline the need to diversify medical knowledge as it is taught to health professionals, in particular the initial academic training and the continuing education of physicians and paramedical professionals. Disciplines other than biomedical must be part of the curriculum of faculties of medicine and the paramedical training schools. The training of health professionals in the health needs of vulnerable and marginalised people and populations, and more generally the social inequalities of health, requires that both initial training and continuing education award a central place to other disciplines such as sociology, economics, ethnology, history, ethics, etc. Finally, the field professionals battle daily against two things which must be denounced now and always: these are discriminatory situations (even more unacceptable when a health policy serves, for example, immigration policies) and conservative attitudes (whether professional, social or political) which all initiatives in these domains come up against. Discriminations and conservative attitudes are even more intolerable when placed in a European perspective because they are seen for what they are: anyhng except unavoidable. Beyond our respective borders, there is always a country, a township, an NGO, a hospital, or a handfid of professionals that had the idea and the courage to question established habits and jostle our certainties. From this point of view, the European confrontation of experiences is an eficient political weapon for all the participants, all the institutions, and all the decision-makers.

Part 1. An Overview On Europeans' Heuith Care Systems

Exclusion from health in different European countries Health promotion and health care for the excluded in Germany Zahra Mohammadzadeh Since the early nineties, health promotion has been an established term in the public debate on health policies in Germany. This is largely due to impulses coming fiom the USA as well as the effects of an international discussion in the wake of programmes such as the WHO campaign "Health for All by 2000". Since then, however, health promotion has suffered fiom the same development as the health care system in general. There is a split between the (largely theoretical) debate on what is necessary and the practice of continuous cuts in health spending with a background of economic recession. Although there is free access to health care in Germany on principle, factual inequities are apparent. Social epidemiology shows strong correlation between health understanding and different behaviour as well as social class. People with low income, low education, different ways of life or other reasons for being marginalised use health care facilities less often than the affluent, well educated, mainstream strata of society. This difference is accentuated by the character of the main care offer in Germany. This is, in general, passive - that is to say physicians do not go out to reach patients or patient groups with health care offers - and it is, as a rule, unspecific - that is to say health care offers are not targeted to distinct groups of society. And as physicians often have attitudes similar to businessmen, patients with freaky outfits, strange behaviour or dirty clothes are not very welcome in the surgery. If this description is true for regular health care .generally, so it is for the particular field of health promotion. And because the latter appears less urgent than other fields of the health system it tends to be among the first to suffer from cuts. Thus, while experts under the influence of developments in the USA or WHO efforts, were still discussing the need for more health promotion, the German Law on the Stabilisation and Structural Reform of the Statutory Health Insurance System already removed some positive steps which had been taken in the years prior to 1993. In view of such retrogressive policies, predominantly dictated by budgetary considerations, the work of a federal agency like the Bundeszentrale f i r gesundheitliche AufkZurung (BZgA) seems courageous but somewhat distant from reality. There is yet another reason why health promotion has difficulties in reaching the destitute and excluded in Germany. The main role-players in health promotion do not particularly represent a new movement towards basic health care for all. Priorities in health promotion concepts are not always based on epidemiological factors irrespective of social preferences. In fact, many health promotion approaches are distinctly tailored to middle class needs. They cannot, therefore, claim to promote health for all citizens. In this respect, local communities may play a constructive role in future. For several years, the "Healthy Cities" movement was able to make some impact and may be responsible for the higher priority health now enjoys in many communities at political, economic, and administrative levels. Local authorities, however, will have to be aware of the need for ensuring quality if they want to add perspective to past achievements. So far, the decisive factors in health promotion for marginalised groups in Germany are municipal public health offices and non-governmental organisations. As the approaches followed by regular health care are unsystematic and not directed towards specific target

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Part 1. An Overview On Europeans' Health Core Systems

groups, municipal PHOs and NGOs try to compensate for the lack of structured offers by the established health system. In many cities, there are projects - usually organised and financed from year to year - for the homeless, sex workers, street kids, drug abusers. asylum seekers, war refugees, and even illegal immigrants.. In many cases the project teams try to bridge the gap between dealing with acute health and social needs and giving information and advice on health promotion aspects. At the Same time, Germany is facing a special set of problems due to reunification. As in other fields of social supplies, there is a definite gradient between the western (old) federal states and the eastern (new) ones. Social detriments such as unemployment. lack of housing, low income etc. may rise to desperate levels in the East, and their consequences present special challenges to the overall health system. These challenges will have to be confronted by approaches to health promotion as well. The relevance of general social factors for health promotion has to be recognised; this is true, too, for low-income groups. migrants etc. in all of Germany. The context between social background and health has been relatively well researched in Germany. It is characterised, mainly. by an unequal access to health services, the different utilisation of these services, and differences in exposure to health risks and resistance against them. But this common knowledge does not mean that health promotion approaches automatically integrate such insights. Self-help groups, for instance, which play a central part in government-subsidised health promotion campaigns, rarely go beyond the margins of the established, educated, and well-to-do urban population. To summarise, health promotion in Germany is still in its teething age as far as the regular population is concerned. As regards the marginalised sections of the population. it has yet to discover the challenges. An important step in the right direction could be the systematic integration of the health and health care situation of destitute and excluded groups into periodic health reporting, as is already done in some cities. Exclusion and precarious conditions in Belgium

Anne Vincent, Pierre Ryckmans Exclusion and vulnerability are very extensive phenomenon, which touch different populations for different reasons. Health care exclusion is thus much more complex than the simple fact of being insured or not, even in a country like Belgium where "social security for all" remains one of the dominating ideas of public health. The concept of "health" is also much broader than being, or not, within the "system" which provides the care: there is a more general access to health, with all that implies in the way of knowledge, attitudes, behaviour, responsibilities, but also decent housing, healthy food, social standing and emotional environment. Both the system and the individual are responsible: the individual must seize the opportunities available but the system must provide a suitable environment. When one tries to keep in mind these different components of health, the problems obviously appear to be more complex. However, the advantage is that the solutions are multiple, both in the actions to undertake and also in the different participants necessary to perform them. The specific role of health workers as regards these problems is perhaps wider than what is generally acknowledged: they serve as alarm signals and set up purely medical actions, but they also participate in decisions overlapping the medical fiamework. Since it appears obvious that precarious conditions (whether social. financial. housing. ' "Illegal" as regards this country's administration. Throughout the document, "illegal'' refers to the immigrants' present status as regards the country's administration. whatever their status on entry.

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employment, health or access to care conditions) are due to multiple factors, the response must also be multiple, even for the health workers. There are therefore several factors or categories of exclusion, which can be added to each other and lead to inextricable situations. We have taken into account those persons excluded from insurance, the financially excluded and the culturally excluded. The Belgian system rests on two main pillars, which are health care insurance and social insurance, supposed to guarantee financial access to health care for all persons living in Belgium. A certain proportion of the population, difficult to quantify but probably 1 to 2%, is completely outside this system. In this group, the great majority can recuperate rights, by means of administrative steps of varying length and difficulty, but which most often require the intervention of a third party. Recent legal measures have enabled the regularisation process to be speeded up or simplified, in particular by removing certain delays and providing the possibility of regularisation for the homeless. One can say that all the persons residing in Belgium can be "regularised"although not all of them will overcome all the obstacles towards "regularisation". The reasons for this are the lack of knowledge of the advantages proposed, of the steps to be taken, lassitude or even incapacity to face the administrative problems, or even the refusal to be reintegrated into society. Social accompaniment can solve quite a few of these problems, if only temporarily. Any action aimed at simplifLingthe procedures and the steps to be taken would improve the accessibility of social protection. The individuals who are in a position of total exclusion, without hope of regularisation, are for the most part foreigners. This population consists mainly of persons who were refused refugee status and undeclared workers. Many nationalities are represented, and it is dificult to identify with certainty the main groups. One can however underline the number of Central and Eastern Europeans, and Central Africans. The reasons for coming to Belgium are usually associated with nationality, without this being systematic: a PoIe is most often a clandestine worker, whereas an Angolan would in principle be seeking political asylum; but the motivations can also be mixed: for example for Latin-American immigrants fleeing from violence and poverty. Some categories must be specifically mentioned, even though they do not represent a great proportion of the persons in difficulty: members of the European Union and nonEuropeans born in Belgium or living there since childhood. European Union members are mainly persons who are no longer covered by an insurance, neither in Belgium, nor in their country of origin, and who are no longer have, or never were, employed, which removes the possibility of being insured. They are entitled to three months of social assistance, and when this time is up, they are expelled from the territory. The legislation in this regard is either unclear or not well known: social Europe is lagging behind free-trade Europe, and this difference could become even more perceptible as mobility within the Union increases. Some non-European foreigners born in Belgium or living there since childhood (mostly Moroccans) have few attachments with their country of origin: their family and their friends live in Belgium. Some of them have been under an expulsion order for years following a breach of the law, but have stayed on, for family and social reasons. Their situation requires the intervention of specialised legal counsel. Others have been struck off their commune's roll for administrative reasons and are waiting for their re-enrolment. They are given a temporary resident's permit, which enables them not to be expelled, but does not give them the right to insurance. All the persons illegally residing in Belgium can nevertheless benefit from urgent medical aid, which enables them to receive care, even preventive care, just on the doctor's decision, on the one condition that the aid be considered urgent. Urgent medical aid is a very interesting last resort for health workers. Unfortunately it is not well known and therefore vastly under-used.

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Correct, at least in theory, social coverage hides another form of precarious conditions that is financial. For an ever-greater part of the insured population, theoretically "covered", the share of the care costs still paid by the individual is becoming prohibitive. These groups then risk entering the vicious circle of medical under consumption. aggravation of the problems, and finally hospital over consumption, where neither the individual's health nor the system's financial health wins. Generally speaking, when a household has financial problems, budgetary priorities will be housing and food - a question of survival - health taking a secondary place. For certain households correct hygienic measures, or preventive care, are already an excessive expense. The patient's contribution is a fundamental principle of the Belgian system, therefore the patient always contributes to medical costs. The amount of the existing reimbursements varies according to the nature of the insured person's care (medicines. hospitalisation costs...), the person insured (retired persons, invalids...), or even the care provider (doctor, medical centre). Above a certain amount of medical costs, a tax exemption is systematically awarded. Curative care is therefore never entirely free in Belgium, and up until now, the participation of the households has been used to control expenditure. It seems that now, for the patients with the lowest incomes - and despite all the existing protective and corrective mechanisms - this system has reached its limits. An important factor is also growing pauperisation, which augments the fiinge population sensitive to any increase in medical costs. This vdnerability can appear in different forms. It can concern persons for whom daily health is a painful choice, but it can sometimes be a serious and brutal illness that breaks a fragile equilibrium. Chronic diseases are a problem in themselves: many of the additional or recurrent costs caused by these diseases could be better reimbursed. The government has recently set aside an additional budget for chronic disease and decided to create a "consulting committee" in charge of the problem. These measures are certainly headed in the right direction but it is still too soon to judge whether they will be sufficient. As opposed to what one could think, this is just as much of a problem for some Belgians as for foreigners. Foreigners have obvious cultural problems: linguistic, religious... and others which are less cultural and more "socio-cultural": the care network is so different fiom that of their country of origin that they are excluded de facfo, at least partially. Cultural mediation services have been created here and there, but they remain difficult to integrate at all the levels. Cultural mediation covers a lot more than simple translation and implies a real accompaniment of the patient. For the Belgian patients, cultural exclusion concerns the sub-cultures rather than the cultures. These are patients who, under the influence of their environment, whether family or social in general, have acquired perceptions and behaviours which impede them fiom being harmoniously integrated into society. There is the fear of the administration, which impedes these patients from benefiting fiom the advantages to which they are entitled. Social aid is a palliative. which can temporarily remedy the problems posed by this attitude. but more is probably needed to break this kind of tradition. Fear of doctors. or shame of assistance, also separates these patients fiom those who could help them, and often impedes the follow-up and continuation of care. The perception of the body (often perceived more as a tool than "oneself'), the notions of health (depending only on the environment and not on the individual) and of illness (fatality), and also the vocabulary used, are all extremely different from those of the health professionals. Incomprehension and misunderstandings are enormous and a good part of the messages is not received. That is the beginning of the vicious circle of incomprehension and rejection. Substance abuse, because of the prejudices that it carries, and the behaviours to which it leads, can also be a cause of rejection and exclusion.

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Precarious conditions and inequality of access to care and prevention in France Pierre Chauvin, Jacques Lebas For fifty years, the French care system has been built on a biomedical curative model. The place reserved to hospitals in medical training, their prestige, the role which they play in care, the public resources made available to them, are all revealing signs. But this model applies more generally to family medicine (where the vast majority of the health needs of the population are attended to): access to care remains the fruit of the encounter between an abundant curative care offer and a demand financed by insurance type protection. This accessibility, both random and consumerist, has shown itself not to be adapted to the care of populations living in precarious conditions. Social coverage is theoretically quasi-generalised, especially since the Couverture maladie universeZZe (universal health coverage) was implemented in 1999. However, effective access to this protection remains difficult for all the persons not aware of their rights. The present complexity of the health insurance system is the result of the principles that presided its establishment. Initially linked to the professional activity (both in its coverage and its financing), health insurance has little by little included in its protection net explicitly defined, and therefore categorised, "entitled to". After 50 years of progressive expansion this complexity constituted - until very recently - that many obstacles, waiting periods, and delays in obtaining one's rights. As efficient as the system is for those persons whose professional, geographical and family status is stable, the difficulties are unlimited when the contribution is paid by a third party or justified by the maintenance of rights. The harmful effects of these threshold phenomena, of these categorisations by regulations and of this bureaucratic functioning may be reduced, if not eliminated, by the recent implementation of universal health insurance which covers the basic health insurance (and also funds for a complementary insurance contracted either with the Social security system, or with non-benefit or private insurance) for all people whose monthly income is below 485 €, and which allows for direct payment by insurers. Nevertheless, the most socially fragile users, and also the least well-informed and those whose income is slightly above this threshold, still bear the brunt of tentative, complex, and unsuitable procedures. For adult illegal immigrants , nothing has changed: at best they have access to emergency (hospital) care only after 3 months of being in France. For the last few decades, the French system has been characterised by the priority awarded to curative care and the principle of free access to practitioners. In fact, these constitute factors of inequality of access to care, as can be seen by the persistent inequalities in consumption of care. As regards national economies, the inflation in health expenditure (with France in the very first place of the European countries) to which care costs contribute raises the question, at the time of budgetary and political choices, of the principle of solidarity which rules their financing. One fears the emergence of a two-speed health system of which those living in precarious conditions would of course be the first victims. At the individual level, this consumerist model, where each person now consults whoever and whenever he wants, is only valid if each person pays the same attention to their health, has a sufficiently high level of knowledge, and all the information necessary, to care for their health and formulate their expectations regarding the care system. This model, both extremely liberal and largely paid for by the community, now shows its limits revealed by the persistence and aggravation in inequalities of care consumption (including preventive), and even more so in health inequalities (morbidity, mortality, life expectation) in France. This despite an abundant medical offer, curative care globally of good quality,

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and excessive health care expenditure. When an individual's living conditions degenerate or become precarious, even temporarily, how can their impact on hidher health be mastered? Health inequalities, which affect precisely the most socially and medically vulnerable populations, appear as that many discriminatory contradictions in the social contract which is the very foundation of the French wellfare state. France's social cohesion is supposed to be maintained by solidarity efforts undertaken by all; including when the individual histories of a growing number of persons are destroyed by ruptures, whether voluntary or not, of their personal and professional lives. The health impact of precarious social conditions cannot be precisely measured, but there is no doubt that it is major. The socio-economic inequalities of health and care consumption persist, or increase, and about 20% of the population now seem to be suffering from these precarious social conditions. When these situations are observed on such a scale, it is in fact the principles (in particular of equity), and the efficiency of our care system, which must be reexamined. If there is no lack of human, technical or financial means, then the question of "doing better" is raised for all. Faced with these increasingly widespread social situations, faced with these life stories with multiple points of inflexion, how should our health care system be adapted? What new structure of the care offer should be conceived? What new public health priorities should be formulated? Some public health strategies in France - evaluating the population's needs and the most efficient ways to respond to them - still need to be established. However, the dysfunction revealed by this health-precarious conditions problem should be the basis for health, medical and social reflection resulting in a true reform of our health care system. Apart fiom uncontrolled evolutions towards specialised ambulatory care, or the programmed development of an ultra-technological hospital medicine, it is striking hob little the French health system has changed in 40 years. However, the emergence of new diseases and new social risks has renewed the public health priorities, and new kinds of care deserve to be taken into account in the definition of new preventive and therapeutic strategies. The institution of regional and national health conferences, in 1996-97, marks a decisive progress in the adoption of authentic public health measures. The health needs will be defined, the health of the populations evaluated, the priorities and orientations for the organisation of care proposed... and taken into account in the distribution of financing. For example, at the national level when the law financing the social security is voted by the Parliament, and at the regional level during the arbitration of the regional health agencies. More specifically, plans of access to care for the populations in precarious conditions were set-up in the departments in 1995 and will be renewed in 2002. By analysing the local situation and proposing action programmes concerning these populations, they will inscribe this problem in the general reflection instated. However, to participate in the emergence of a real public health culture in our country these institutional mechanisms will have to associate all those concerned - health professionals and social workers, whether associative or liberal - and relay, debate, and circulate their work and their conclusions to public opinion. Original measures have been set up to respond to this dysfhction. They have enabled the problems to be revealed and the paths of solutions to be traced. Some of these measures come fiom "humanitarian" non-governmental organisations that have found there. at the very heart of our prosperous societies, an area of intervention responding to their ethical imperatives and their responsibility of bearing witness. Others have developed within hospital institutions, increasingly directly confronted with a growing demand for primary care, whose urgency is no longer strictly medical. In 1999. together with the Cowertrue maladie universelle, the law organised the generalisation of socio-medical care

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consultations for precarious or excluded people in every public hospital in France. Finally, others have been set up on the initiative of general practitioners, the privileged witnesses of these situations. These new structures alert us as to the state of health, and the exclusion fiom the care system, of the ever more numerous persons who consult them. They are also the place where, day-by-day, professional practices are renewed. In the singularity of an individual relationship with a patient, how can the social worker ensure the continuity of social coverage and how can the doctor diagnose health needs and supply appropriate care? The answers to these questions allow us to accumulate, empirically and day-by-day, new knowhow that deserves to be formalised, evaluated, transmitted and taught. This is truly providing primary health care and renewing a particular medical exercise: family medicine. The structures thus created are so many mechanisms, not specific second order medicine, but truly "low social threshold" mechanisms. They provide access to care (curative and preventive) without the condition of social coverage and without advancing the costs', "single booths" which can take charge of people's health and social situation, ambulatory mechanisms reaching out to the populations on the fringe of society. The ambition of these mechanisms is to be as close as possible to the users and to integrate social and health care in such a way that it cannot be disassociated. Networking between private practice and the hospitals, and also the medical body's acknowledgement of the role of users' associations, and their social support activity, are innovations developed in the care of certain serious illnesses, such as HIV infection or genetic diseases, which should be applied to many other chronic diseases. In France, since 1994 neighbourhood health networks, to facilitate the access to care of persons in precarious conditions, have been financially supported by the General Directorate of Health (mainly in terms of co-ordination and training of the professionals); in 1996,450 initiatives were thus undertaken in 87 departments. Another example is the follow-up of pregnant women in France. The random care of pregnancies by generalists, gynaecologists, public hospitals and private clinics leads to an unsatisfactory screening of at-risk pregnancies, in particular among women in precarious conditions or underprivileged environments. Thus, the rate of French perinatal mortality (sixteenth in the world) is not on a par with the systematic medicalisation of all deliveries, when in certain European Union countries, normal deliveries take place at home. This example, in one of the rare areas (that of mother and child health) in France where there exists a care mechanism widely accessible to all (the Maternal and Infant Protection centres), clearly shows us to what point the absence of formalised care channels is detrimental to the efficiency of the care system and its equity, even when there is no financial obstacle to care. A global, multidisciplinary and integrated approach to illness deserves to be developed in our country, for the benefit of all, and in particular that of the most vulnerable persons, the most powerless in the face of the present system. This approach - initially developed in the United States under the name of disease management - aims at optimising the patient's benefit, in terms of state of health, lack of complications, quality of life, and to diminish the global costs of care. The use of tools such as the co-ordinated delivery of care, health education for patients and people at risk, the information and training of the medical and care personnel, an operational information system, indicators to systematically measure results, and the establishment of optimal clinical care guidelines, is indispensable. These strategies, centred on the patient or the individual at-risk, are obviously interesting to reduce the social inequalities of resort to the care system, whether curative or preventive. The education of the patients and health promotion among the general In France, within the Social security system, ambulatory health care is usually paid by the patient who is then reimbursed.

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population are approaches widely developed in certain countries (in particular those with a national health system). In France, they should be encouraged and valued in the different kinds of medical exercise, whether hospital or ambulatory, and developed even outside of this exercise: the paramedical professions and those who master the training techniques and the information tools can substitute a care (curative) culture with a prevention culture. In France, the delivery of care is virtually limited to the medical professions whereas, in certain European countries, a whole series of nursing specialities have been developed (clinical assistant, clinical speciality nurse, primary care nurse, etc.), enabling the responsibility of care to be shared among doctors and nurses. For everyone's benefit. and in particular that of the most vulnerable persons, the development of care networks and channels, the application of the concepts of diseuse munugement could be the opportunity to promote the specific role - redefined and enlarged - of the paramedical professions. All the professionals notice how often, among persons in precarious social situations, a request for care reveals an underlying social request and therefore the importance of integrating social and medical care. This integration and co-ordination between social work and medical care is just what enables each professional to find his marks and his area of competence. Behind the apparent disassociation of medical and social care, established by French legislation since 1975, part of this social demand is attended to by the medical body, and particularly by private practice. For example, for certain isolated old people, with low incomes, one of the last remaining social links is the home visit of their general practitioner. This situation is similar for other fiinge populations, such as drug abusers or sex workers, whose only "institutional" link, other than with the police or the legal system, is that - even infinitely tenuous and w i l e - which develops with the care providers. We also know that, in view of the lack of "precarious" hospital mechanisms integrating social and health care, the resort to hospital emergency services and certain days of hospitalisation correspond to a social rather than a medical problem. Is it really up to our care system to undertake this social demand? Is it the responsibility of health insurance to finance a social response that at times becomes (and probably not in the most economical way) hospitalisations, medical acts and prescriptions? The opposite is true when the place of care is an interface, a point of contact with fiinge populations. This kind of encounter is the opportunity for these persons to formulate a request for help. The social accompaniment which is then established is often much longer than the medical act which motivated the initial contact. For the more excluded individuals, "transitional care areas" should be established which would allow the intervention of competencies other than those of the prescribing doctor and the social worker: those of lawyers, psychologists and psychiatrists, advisers and educators, etc. From a strictly medical point of view, this specific accompaniment - well beyond a simply curative response - seems a unique opportunity to establish a care relation in which health education, health promotion and prevention would have their place.

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Poverty and social inequality in Spain

Pilar Estebanez We must first define and differentiate poverty, being on the finges of society, and exclusion, as they are concepts that are used interchangeably. The concept of poverty we consider as more related to social inequality regarding access to possessions. Being on the fringes of society implies the people or groups who are outside the social systems (in this case the health systems), and exclusion is a consequence of the limitation, violation and/or absence of the individual's human rights. Though there are multiple links between these three terms, we consider exclusion a much wider term than the others, covering larger areas, even political and social ones. It is discrimination that, as regards health, generates precarious and vulnerable situations in the populations. The causes, circumstances and motives that are generating the present exclusion of population groups must be studied, as must the fhture perspective. The possible consequences of the application of the Maestricht treaties must be taken into account, within the framework of the globalisation of the economy, as regards the control of public expenditure which couldimply a decrease in social budgets because of their not being productive from a purely economic perspective. The opening of borders and the idea of Europe as a common home are aspects of great relevance to the problem under consideration. From a general perspective, there are different types of exclusion depending on the causes and circumstances of which they are the result: Legal: that which affects populations and persons who though living in Spain are refused citizenship, depriving them of the rights proper to the condition of citizen, while allowing them to participate in the sphere of the submerged economy. This situation has worsened during the last few years as a consequence of the opening of the borders and the increase in the inequalities between North and South which forces certain populations to leave their countries in order to improve their living conditions. In Spain legal exclusion, the non-right to citizenship is mainly encountered among the poor immigrants. These persons who come fiom the Third World looking for work and who, because of the European and Spanish laws regarding foreigners, and in particular quotas, do not have the right to legalise their condition of resident. Though it is virtually impossible to calculate their numbers, most of the press or institutional reports estimate this community at about 500 000 persons. Administrative: exclusion related to administrative problems, affecting those populations which, fundamentally for financial reasons, are obliged to change their place of residence, and who lack a permanent home and are therefore excluded from the census. These are the people at present called "homeless", "on the move", etc. their absence from the administrative roll excludes them from social rights and thereby also from health rights. Though data are not available, it is estimated that in Spain there are between 150 000 and 200 000 persons classified as "homeless" according to Caritas' latest report. As a result of structural reasons, unemployment and drug or alcohol abuse this community is growing at an alarming rate, a few years ago it hardly existed. Prisoners: this is another population group that can be considered as socially excluded. Their fieedom having been taken away, by a ruling of the very same social system, they lose their social rights including the right to health in the same conditions as the general population. In Spain, there are at present between 35 000 and 37 000 persons in

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jail, 70% of them for offences related to drugs. In this community of prisoners exclusion factors, intravenous drug abuse or illegal immigration are added to one another. Unemployment: this is another of the circumstances that now produces exclusion. Society recognises the existence of what is now called "structural unemployment", i.e. that society itself generates conditions which deprive a segment of the population of the right to work and thereby the associated rights. Being outside the productive circles implies discrimination, which is reflected in lack of health care and its immediate consequence on health. The June 9* 1998 report of Caritas states that there are now approximately eight million poor people in Spain, which would correspond to the two million persons who are at present unemployed and their families. These unemployed receive minor financial assistance but their situation makes them the group whose health is most precarious and vulnerable. There are many studies in Spain, which show how unemployment and poverty are linked to exclusion and to an increase in illness, in particular communicable and mental diseases. Socio-cultural: this type of exclusion is dual in that it is caused on the one part by the conditions and culture proper to the excluded populations and by society which recognises these cultures and conditions but discriminates against them. Three circumstantial examples of this kind of exclusion are Roma, sex workers and drug abusers. in Spain there are approximately 150 0oO persons addicted to illegal drugs. The sex workers community is not homogenous and suffers from various factors of exclusion and vulnerability, for example the association sex-worker-drug abuser, the association sex worker-illegal immigrant. Whereas the statistics speak of 500 000 sex workers in Spain, this group's socio-economic exclusion factors are extremely varied. Street sex workers are the population with the greatest exclusion factors, in many cases associated with drug abuse or illegal immigration. At present there is a new type of sex work, controlled by mafias, of persons from the Third World who, because their passports and documents have been taken away, live as virtual prisoners. It is estimated that sex work networks maintain between 15 000 and 20 000 persons in these situations. These are estimations as no studies exist, they are numbers taken from the press. Others: in this sector we refer to those populations which are excluded because of specific circumstances, such as Aids or drug abuse. From the perspective of the health system, as regards the restrictions of access to the health system and treatments. six types of exclusion can be distinguished according to the causes. Legal: this aspect mainly concerns illegal immigrants who are not entitled to the public health system. Financial: certain treatments are not financed by the public health system, such as dental or psychological care, and certain state of the art technologies. The above-mentioned communities, because of their precarious financial situation, do not have access to these. Administrative: populations which have been discussed from the general and the administrative point of view also suffer from lack of access to care due to regulations or norms. For example, treatments that are not allowed in prisons, or methadone treatments not extended to the homeless. Geographical: many of the areas in which these excluded groups live are geographically inaccessible, because they are far from health centres and lack public transport. This is the case in ghettos, slums, etc. Human: cultural, linguistic: the attitude of the professionals towards certain diseases and groups entails that many populations feel excluded from the health system. such as Aids patients, sex workers, intravenous drug abusers, or illegal immigrants. Barriers are created by the health personnel's lack of knowledge of their cultures and illnesses. at

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times medical care can overcome these, this is not the case for prevention and health promotion. Ideological-political: in relation to diseases or behaviours which are socially taboo, such as drugs and sex, the very health system also tends to exclude certain communities from certain scientifically proven treatments and also from disease prevention. This is very clear in the case of Aids patients, access to treatment in prisons, and treatments for drug abusers. The multiple cause exclusion of these communities could be analysed with these factors: (i) Proper to the individual as a citizen; (ii) Social systems in which he/she lives; (iii) Health systems; (iv) Cultural factors proper to the individual; (v) Specific illnesses. In providing assistance for the populations from the triple perspective of health promotion, disease prevention and care once disease has manifested itself, we have to differentiate which aspects exclude certain populations. In which way the very system itself excludes, by omitting some of these care aspects. Any one of the types of exclusion in which we have so far divided the affected populations makes them more vulnerable to disease. In Spain, the INSALUD provides care for health problems without discrimination when these are urgent. That is, it does not refuse care, in the case of serious illness, to any of the populations that we have previously defined with exclusion factors. This is extremely expensive for the system and clearly promotes exclusion, as these populations are not recognised as fully-entitled citizens, and therefore do not benefit from health promotion and disease prevention services, thereby increasing their degree of exclusion and thus of vulnerability to illness. In other words the inequalities in access to health care, such as promotion and prevention, are in themselves additional exclusion factors. It would be very interesting to know how and to what degree other administrative instances attend the problem of health among these populations according to type of exclusion. These instances (Autonomous, Municipal) have created mechanisms to attend some of the excluded populations, mainly including them in specific programmes to control certain diseases such as Aids or sexually transmitted diseases, or for their social influence, as in the case of communities affected by drug abuse. Another aspect to consider is in what measure the present health policies for these communities are influenced by the very health system, by the health professionals, the community’s response, the NGOs, the foundations, religious orders, small town-halls, etc. who attend these communities. From the present perspective we have to take into account the increasingly precarious conditions of a growing segment of the population of Europe and Spain, which accumulates social exclusion factors such as unemployment, absence of resources, inadequate training, family isolation, regular and clandestine immigration, etc. In the health area these situations raise the question of the organisation of the health offer and the mechanisms which finance health expenditure.

Socially excluded at the Me‘decins du Monde-Greece Polyclinic in Athens The0 Rosenberg MCdecins du Monde - Greece operates a Polyclinic in a poor urban neighbourhood of Athens, providing primary health services free of charge to the disadvantaged inhabitants who are excluded from the State health services. Approximately 50 unpaid volunteers, including specialised doctors, nurses, dentists, psychologists, social workers and medical students, give their time and expertise. The following figures are for the first year of operation.

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The number of patients seen at the Polyclinic in the past 12 months exceeded 8 000, of which 57% were male, and 43% female. The age group chart peaks between 25 and 36 years of age and there were a surprising number of children, 14%,under the age of two. Only 3% of the patients were Greek nationals, the rest were foreigners most of whom, 72%, had been in Greece for less than two years. The highest rate of attendance per nationality was Iraqi at 30%; followed by 18% Polish (the Polyclinic is in an area with a high concentration of Polish residents). Next were Albanians with 12%, and 9% were Bulgarian. Their social status was overwhelmingly “illegal”, at 72%, and 40% of the patients seen were unemployed. Four percent were homeless, with 8% living in various she1ters. Their health care needs were mostly medical, at 64% - but there was also a relatively high level of dental cases - 3 1 %, and 5% received psychological counselling. The psychological problems often associated with social exclusion were present, such as depression, anxiety, shame, aggression and indifference. The most fiequent complaints were colds and viruses; sore throats and respiratory duct problems; tonsillitis; skin infections and parasites; bronchitis and muscular problems. The high rate of dermatological problems and injuries among the Iraqi population is understandable because of their living conditions and the difficult journeys they have undertaken to reach Greece. It is, however, not clear why there should be such a high instance of injuries among the resident Polish population. The Polyclinic is one of the primary healthcare sources in Athens for the socially excluded, and the staff is in contact with other services and attempts to build bridges for the social integration of these disadvantaged minority populations. Populations vulnerable to exclusionporn care in Italy

Paolo Contu, Manola Bacchis, Danila Ghiani The Department of Hygiene and Public Health, University of Cagliari, on the basis of the National Health System and the Regional laws, presents a document regarding the populations vulnerable to social and medical exclusion: illegal immigrants, the elderly, the homeless, drug abusers, Roma minorities. According to the Ministry of the Interior there were about one million nonEuropean foreigners legally residing in Italy in 1997, as well as between 200 O00 and 300 000 illegal immigrants. As well as the factors which threaten the health of all underprivileged populations (malnutrition, precarious housing and unemployment) in the case of immigrants the cultural (communication and social integration problems) and psychological (absence of an affective environment and of social recognition) conditions can determine inequalities in access to care. Health care for foreigners is managed by a new law (40/1998) called “Immigrationdiscipline and norms for+foreigners”, this law plans to attain three objectives: - to estimate and programme migratory flows, - to prevent and repress illegal immigration even by means of a new expulsion policy , - to individualise the so-called “path of citizenship”: recognition of certain fundamental rights such as the right to schooling and professional training, the right to housing, and the right to social assistance and health care. As regards health care the reform stipulates that the following subjects are obliged to register with the NHS:

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- foreigners with a resident's permit who are registered at the employment bureau.

For them registration with the NHS is free, just as it is for Italian citizens in the same conditions. - foreigners with a resident's permit and employment recognised by Italian law. - foreigners with a resident's permit or who have requested the renewal of their resident's permit for family reasons, for political asylum, for humanitarian asylum, to request asylum, to await or to request citizenship. Foreign citizens whose situation regarding entry or stay in Italy, is irregular, are ensured ambulatory and emergency or essential hospital care for illness and accidents by the public, or under convention, health structures. These foreigners are also included in preventive health programmes to protect individual and collective health (article 33). This law concerns citizens from countries that do not belong to the European Union and the stateless. In particular it ensures maternity care, health care for minors, vaccinations and the diagnosis and treatment of communicable diseases. If the patients do not have sufficient financial resources, health care will be provided fiee of charge, except for the cost participation paid by all citizens, whether Italian or foreign. The elderly (who are subdivided into "senior citizens" for those over 65 years old and "old people" for those over 75 years old) are a rapidly increasing population with multiple problems. The reality of the elderly is not homogenous, but as regards privations it is heterogeneous. Elderly people not only need quantitative material help and comfort, but also and above all qualitative. Their life is one of hidden social deprivation: living and suffering in solitude, being badly treated ... The Italian legislation, for the Public Health Services and the Social Services, provides guarantees of social assistance; however the law does not protect the elderly against social injustice as a "human':, because they have all the civic, constitutional rights etc. If one considers Italian law in this light, the Public Health and Social Services are limited: more attention must be given to training social and health professionals, information must be available to all. The Health and Social Services must establish better links to guarantee all the rights. Public Health Services are guaranteed thanks to medical care (whether basic, specialised or pharmaceutical). Social Services are provided by home services (care of the person and their home) and residential or semiresidential structures with: - nursing homes for the self-suficient elderly - emergency reception centres - housing communities for the hospitalisation of people between 55 and 65, who do not belong to the "elderly" category but because of their state of health are in a serious situation - social and meeting centres which organise holidays, recreational activities, excursions etc. The health data concerning the homeless are at present insuficient. The "homeless" are not protected by any specific law, though law n.4/88 "...organises the creation of services and structures for the prevention and displacement of persons at social risk (art.25) and the institution of help centres (art.39); but, as far as social and health assistance is concerned these are ensured by private associations of volunteers". It is difficult to identifl and know the homeless, and no health data are at present available. To obtain these data specific studies need to be undertaken. Drug abusers are protected by law 309/90, which provides certain services and health care through the SERT (drug abusers rehabilitation service). This structure guarantees information and prevention for secondary school students, care and psychophysical treatment for drug abusers, collaboration with the Centre for mental patients. The National legislation and the existing structures ensure suficient health and

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Part 1. An Overview On Europeans' Health Care System

social care for these persons. For this reason we decided that in this document the data relative to drug abusers would not be analysed. Roma differ greatly fiom each other. The group which lives in Cagliari comes fiom "Montenegro". Before 1996 the Roma lived in camps, without any public health services. in different areas. This situation caused serious problems, both for them and for society in general. Following the death of a small Rom child, a special Regional Law (n.9/1988) was enforced to "Safeguard the ethnic nature and the culture of the Rom minorities". This law also financed the construction of camps with all the services: hygienic services (WCs, showers, sinks) for all, running water and electricity (both public and private), areas for social, recreational, and school activities, ambulatory paediatric care, sites for a "stay" or a "halt". In the Cagliari camp, there are 134 minors and 3 1 families. The health legislation is the Same as that for foreigners who are not members of the European Union. In the camp of Cagliari, there is an outpatients service for the children and their families: a Mother and Child Service managed with the collaboration of the medical consultants, all children born after 1992 have thus received the obligatory vaccinations. All the children regularly attend schools for compulsory education. The characteristics of this Rom population are that: - women become mothers at an early age, all the first births were to women under twenty years of age; - the most frequently observed illnesses are gastro4nte;tinal and respiratory, and these are most fiequent among children, most of whom have been hospitalised at some point; - testing for tuberculosis gives positive among 10.7% of the children; Despite the major activity undertaken by the Municipality and the health services, the Roma's state of health is still poor, either due to insufficient education, or to environmental conditions. Destitute populations and health promotion in Portugal

Rui Gentil Portugal In a study published in 1995, Giraldes compared the mortality rate for different diseases of 7 classes of professionals as classified by the Labour Ministry. The author concluded that, in general, standardised mortality rates were higher among the lower classes than among the upper classes. In 1996, the same author compared morbidity among people with different levels of education. As in the previous study she concluded that health status is positively correlated with education level, including when age is taken into account. Considering these results the strategies for improving the health of the Portuguese during the 1998-2002 period should target the main diseases, while developing specific strategies for populations with greater health risks. The constitution of the Portuguese Republic and the general law for health are very clear as to the need of paying particular attention to the development of health strategies with a specific emphasis on these populations. As far as we know, which of the populations should receive particular attention to improve their health in general terms has never been agreed, nor discussed. In Portugal everybody is allowed to go to a public health cafe provider and get curative and preventive care for k e . Some problems arise when analysing this right of the citizen. As a matter of fact, if a person wants to go to a health service, that person has first to know where, when, how, why, with whom, etc. - be informed - to use the service. In a country with an illiteracy rate of approximately lo??, that simple act could mean overcoming several major barriers. However. people know that they can easily go to the

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hospital emergency rooms, where 80% of the consultations are not emergencies. Primary health care and ambulatory hospital care are not sufficiently developed to give real and equitable access to the population. There are several institutions in Lisbon that provide to the homeless social and medical care, nursing support and advice on various prevention measures such as vaccination and how to avoid sexually transmitted diseases. The impact of these measures has never been evaluated. Health professionals empirically think that the homeless attend the emergency departments of the central hospitals of Lisbon for any little sign or symptom. In a study we conducted in 1993, 80% of the homeless had been in a hospital in a three month period. Hospital doctors at the emergency departments hold the same opinion. Today, a significant percentage of the homeless are drugs abusers. In Portugal there are approximately 100 000 people consuming heroin on a regular basis. The Rorn community in Lisbon includes about 2 500 people. Roma are mainly involved in trade (selling cloth at open-air fairs). Today some Rom communities in Lisbon are involved in drug dealing. This is changing the traditional structure of decision making in the communities, and makes it more difficult to obtain their participation for health related problems. Vaccination coverage is very low. In the regular three to four year outbreaks of measles the first cases are among the Rom communities. Sometimes parents do not allow their children to be vaccinated. For medical care the Rom communities usually seek hospital emergency rooms. When one of them is in a hospital it is common that the family stands by day and night waiting for their member. There is one association that gives social support to the community, particularly to children. The illiteracy level is very high. There is no regular health promotion programme specifically for the community. Portugal used to be a country of massive emigration. But, today people are coming there to work, mainly in construction and domestic service. Most of the immigrants who arrive in Lisbon are from Africa - Cape Verde Islands, Guinea-Bissau, S. Tome and Prince. Culturally these people are African, however a very high percentage speaks Portuguese, and some can also read it. Immigrants come to join their families, when this is the case they have good opportunities to know how to use the NHS. If an immigrant is not allowed to live in Portugal, in theory the person cannot use the public health services. But, because the bureaucracy of the country is not very well organised it is not impossible to attend every public health service without any problem and without paying. Things will change very soon because the government is introducing a magnetic card to be used by every citizen entitled to use the NHS. Health promotion is usually available for those whose children attend day care centres, most of the time run by non profit religious institutions, where it is common to have programmes in oral health, vaccination, nutrition, health education for domestic and traffic accidents, etc. But, this of course will be for those who bring their families. In this community the major problems are domestic violence, sexually transmitted diseases, adolescent pregnancy, trauma, tuberculosis, alcoholism and related health problems. The immigrants are heavy users of hospital emergency rooms in paediatrics (young population) and in casualties (occupational health). More recently, people from other non-Portuguese speaking African countries, such as Nigeria, arrived in Lisbon. Studies of these communities were not undertaken as this immigration movement was thought to be temporary (for some major construction work being carried out in Lisbon). Of course, it is supposed that there are no health promotion services for them, except prevention at the work place (if this exists). EZderZy with low incomes are probably one of the country’s most serious problems. Despite the new government introducing a minimum pension for all Portuguese, the elderly with minimum pensions get less than people in other situations. For an elderly person with a pension that could be around 100 €, life at the end could be hell. It seems that there is an over utilisation of the health services by the elderly people in Portugal, both as regards

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P a f l l . An Overview On Europeans' Health Care Systems

hospital care and medical appointments. One of the main reasons is the lack of opportunities for social contact and another is related to the non-existence of preventive measures. Whereas appointments are fiee of charge the medicines, which are prescribed at almost every medical consultation, have to be partially paid for by the patient. These could easily amount to 20 €, that is 20% of the pension. As a matter of fact in Portugal low income elderly persons are nowadays the most deprived population. Health promotion activities could add years to life and save money for those that unfortunately do not have much, and who become more and more dependant. There are no official numbers regarding drug abusers in PortugaI, but it is known that the figures would be very high: there could be as many as 100 O00 heroin users. The only preventive measure that is being taken for this particular group is the syringe exchange programme. In return for a used syringe, a box containing a syringe, injection necessities, and a condom is provided. With the help of the pharmacies this system is present throughout the country. The activity is run by the government through the National AIDS Commission and costs 600 OOO € per year. A group is planning to evaluate the impact of this activity. There are special health service units to treat these patients, but the benefits are not well proven. The rate of successfid treatment is very low and depends on many variables. Refigees (a small community of less than 300 persons h m East Timor), the unemployed (6% of the population) and psychiatric patients could be analysed, but, whereas some information exists about groups for whom there is some health research tradition in Portugal, for these there is simply no information. In 1976, Portugal's Constitutional Law introduced the organisation of a national health service for all financed by general taxation. The NHS is a universal model, which means that everybody has the constitutional right to health services. It is also specified that there should be general geographical coverage and that the services be free of charge. Access to the system is mainly through general practitioners in health centres With referral to hospital care if needed. Health centres have the duty to develop health promotion activities. Public health physicians and other staff are present in the health centres to, among other activities, monitor and develop the status of special groups in need of health prevention and health promotion. However, the majority of those who can be considered as excluded (apart fiom the elderly) use the hospital emergency services to obtain health care. In theory, and in fact, everybody who requests help in an emergency service will receive whatever curative care they need. In theory only the people who live illegally in the country are not allowed access to the NHS, but even a very significant proportion of these use the hospital services with false identities. The control system is (fortunately for these cases) not very efficient. By July 3 1 st 1998, 3 343 NGOs for social proposals were registered in Portugal. Of these NGOs, 154 are specialised exclusively in health care services. NGOs are very important in ongoing care (particularly for the elderly), health education activities and screening projects. A very high proportion is "Misericordias" which have a 500-year-oid tradition in health care services, mainly in curative care, for the excluded. They also play a major role in Portugal's social security. In fact, until 1978, some of the hospitals and health centres of the NHS belonged to them. The "Miseric6rdias" where founded 500 years ago by Queen Leonor with very strong links with the Catholic Church, which are maintained to this day. Some NGOs have ambulatory clinics open to the excluded population in big cities such as Lisbon, Oporto, S e ~ b a lBraga , and Coimbra. Attendance at these clinics is usually quite low. NGOs also play a very important role in the national education system, especially in poor areas. A new law is coming into force to create what is being called "Local Health Systems (LHS)". These are the basis for the organisation of all the institution involved in

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health care, including health promotion, such as municipalities, hospital and health centres, "Miseric6rdias", other NGOs, etc. The main idea is to provide opportunities to plan common activities in order to use each resource for the same goal, as well as to give common responsibilities for the health status of local populations. LHS are on the way to making contracts with the NHS to be specifically financed for their health care activities.

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Part 1. An Overview On Europeans’ Health Care Systems

The European Health Care Systems: a focus on Germany, Belgium, France, Spain, Greece, Italy, Portugal, and Switzerland. Pierre Chauvin, Farid Lamara and the EUROPROMED working group

Introduction Although the European health care systems were all established on different principles, they are all facing a major obstacle to their stability: the issue of continued funding of a particularly inflationary area in a period of economic slowdown. Public spending on health and social welfare is increasing much faster than revenues, thus thrusting to the fore the issue of fbnding, which has been looming over industrialised countries for the past twenty years. This situation is referred to by some as the “Welfare State Crisis”. Several reforms have been introduced to remedy this so-called crisis through a reduction of health care expenditures. Overall, these reforms conform to the same logic and are thus very similar from one country to another. However, different institutional. social. historic and cultural contexts lead to important distinctions, and major disparities are indeed observed between these countries. Temporary adjustment measures, focused on attempts to keep the books balanced. have been followed by a more structural approach to health care and welfare protection systems. The activities of the health sector are thus rationalised, and in some countries, taken out of the hands of public administration, in accordance with a given ideological viewpoint. At the same time, reforms have also been driven by the emergence of new objectives, related to new concerns of society in general, with respect to the environment. life style and new risks. This trend has also allowed the integration of a concern for the quality of health services within the current reforms. The hnding of the health care and social welfare systems, public health and new concerns, are the main issues in these reforms, while technological advances and the proliferation of costly new diagnosis techniques present additional problems. Guaranteeing equal access to health care for all is a problem highlighted by this configuration of circumstances. Although the health care system has been much discussed, in Europe the issue of equity has not necessarily been at the core of the debates. Any comparison between health care systems must take into account the fact that the health sector is an area of public intervention. Its specific activity - providing care - is not an entity separate fiom the common good, especially in regard to its funding. This link has a considerable influence on the relationship between health service providers and patients. In two given countries, patients may be provided with the same medical solutions with diverging results, depending on the organisation of the health system in each of the two countries. The relationships between the various participants in the system - the administration, managers, care providers, the insured and patients - reflect the ideological orientations of health policies. The European systems of health and welfare stem fiom founding principles related to two ideological bases: one attributed to Beveridge and the other to Bismarck. In the first one, the original principles are those of universal access to health care and of a tax-based funding of health care expenditures. The second of the two approaches favours a link to

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employment, and thus to the necessity of belonging to a professional category to benefit from a health and welfare system, funded by means of contributions levied on salaries. In actual reality, the borderlines between these two paradigms are not so clearly defined. However, practical implementation, accompanied by social evolution, leads us to distinguish three main categories of systems within the European Union, in addition to the situation in Switzerland that is an exception amongst the countries on which we shall focus: - Systems based on a government-run health and welfare plan (Germany, Austria, Belgium, France, Luxembourg, the Netherlands). - Northern European national health care systems (Denmark, Great Britain, Finland, the Irish Republic, Sweden). - Southern European joint (PublicPrivate) health care systems (Spain, Greece, Italy, Portugal). - Switzerland, a system based on private health insurance companies. The present study focused on the first, third and fourth of these categories. A brief summary of the characteristics of the four categories is given here in order to facilitate an understanding of the distinctions between them. In Bismarckian tradition as mentioned above, the systems are based on governmentrun health and welfare plans. Although coverage was originally linked to employment, since the 1970s it has been extended to the general population. Therefore, the original need of belonging to a given professional category no longer applies to health coverage. However, the distinct roles of those who fund the system and the authorities that run it still remain. These systems are organised in a way that defines the distribution of the social functions of the participants involved: government, health plan, health care professionals. While the first of these three is the guarantor of public health, the second oversees the management of its accounts. The mission of health professionals, on the other hand, is specifically to provide medical assistance to those who need it. Beyond these general considerations, the nature of the relationships between these three functions is not the same from one country to another of the same category. Here, one must distinguish between three sub-categories of systems: - Systems of integrated relationships, in which the activities and remuneration of practitioners are strictly dependent on the health plan (Germany). - Systems of open relationsh@s, in which the interaction between care providers and patients, and between practitioners and the health plan, is more flexible (Belgium, France). - Intermediate systems, which combine a rather strictly regulated public health plan with a more market-oriented private health plan. This category does not relate to any of the countries on which we shall focus here (this system is in place in the Netherlands). In Northern European countries, funding and running the national health care systems is the responsibility of the same administration. Although these systems are essentially Beveridgian (universal access to health care and tax-based financing of health expenditures), some of these countries have weakened the principles on which they are based, and gone as far as introducing a mechanism of internal competition (Great Britain, Finland, Sweden). It is more difficult to split the intermediate systems of Southern European countries into clear categories. When national health care systems were put in place in these countries (late 1970s to mid 198Os), a multitude of mutual insurance plans had already been established. These widespread plans favoured certain social categories, and, contrary to new systems being implemented elsewhere, they were not inspired by Beveridgian principles. Indeed, the implementation of national health services in these countries was

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Part 1. An Overview On Europeans’ Health Care Systems

clearly ideological and rather the expression of a reaction against previous political regimes. The implementation of these health and welfare systems was thwarted by a looming economic depression and was, in the end, only partial. The result was a confirmation of a national health care system alongside a number of private plans. Furthermore, over the past few years, new political orientations have favoured attacks on the principles of equity and universality of access to health care. Switzerland represents a special case. Its system of health and welfare is organised around a number of private insurance funds that are maintained, primarily, by contributions from the insured, but that also receive a number of government subsidies. Health care expenses are exclusively covered by these funds which are subject to federal laws defining the conditions for and the level of such coverage. The rates of medical care services are also determined by agreements concluded between the funds and the providers of health services. The government’s role is to provide subsidies and monitor the private insurance funds. This is a market-oriented system with a built-in obligation to insure.

Systems based on a government-runhealth and w e v i e plan Germany The first elements of social policy that paved the way to the modem notion of the Welfare State appeared in Germany. Indeed, at the end of the last century Bismarck attempted to develop an active social policy, in order to compensate for the vigorous repression mounted against rising social democracy. The Geman model was thus the first to establish a system of mandatory insurance to protect the working-class Erom health risks. It was designed to offer coverage for the employed masses and turned out to provide a long-lasting basis for the funding of health services supplied to the majority of the population. Later on, coverage was regularly extended to apply to more people, and services were also extended. ARer the Second World War, legislation generalised health care and protection and harmonised the levels between various social groups. in 1977, the debate on cost containment started with the implementation of the Concerted Action, a working-group involving all the main participants from the health sector and advising the federal government in its decision making process aimed at cutting health costs. The Concerted Action proved not very successful as public health spending continued to soar despite its efforts. In the following years, rising unemployment and demographic changes led to a serious financial crisis and, in 1988, forced parliament to pass the Act on the Structural Reform of Health Care which introduced some degree of competition, the principle of economic efficiency, reference prices for medical services, and insurance-based health promotion and prevention into the care system. In 1992, [he Health Care Reform Act followed in order to keep health insurance fees at about 13% of the insured person’s gross wages. Since then, almost all expenditures, e.g. on hospital services. medical and dental treatment, and medicines (now at 20% on average) have been limited by single budgets, and co-payment rates have been increased. After Geman Reunification in 1990, the five new federal states were compelled to adopt the Western health care system. This was an economic burden at the time, and still is: in view of the high unemployment rates in the East, West German insurance companies have to subsidise their eastem affiliates. The structure of the GDR health care system had been fairly eflicient, in some respects even more so than the western system. Consequently, and understandably, the professionals and institutions in the new federal states were facing

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a lot of problems. In 1993, the Act on the Stabilisation and Structural Reform of the Statutory Health Insurance System was introduced to solve some of these problems. In the Federal Republic of Germany, the power to legislate in health matters is shared between the federal and state governments. At the national level, uniform standards of services have to be ensured by, e.g. legislation on the statutory health insurance, antidrug laws, or the hospital-hding act. The federal states are responsible for regional hospital planning, legislation bearing on professional medical associations, emergency medical services and public health services. Local authorities, i.e. counties and cities, are responsible for social welfare and the implementation of public health service legislation. In 1999, the statutory health insurance system comprised a total of 455 health funds. Their total budget amounted to about 260 billion DM (133 billion €). Membership is mandatory for employees with a monthly income of up to 3.375 € (year 2002). If income exceeds this amount, there is no obligation to be insured although health f h d s offer voluntary membership. Unemployed spouses and children are included in the insurance of the working family head (with the exception of students who have their own mandatory insurance at a fixed rate). Employees with higher salaries - much like self-employed people - can choose private health insurance companies which are able to keep fees lower because of the better health profile of their members. Fees for mandatory members depend on the wages earned by the insured person, the current rate being approximately 13%. Social welfare offices pay fees for their clients or function as health funds themselves. In this way, most people in Germany are insured, excepting asylum seekers, war refugees and illegal immigrants whose health care is paid for by means of special h d s within the social budget, or who have no official coverage at all. The regular health care system has a high level of provider orientation. Physicians in private practices, hospitals, powerful pharmaceutical industries behind local pharmacies, and the companies that produce medical technology and devices are the market force on the producer side. On the consumer side there are the patients insured by the health funds. In the mandatory insurance system, there is no prepayment and reimbursement, the insured person has a chip card and utilises services by consulting a private physician, no matter whether a general practitioner or a specialist. The patient can change doctors as many times as he or she wants to. For hospital admission, referral by a private physician is necessary. In case of sick leave, the employer has to continue paying the salary for up to the first 6 weeks of the illness. After that, the health fund takes over for up to 72 weeks. The statutory accident insurance funds and the statutory retirement pension scheme insure their members against the consequences of accidents at work, the risk of disablement, and loss of income in old age. The statutory long-term care insurance provides coverage for the risk of permanent care, whether at home, in nursing facilities or homes for senior citizens. Thus, most citizens in Germany (including immigrants with legal residence and working status) have free access to health care, although the increasing co-payment rates function as a threshold to part of the services. The patient now pays for almost 20% of the cost of medicines. Patients also have to contribute to their hospital treatment, rehabilitation measures, and to dental care. Overall health expenditure in 1999 was 470 billion DM (241 billion €), or 10% of the gross national product, equal to 5 800 DM (2 974 €) per inhabitant. The third pillar of health care in Germany, besides private physicians and hospitals, is the public health service. Its portion of total health expenditure is incomparably tiny, between 1 and 2% or about 5 billion DM (2,6 billion €). Roughly the same amount is spent on advertising by the pharmaceutical industry. Public health offices are responsible, at the municipal or county level, for health protection, prevention, and special services for those who are not able or willing to enter the regular system. On the principle of being subsidiary to services covered by the health fund system, public health offices are running counselling and treatment facilities for psychiatric patients, drug abusers, the homeless, sex workers,

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asylum seekers and others not reached by regular health care or who have access problems to it. In 1999, 2.4 million people were employed by the health sector in Germany. Medical density in ambulantory care was 1 doctor per 656 inhabitants, additionally 135800 physicians were working in hospitals. In 1999, the number of dentists was approximately 62 000; the corresponding density was 1 dentist per 1 320 inhabitants. Doctors belong to local associations of doctors affiliated with the health funds. The local associations are part of a federal society. The latter has a mandate to negotiate all agreements with the health funds for its members. The freedom to establish a practice anywhere has been strongly curtailed since the implementation of the Act on the Stabilisation and Structural Reform of the Statutory Health Insurance System in 1993. From 1999 onwards, a provision of the law restricts the number of new practices in accordance with regional demand. Between 1.2 and 1.3 million people work in the hospital care sector. The Hospitals with 730 000 beds may be classified as public, non-profit or private, 8.9 beds / 1 000 habitants. The average occupation rate is high (80.9?/,). In order to reduce the length of hospital stay, hospital doctors with a special qualification are allowed to provide highly specialised ambulatory care. 22.150 private pharmacies are serving the population. This is the equivalent of 1 pharmacy per 3 700 inhabitants. Prevention and health promotion do not play an important role in the German health care system. Between 1989 and 1993, the statutory health fimds implemented some measures but these were cancelled by the Act on the Stabilisation and Structural Reform of' the Statutory Health Insurance System. In 1999 the government changed. The new coalition of Social Democrats and the Green party started the Health Reform 2000 which included reducing co-payment rates for drugs, increasing responsibility and steering power of general practitioners (gate keeper function) increasing cooperation between ambulant and hospital care giving high priority to the support of prevention and self-help-groups. At the heart of the reform were strict global budgetary limits for private physicians and their drug prescriptions. The introduction of hospital DRGs (Australian model) in 2004 is being prepared. In January 200 1 , after doctors, dentists and pharmacists had protested for months, the acting Health Minister resigned. Since then the reform has slowed down, although the general political goal of cost containment and structural change is still on the agenda in order to reduce wage extras and increase efficiency. Systems based on government-run health care plans in a market-oriented context Belgium

Belgium is marked by internal linguistic and cultural differences, which are reflected in its administrative structure. The Belgian autho-ritiesalways wished to encourage private initiatives from mutual benefit insurance companies or private insurance companies. In the middle of the XIXth century, the mutual benefit insurance movement was legally recognised. In 1903, the first legislation concerning occupational accidents was approved. Invalidity health insurance was then gradually organised in a liberal perspective. offering only partial protection. It was

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only at the end of the Second World War that social security for employees was established (Act of December 28‘h 1944). The planned financing of this is tripartite: employees, employers and the State. The mutual benefit fund structure is included in the management of the insurance. During the post-war period, a time of economic expansion, social security developed and progressively included all of the population. In 1967, social security for independent workers was established, but only for major risks. In the image of the new Belgian constitution, the health administration is fragmented. Belgium is made up of 3 linguistic communities: French, Flemish and German speaking, which are responsible in particular for curative and preventive medicine, the protection of youth and social care policy (Public Social Care Centre). Belgium is also divided into 3 regions: Walloon, Flanders and Brussels Capital. The Ministry of Public Health exercises a role of co-ordination and general regulation of the health system. It is responsible for public health, social medicine, and the health establishments. It is the link between the preventive component, which is under the competence of the Communities and the regions, and the curative care component that is the responsibility of the federal government. The Ministry of Social Affairs is in charge of social security. The Walloon and Flanders regions have Departments of Social Affairs and Public Health which are responsible for prevention, health education, and the application of the certification norms for hospitals as well as planning. They also manage palliative care, home care, the problems of the handicapped, the mental health services, the family planning centres and old age policy. The Brussels Capital region is divided into 3 entities: the Commission of the French speaking community (COCOF), the Commission of the Flemish community (COCON) and the common community Commission. These commissions have the same powers as the two Walloon and Flanders regions. As regards health, they are in charge of health education (primary prevention), early screening (secondary prevention), rehabilitation (tertiary prevention), and the management of the hospitals, nursing homes and health centres. In 1994 the French Community transferred a large part of its powers to the Walloon region and the COCOF. In Belgium, there are several social security schemes: mainly, the general scheme for employees (80% of social security expenditure) and the scheme for independent workers. The social security scheme for employees consists of seven branches implementing the principal components of social security: obligatory health insurance, disablement as the result of an accident or illness from private life, pensions, unemployment insurance, family allowances, professional risk (occupational accidents or illness), annual holidays. These are financed by the social security contributions of the employees and the employers, by the State and by revenues determined by law. The ONSS (National Social Security Office) collects and distributes the resources among the different branches. Virtually the entire population of Belgium has mandatory health insurance but the benefits provided by the social security scheme depend on the worker’s professional status (employee or independent worker). The INAMI (National Institute of Health and Invalidity Insurance) ensures the administrative and financial management, and the hctioning, of the health insurance (intervention in illness costs), the compensation insurance (awarding income replacement in the case of salary loss due to accidents or illness), and the maternity insurance (awarding income replacement in the case of pregnancy). The INAMI is also in charge of important medical and administrative control tasks regarding the application of health care insurance and compensations. It distributes the resources of the disablement insurance among the

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institutions in charge of payment. Among these insurance funds, a distinction must be made between the public and the private institutions (mutual benefit insurance funds). The mutual benefit insurance b d s are grouped into five federations according to political, religious, or activity criteria. They pay the health insurance reimbursements and the indemnity insurance compensations to their members. The rates of the health services are agreed each year by conventions between the INAMI and the professional organisations, and must be approved by the federal government. Access to health care insurance mainly depends on the professional activity of the insured: - the general scheme for employees, the unemployed, students, and all other categories. About 86% of the population belongs to this scheme; - the scheme for independent workers only covers major risks (hospitalisation, surgery and some illnesses), 14% of the population is covered by this scheme. Medical benefits cover both preventive and curative care. The share of the costs reimbursed by the insurance schemes varies according to the nature of the benefits, the status of the insured person, and whether the person providing the care is accredited or not. Reimbursement is on principle fixed at 75% of the fees agreed by convention. VIPO status is a preferential scheme enabling certain categories of insured persons (widowers, invalids, retirees, and orphans) to benefit from a g q i t m reimbursement by the health care insurance (85 to 90%). Since July 1'' 1997, VIPO status has been extended to other categories of beneficiaries: people receiving the minimum integration income (Minimex) or the equivalent, those receiving the income guaranteed to old people, etc. Disablement insurance reimbursements of the costs of medication depend on the medication's social and therapeutical value. Health promotion, within a global health perspective, in its more thematic aspects such as Aids is the responsibility of the Communities. As regards structure, the 2 Communities are organised in different ways but overall the prevention programmes are similar. The health system includes a liberal sector, which provides nearly all the ambulatory care, and a public or non-profit private sector, which provides the hospital services. In 1996, there were 35 202 doctors with a clinical practice (i.e. one doctor per 284 inhabitants), 44% were generalists and 56% specialists. The generalists essentially have a liberal mode of practice. Only they, and the paediatricians, are entitled to make house calls. Most specialists exercise in hospitals but some of them also have a private practice. The doctors are paid per act. There is a Scale of payment fixed within the framework of the conventions between the professional associationsand the MAMI. The health centre acts as a neighbourhood health team. Organised in multidisciplinary teams they have several fhctions: curative and preventive, community health and coIlection of data relative to state of health. These integrated health centres are recognised by a decree of the French Community. The mental health centres are integrated in the social and health networks; collaboration with exterior professionals and networking are privileged. These mental health services are primarily public health services open to all, they must also provide prevention and mental health action. The family planning centres, which are open to all, are included in the fiamework of the health promotion policy. They ensure not only curative consultations, psychological consultations, legal and family mediation, but also prevention actions in different domains: contraception, HIV and STD screening, pregnancy follow-up, pregnancy termination, gynaecological care, fertility problems, marriage counselling. etc.

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In 1995, there were 363 hospitals in Belgium with a total capacity of 77 200 hospital beds. 223 hospital structures are private and 62% of the hospital beds belong to them. The federal government is responsible for defining the hospitals’ framework and h c t i o n . It regulates the medical equipment, subsidises the hospitals, and can if necessary make up the deficits. The financing of the hospitals is fixed prospectively from budgets and objectives quantified annually in terms of days of hospitalisation. The price per day only covers the nursing staff and the lodging costs, the rest is covered by a global budget. A quota is fixed for the clinical examinations. The patients are fiee to consult the doctor of their choice, whether generalist or specialist. There are no care channels. The patients pay their doctor directly and are then reimbursed 75% of the cost if they consult a government-regulated doctor. The system of direct payment by the insurers is obligatory for all hospitalisations. However it is forbidden for doctors’ consultations except when the services are dispensed in health centres, mental health services, family planning centres, drug abuse centres, or in establishments specialised in the care of children, old people or the handicapped. Direct payment by the insurer can also be applied depending on the patient’s situation or status: the beneficiaries who find themselves in difficult financial situations, the beneficiaries of the minimum integration income or the income guaranteed to old people, the long-term unemployed and the handicapped. Since December 12th 1996, a Royal Decree allows access to care for persons in illegal situations by means of urgent medical assistance. This decree includes curative and preventive care, whether ambulatory or hospital. A medical certificate attesting that the care is essential and urgent must be issued, this can be done by any general practitioner or specialist. The Public Social Care Centres cover the costs of urgent medical assistance; they are then reimbursed by the Federal State on the .basis of health care insurance reimbursements. France

The French health care system is characterised by the fact that it is has an intermediate structure, both in terms of the provision of medical goods and services and in terms of its funding. In France, the first forms of social protection appeared in the XIXth century when a pension system was established for certain workers, for instance miners, and with the implementation of a law on occupational injuries. The notion of social protection underwent a first major development with the social insurance laws of 1928 and 1930. These laws applied only to low-income employees of the commercial and industrial sectors. Coverage was intended for sickness, maternity, invalidity, old age and widowhood. The second major development occurred in 1945 with the creation of social security. This protection, which was also initially restricted to employees of the commercial and industrial sectors, was gradually extended to other categories of the population. Today, it is, in theory, universal. The French system has undergone an important reform based on the three decrees of 24’ April 1996, regarding, respectively, the organisation of the social security, the medical control of health expenditures, and private and public hospitalisation. The organisation of the social security was reformed on several levels. The decree establishes a system of agreements on objectives and management, signed by the Government and the social security organisations. These agreements determine the multiyear directions for government action. An additional clause sets the anticipated objective of urban care development in terms of the national objective for the trend of health care

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expenditures, as voted by parliament. In each region, a Regional Federation of Health Insurance Funds was established; it will define the regional risk management policy, and will contribute to the implementation of preventive actions and health education. The decree regarding the medical control of health expenditures is essentially aimed at private medical care. Ongoing training is made mandatory for all private practitioners. Incentive measures for early retirement are put in place; these are covered by the Fund for the Restructuring and Modernisation of Private Practice, created by the decree. The decree also establishes a principle according to which doctors may have to reimburse any honorarium exceeding their target. Medical guidelines are enforced. Henceforth, they will be established by the National Acreditation and Health Evaluation Agency (ANAES), newly created with regards to ambulatory care and outpatients care in health establishments. In order to ensure better patient orientation and favour the co-ordination and continuity of health care, a number of experimental tracks and networks (co-operation between ambulatory care and hospitals) were put in place. The patient’s freedom of choice of the care provider was upheld. The information system was also reformed with the introduction of electronic billing. In each region, a Regional Hospitalisation Agency was also created. Amongst various mandates, the Agency sets the overall budget allowances of public health establishments and oversees all matters of health planning. Health institutions must begin an accreditation procedure over the next five years (external evaluation of their activities). The national Health Plan will no longer be represented on boards of directors of public hospitals. The Government defines the objectives of public health, through the High Commission on Public Health. Health safety remains within its jurisdiction; i.e. the Government sets the quality standards and enforces compliance (medication, blood products), as it also does for hospitals. It is responsible for the training of health professionals and sets the conditions for their practice. Social protection organisations and public hospitals are also overseen by the Government, which determines the health objectives and sets the framework for the funding of social protection organisations, through legislation. At the local level, the Ministry of Health is represented by the Departmental Division of Health and Social Affairs. The National Conference on Health, which is comprised of representatives of the health professions and health care establishments, provides the Government with analyses and proposals based on the health situation and needs of the population. The Regional Conferences on Health may put forward proposals of public health priorities, based on analysis of local health situations. Health risk is essentially covered by the health branch of the social security, which is under the Government’s jurisdiction. Subscription to the Health Plan is mandatory and 99% of the population is covered. There are three main plans: the general plan, which covers 80% of the population; the Farmers Mutual Benefit Insurance Fund (MSA), which covers all salaried agricultural workers and their eligible dependants (9% of the population); the National Health Insurance Fund for non-salaried non-agricultural workers (CANAM), which covers approximately 6% of the population. Besides these three main plans, there are other minor plans that cover a much smaller portion of insured. The National Health Plan’s contribution to expenditure on medical g o d s and services has decreased significantly since the 1970s, and is now at approximately 75%, for this reason the number of additional coverage systems is on the rise. 87% of the population enjoy the benefits of additional coverage through private insurance companies, mutual benefit insurance funds or provident funds. These organisations fund approximately 6% of medical

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goods and services expenditures. Additional coverage is often offered to the insured through their jobs. In 1999, the Couverture rnaladie universelle (universe1 health coverage) was implemented. It now covers 6 million people in France; those who were not covered by the usual Social security system before (but, for many of them, by the old Aide rne'dicale gratuite, a local-ruled plan for poorer people, which now disappeared) and/or those with a monthly income below 480 €. This coverage is ruled by the Social security system - as it is for the rest of the population - but offers also a complementary additional insurance for the health costs not funded by the basic Health Plan. The health sector corresponds to approximately 8% of the active population. Regional disparities are observed, in terms of hospital equipment. In France, there are 174 500 doctors, with about the same number of general practitioners as of specialists. They are remunerated per act of medical service provided and are free to set up a practice. The number of physicians is restricted by a numerus cluusus, a set quota for entry into medical schools. Other health professionals may practice in hospitals or in private offices. For instance, there are 320 000 nurses, of whom 16% are in a private practice. The relationship between the disbursing organisations and the health professionals in private practice is managed by agreements. Each year, quantified objectives to limit expenditure trends are set for every health profession. The French hospital system is a joint public/private system. Private health institutions can be run on a for profit or a not-for-profit basis (they may contribute to providing "public hospital service"). Today, there are 533 000 beds; i.e. 9.2 beds per 1 000 inhabitants, of which 64.6% are in the public sector. While long-term hospitalisation and medical care are mainly provided in public hospitals, the private sector essentially provides treatment for acute diseases, psychiatry, obstetrics and surgery. Technical advances have led to the development of alternatives to hospitalisation, such as home care or ambulatory surgery. The 1996 reform urges hospitals to establish ambulatory care networks, and to share medical equipment by setting up Health Co-operation Groups. Hospitals that provide public health services are funded by an overall budget to which the government assigns, every year, a set operating rate. Private, for profit, hospitals receive a daily rate allowance and a flat operating room rate from the Health Plan (doctors' honoraria and medical lab tests are paid directly to the health professionals concerned). The insured have the freedom to choose their health care provider and have free access to specialists, without referral from a general practitioner. In spite of the implementation of medical guidelines, doctors can still establish their prescriptions fieely. Each medical care act is paid for directly by the patient, except for hospitalisation that is covered directly by the Health Plan. The patient is required to contribute to hospitalisation costs, through the payment of a flat daily hospitalisation rate, which is at times, if only rarely, covered by the Health Plan (for instance, in the case of maternity related hospitalisation). The insured must pay a flat rate contribution for ambulatory care, this contribution is smaller or not required for hospital care. For 87% of the insured, this contribution is reimbursed by some additional coverage. Thejoint (public/private) health care systems of Southern Europe. Spain

The Spanish health care system underwent important transformations in the early 1980s. These were aimed at the consolidation of the national health system that came into effect in

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1986. The main reforms introdud consisted in the extension of mandatory health insurance to practically the entire population. Health institutions are henceforth federated under the coordination of the Government. This new system is and open to all. Other objectives of the main reforms were to improve primary and hospital care planning, to introduce tax-based h d i n g of the health care system and to decentralise its management towards the autonomous regions. The prior Spanish health system was the result of often poorly co-ordinated consecutive reforms. A number of social protection plans appeared in the late 1930s. The Government implemented mandatory health insurance in 1942, but only for salaried workers. In 1963, a law centralised the system, and, in 1974, a second one endorsed the existence of two health care systems: one run by the State, local or municipal governments, and another linked with health sectors of the mandatory health insurance. In 1980. the Spanish health care structure was dominated by a mandatory health insurance system, the INSALUD (National Health Institute), the main link in the entire social security plan, through public networks of primary care and public hospitals. This mandatory plan was supplemented, to a significant extent, by private coverage and personal expenditure. The 1986 law affirmed egalitarian principles. The system was gradually decentralised towards the provinces, particularly those that acquired the status of Autonomous Region. It was only in 1989 that fiee medical coverage was extended to all Spanish citizens without resources. In 1991, the health authorities favoured the development of evaluation procedures of medical technologies. The system is moving towards management principles closer to those prevailing in the private sector. Some regions have initiated agreements with private health centres and are experimenting with new modes of hospital management. The notion of hospital-business - decision-making and financial autonomy - is gaining ground. In 1997, the Government announced the impending dismantlement of the INSALUD and confirmed the acceleration of the decentralisation process which finished recently. The Ministry of Health, which favours the extension of the patient’s fieedom to choose his or her doctor and health centre, wishes to generalise a health card system. A system should be put in place to inform patients of the different levels of service quality. Furthermore, a health charter should soon be adopted to provide a certain number of guarantees to the user. As far as medication is concerned, a global policy could be initiated to promote generic brands and define reference prices. The Ministry of Health is the main participant at the central level. It guarantees the upholding of the principle of access to care for all, and is responsible for the general health policy. This Ministry also oversees public health and monitors the health professions. It implements the Government’s decisions and oversees the co-ordination of health and social services, in partnership with the Ministry of Social Affairs. The Ministry of Health oversees the INSALUD, the institution that ran and hnded the public health institution up until last March. The delegation of the central administration’s powers began in 1981. Nowadays, all autonomous regions have 1 1 1 power on issues of public health, health planning, and the management of the health system. The co-ordination between the central administration and the autonomous regions is carried out by the Inter-territorial Counsel of the National health service. However, the Ministry of Labour and Social Security determines the social security system’s economic structure and the conditions of insurance subscriptions. The Ministry of Social Affairs manages social problems linked to illness. Each year, Parliament votes the health and social security budget, which is then divided between all the autonomous regions, according to the number of people insured. These shares are subdivided within each autonomous region according to decisions taken

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by the Regional Parliaments. The budget allocated at the regional level may be supplemented by local taxes. 99% of the population is covered against any risk of illness; 94% through the social security system and just under 5% by mutual benefit insurance companies. Nearly 6 million people subscribe to a private insurance plan. One third corresponds to the civil service (civil servants may freely choose between the national health plan and any private coverage). The remaining 4 million enjoy double coverage (social security/private insurance). Mutual benefit funds and private insurance companies provide additional social and health protection. The first are non-profit organisations. The latter are part of the open market sector. The "Iguulutorioscollegiules" are federations of health professionals that provide health care for an annual flat rate payment. The proliferation of this form of federations is encouraged by the low remuneration offered to practitioners by major insurance companies. Over a third of the insured population uses these services. Primary health care is integrated into the national health service and is organised at the local level. The 1986 health system reform focused on primary health care that is provided either in traditional ofices or in public health centres. Within traditional primary care offices, practitioners work alone, generally on a part-time basis for the public service. These offices offer only curative care. Full-time salaried primary care teams (general practitioners, pediatricians, and nurses) provide public ambulatory care. Such care could be of a curative or preventive nature. Six people out of ten use the services of these centres that collaborate with social workers. Doctors may act freely, as far as drug prescriptions are concerned; however, a large number of drugs is no longer covered. Specialised care is provided either in hospitals or in associate centres. In certain Autonomous Regions (such as the Valencian), specific Public Health structures have been set up, geared towards epidemiological surveillance, food hygiene and control, occupational medicine, health promotion, etc., for the entire population of the Region (and not only underprivileged persons or those living in precarious circumstances). In 1995, there were 790 hospitals with a total capacity of 170 000 beds, of which approximately 130 000 were in intensive care units. The average bed density is 4.3 per 1000 inhabitants. Regional discrepancies are significant. Overall, in comparison with most of its European neighbours, Spain is poorly equipped. Approximately 70% of the hospital centres are public, 12% are private non-profit, and 18% are private and for profit. Some private institutions sign agreements with the autonomous regions health service, in some regions these represent a majority. Each health service area has at least one general hospital for acute care that is also obliged to offer basic health care. The INSALUD hospitals are funded on the basis of the government budgets of the autonomous regions, any savings are poured back into these budgets. Depending on a functional classification public hospitals receive a daily rate allowance. Since 1990, some regions left the traditional mode of funding for a system of socalled objective agreements. Furthermore, in some of these institutions, the autonomous regions health service has begun to apply a new mode of funding based on the UPA, a conversion table between hospital activity and a standard basic activity. Private hospitals are funded by public or private mutual insurance companies and by individuals. At times, the agreements signed with the national health service supplement this mode of function. Hospital health professionals are, for the most part, salaried employees. In private hospitals, they are generally remunerated on a per-act provided basis. A major part of the physicians linked with the autonomous regions health service works in both sectors. Special bonuses are now offered as an incentive for doctors to work full-time for the public sector. In 1994, medical and paramedical densities were 3.9 doctors, 0.3 dental-surgeon, 1 pharmacist and 4.3 nurses per 1 000 inhabitants. Of the 153 000 active doctors (highest

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Part I . An Overview On Europeans ’ Health Care Svstems

medical density in Europe), 37% are specialists and their percentage is on the rise. In some disciplines, there is a surplus along with an even geographic distribution. Most practitioners work simultaneously in the public and private sectors. There is a quota system to enter medical faculties. In 1996, there were 29 526 students enrolled in the Spanish Medical Faculties. Most doctors have no job security. Access to a specialisation in the domain of Health Sciences, can only be through the MIR (Resident Intern Doctors) programme which functions to its full extent since 1984, through the Public and Private Hospital network, accredited by various indicators (regular class attendance, scientific production, etc.). The number of places available in each medical speciality is stipulated in advance. Nearly 40% of trained doctors never manage to enter the national health service which includes 90% of practitioners. Furthermore, although pharmacies are required to sign an agreement with the national health service, the majority of them operate in a free market context. The density of dental surgeons is particularly low and most dental care is not covered by the national health service. The national health service allows free access to primary and secondary public health institutions. A certain number of health plans prior to the 1986 law manage their own health institutions, and allow their insured fke access to their network. The sole financial contribution from patients is related to medication. The flat rate contribution is equal to 40%, and must be paid on pharmaceutical costs by the entire population, except for persons who receive a retirement, illness. or any other pension . Greece

The Greek national health service was created in 1983. In spite of ambitious institution development programmes, it has yet to reach the objectives set in its constitution. This system is based on Beveridgian principles of universal access to health care. The first attempt to implement a full-scale health insurance system was launched with the creation, in 1937, of the social security institution: the IKA. Coverage for workers in urban areas or industrial companies of over 70 salaried employees was made mandatory. However, pre-existing insurance plans were not discontinued. Overall, only one third of the population is covered. Generalisation was implemented from the 1950s in a very particular way, through territorial and professional extension of coverage. Until the creation of the agricultural insurance organisation (OGA) in 1961, rural populations (over 50% of the total population) had no health care coverage. During the 1960s and 197Os, financial and banking institutions built up their own insurance networks: with a subscription from only 3% of the population, their audience remains limited. This portion of the population enjoys quality preferential conditions of protection. Greek social security evolved a great deal between 1974 and 1981. In 1983, 80 insurance funds were established on a professional basis to extend coverage to practically the entire population (approximately 95%). Subscription to one of these funds was made mandatory. However, the nature and the importance of the services offered varied a great deal from one fund to another. The founding law of the national health service was voted in 1983. It is based on great principles: prevalence of the public sector, equal access, decentralisation of decision-making process and planning, development of primary care service. The public administration has always sought to increase the number of institutions providing health care. Depending on the Government in place, this objective translated into greater intervention of the public sector or greater latitude for the private sector. The 1992 reform included several provisions aimed at a certain privatisation of the system. Flat rate contributions were instituted and significantly increased the portion of the costs borne by the patient. The ban on opening new private institutions (dating back to

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1985) was officially lifted. At the same time, the contribution rates of the various social security funds were harmonised. Freedom of choice for patients was instituted. At the beginning of 1994, the Government abolished a major part of the measures brought in by the 1992 reform. Two committees were instituted. A local committee produced a report on the Greek health care system. The second committee, an international one, produced a report on the main problems affecting the Greek health system. This report reviewed the poor use of health resources, the increase of hospital centralisation, the development of bureaucracy, the strong geographic disparities and the lack of professional incentives. Many of the measures that it advocated were partially incorporated in the Reform Plan. The proposals put forward in 1996 should lead to an in-depth reform of the health system. The national health service was assigned a new management role, which, until recently, was reserved to the central Government. Hospital funding will now be based on the introduction of overall budget allowances per hospital unit and per pathology costs. A rationalisation of financial resources will be sought through a possible unification of the main health insurance funds, and through regional budget allowance packages. Health services will be decentralised and regional authorities instituted. This last provision is directly inspired by the British health system. Public health insurance funds will have the capacity to organise health care networks. The legislation project may pave the way for the promotion of the role of the family doctor. While the Greek health system is very centralised, health insurance is spread out in a mosaic of health plans. The national health service operates under the responsibility of the Ministry of Health and Social Affairs. The latter determines the size of the budgets allocated to public health institutions as well as the personnel and equipment management conditions. It is assisted in some of these tasks by the Central Health Council or KESY, founded within the framework of the 1983 reform. In practice, KESY oversees matters of medical activities and has not been involved, so far, in any of the debates on reforms. Furthermore, since 1995, health insurance funds, as well as the nature and level of services fall under the responsibility of the Ministry of Labour and Social Security that determines the recognised medical specialities and sets the contribution rates in collaboration with the Ministry of Economy. The national health service is spread over 13 regions and 52 districts. Apart from Athens and some other major cities, municipal authorities are rarely in charge of health services. Theoretically, the allocation of budgets to hospitals and public health centres, along with the approval of staff allocation, the institution’s management and setting the tax rates are the responsibility of the districts. In practice, these allocations of power have never been applied. Since the 1983 law came into effect, the regions are in charge of planning and coordinating the health care services. The central Government appoints the regional secretary generals and decides the composition of the regional councils. Regional committees are in charge of advising the Government on the local needs of the population. Neither the council nor the committee have ever been operational. Practically the entire population is covered by the 300 Social security institutions through one of 40 plans. The majority of these institutions are state-controlled. Health care insurance for salaried employees is mandatory and is based on their professional category. IKA is the insurance plan for salaried employees of the trade and industry sectors. It covers approximately 50% of the population. Besides contributions from its members, the plan also receives state subsidies. It provides primary care services, both directly to its members, and for non-members, through a number of hospital institutions it owns. The OGA is the plan for employees of the agricultural sector, 25% of the population belongs to it. Until 1970, the OGA covered only hospital care. Today, it provides coverage of primary

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care, with the exception of dental care. Health services are offered by the national health service. The OGA is funded mostly through a specific tax. Its members do not pay any annual contributions and the flat rate portion of medical costs borne by them is very low. The TEVE-TAE is for craftsmen and tradesmen, which represent approximately 13% of the population. Civil servants are covered by a special plan. 140 000 people were employed by the health sector in 1994. Since the institution of the national health service through a 1983 legislation, ambulatory care is provided in dispensaries and clinics. It may also be provided in other ways: - care provided within the national health service, funded by the State's budget and, in smaller measure, by the health insurance; - care managed and financed by the health insurance; - care organised by local administrations and fimded by the State's budget; - care provided in the private sector, funded by health insurance companies or by the patients themselves. Health centres which are part of the national health service provide curative, preventive and rehabilitation services. These centres are generally first recourse institutions; their role is to dispatch patients towards other institutions. Here again, there is wide gap between reality and set objectives: few general practitioners work in these centres, 70% of doctors are specialists. The number of doctors employed depends on the size of the area covered by the centre. Nurses employed in these centres are salaried by the State. There are significant discrepancies in the development of these centres. Rural areas are underequipped and offer few incentives to the professionals. Low remuneration and the difficulty of simultaneously working in private practice are the main obstacles. Today, 48% of the necessary medical positions are filled and approximately 60% of the paramedical and administrative positions. Health care centres are not autonomous and. since 1993. they are fbnded by the districts' health care budget. Furthermore, there were approximately 1400 "provincial" clinics linked, administratively, with health care centres. One to three "country" doctors usually work in these limited institutions with the assistance of some nurses. This network of clinics is supplemented by public hospitals' outpatients care. Contrary to 1983 predictions, the health care institutions of the IKA have not been integrated into the national health service. Like other health care plans, IKA owns and manages health services in a system of clinics and polyclinics (ambulatory care centres). Medical, paramedical and administrative staff is salaried. The extent of the services offered depends on the importance of the plan. A number of municipalities offer health care services which are generally directed towards elderly people, young children and preventive care services. Some even run small clinics, though the prevalence of such situations is hard to measure. The inadequacies of the public sector coupled with the large number of doctors have favoured the development of private practice. An increasing proportion of doctors employed in public hospitals, or centres managed by the health insurance, also work in the private sector. The organisation of primary health care was a factor of dysfunctional operation. In urban areas, health care services, particularly those connected with health insurance funds, are ubiquitous. Co-ordination between management and health institutions is practically non-existent. Material and financial conditions have favoured a significant "drain" of general practitioners towqds the private sector. In the end, inequalities of access to health care are persistent and they are even on the rise for primary health care. In comparison with the great majority of European countries, Greece lacks hospital beds. In 1992, there were only 5 beds per 1 000 inhabitants compared with the European Union average of 8.9. In the private sector, a large number of small hospital institutions has

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disappeared or been integrated into the public sector. From a legal point of view, the system distinguishes between hospitals of the national health service, hospitals managed by ministries or by health insurance plans, and private for-profit hospitals. The 1983 reform opened the way for the gradual integration of a major part of the private sector into the national health service. Until 1992, the opening of new private hospitals was banned and efforts were made to integrate private clinics into the national health service. However, private institutions resisted this policy by signing agreements with health insurance companies or even with the national health service. Since 1992, when the ban was lifted, the private sector has grown, and now provides a significant part of health care, although its extent is difficult to measure accurately. Over two thirds of the total number of beds are found in the public sector. In 1994, within the national health service there were 27 300 general hospital beds, distributed among 96 district hospitals and 23 regional hospitals. Furthermore, there are within the public sector 6 000 hospital beds in psychiatric wards. Apart from the national service, 27 public institutions belong to various administrations and organisations (Army, Education, IKA...). 70% of public hospitals are funded mainly through the State's budget. They also receive payments from health insurance plans through agreements regarding health care provided to the insured. While in 1994, the State's budget contributed 74% of hospitalisation funding, health insurance covered 13% of these costs. In principle, public hospitals are managed on the basis of pre-set budgets. However, these allowances are often exceeded since there is no obligation to adhere to them. The private sector has 209 general hospitals with a capacity of 1 1 000 beds and 40 psychiatric clinics with 4 200 beds. Private hospitals are generally small (20 to 30 beds). Health care insurance and contributions from patients or their private health plans fund them. Medical density increased by a factor of 2.5 between 1970 and 1994, from 1.6 per 1000 inhabitants to approximately 3.8. In 1994, there were approximately 39 000 practising physicians. Most general practitioners who are salaried employees of the national health primary health care centres, or centres managed by the health insurance plans, also work in private practice. Specialists are found mostly in public hospitals and urban clinics of the IKA. Only 18% of them have an exclusively private practise, and are remunerated on a per act basis. The ubiquity of surgeons and gynaecologists contrasts with shortages of general practitioners, and geriatric and public health specialists. Geographic disparities in the medical profession are very significant. Most dentists work in private practice, while a minority works in health care centres or health insurance polyclinics, or the IKA. While there is 1 dentist for a little less than 1000 inhabitants, their density is significantly lower for health care centres (1 per 6 700 inhabitants). Nurses make up 30% of the Greek health care staff. Between 1970 and 1994 their density went from 0.8 to 2.6 per 1 000. Despite this significant increase, this rate remains lower than the European average. 79% of nurses work in public hospitals, 11% in private clinics and 10% in primary health care centres. Access to public health care is based on the principles of Beveridgian models. Generally, access to primary care is free for all residents, regardless of the health centre or the hospital they choose. However, because of the inadequacies of the public sector, the portion of the overall health care expenditures funded by patients and private insurance remains very high (42%). "Underground" activities are gaining ground. Since 1992, patients pay a flat rate contribution for all outpatients hospital care, except for emergencies. Patients have free access to public and private hospitals accredited by insurance funds. There are no restrictions on prescriptions. The rate of the flat contribution towards the cost of medication borne by the patients is 25%. There are exemptions for elderly and lowincome patients.

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Italy

Italy's health care system is a regionally-based national health service that provides universal coverage free of charge at the point of service. The system is organized at three levels: national, regional and local. The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system. Regional governments are responsible for ensuring the delivery of the health actions through a network of population-based Local Health Agencies and public and private accredited hospitals. In Italy the company insurance funds began to federate into a central fund, the National Institute for Health Insurance, only during the Second World War. Later, coverage was extended to new professional categories. In the mid 197Os, about a hundred health insurance schemes co-existed. Health care providers were bound by agreements with these fimds. The health care system was created in 1978 to respnd to the insufficient coverage of public health issues and to the inadequacies of a social protection system linked, perhaps too closely, with professional categories. The health care reform project assigns an essential role to political administrators in the management of local health Units (USLs), which are the founding-stones of the entire system. The law of December 23rd1978 (n. 833), constituting the national health service, represents one of the major politico-social reforms of the 1980s. Article no 1 of the law establishes that: "The Republic defends health as a fundamental Gght of individuals and the interest of the community through the NHS". An important principle was thus introduced: individuals are no longer considered as simple beneficiaries of the dispositions of the law. but as beneficiaries of the subjective right to demand a certain number of care services from the competent administrative structures in order to defend their health. Lengthy debate between the political, social and trade union powers preceded the publication of the law. However, there were three elements on which the objectives and the will of the social groups converged: (i) the need to reduce health expenses in relation to the PNL; (ii) the demand to rationalise the employment of personnel through professional qualification and mobility, in order to concentrate the resources in function of the needs: (iii) the demand to privilege the preventive component as opposed to the diagnosis and care component. Since the 1978 reform "The national health service consists of all the functions. structures, services and activities destined for the promotion. supervision and protection of the physical and mental health of the population". Among the fundamental principles which characterise this reform are: - the principle of equality: the national health service exercises its action for the benefit of the entire population, without distinction between the individual or social conditions and according to modalities ensuring equal access to care for all citizens. - the principle of globalisation of the interventions: the national health service coordinates the activities performed by the other centres and institutions which offer, in the social domain, services linked to the state of health of the individuals and the community. - the principle of social health supervision: health supervision no longer concerns the individual as an entity but rather the citizen as a part of a whole. Health considered as "social value" cannot be simply limited to the care of diseases but must necessarily expand to the prevention and limitation of these diseases. The health organisation model planned by law no 833 did not manage to attain the objectives outlined during its constitution. In fact, the activities of the Italian health system have been inspired by the so-called "quantity ideology". Faced with a demand more qualified as supervision of the "right to health", the public services' response has been to increase the "quantity" of the offer to the detriment. in most cases. of the quality level. As

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well as this, the objective of favouring prevention has remained on paper as it comes up against a health system that has concentrated its efforts on diagnosis and care. It has long been invested by politics. Recent reforms attempted to remedy this situation by breaking the link between politicians and the system's management structure. The poor performance of the health institutions, particularly in terms of regional discrepancies and social disparities, has been the staple of discussions for more than ten years. Since 1992, an important reform has introduced new measures as regards health programming. The measures adopted reassert the fundamental concept of tri-annual planning, already established by the 1978 law, but state that public intervention can take place within the limits of the financial resources available. The prevention, care, and rehabilitation objectives, the levels of assistance which must be ensured throughout Italy, and the general orientations are established by the national health plan. This plan should also conform to the objectives of the socio-economic planning as well as to the budget awarded to the national health service. The national health plan is adopted by the Government, for a three year duration, but it can be modified during this time, even as regards the limits and the criteria of affectation of funds, and the various forms of the users participation in costs. These forms of participation are established according to the financial resources registered in the law of finances. The national health plan indicates: - the priority intervention domains with the intention of eliminating, at the territorial level, the disparities in the health conditions of the population. - the uniform levels of assistance determined on the basis of the available resources and containing the specification of the services to which each citizen is entitled. - the "objective-projects" which must be undertaken through the functional and active integration of the care and social services of the local administrations. - the control indicators and measures of the levels of assistance actually provided as opposed to those planned. - the financing allotted for each year of the plan's validity. The Italian health management structure is based on three levels of power. The ministry in charge of health sets, ultimately, the national priorities and objectives. A High Counsel on Health is consulted on issues of national priorities. This counsel defines the level of coverage of the population by the national health service and allocates funding according to quota based on population size. Its role is to guarantee that health care services are adequately provided throughout the entire territory. The 1992 reform endeavoured, amongst other objectives, to reinforce their autonomy and power by making health care funding regional. Regions collect the mandatory contributions, and may set the rates for the overall mandatory contributions and the flat rate portion borne by the insured. These rates may be higher than recommended, within some legal limitations. The regions are also in charge of health care planning and organising. They allocate fimding between the USLs, on a per person quota. In 1998, through the Legislative Decree 229/1999, the NHS was again reorganized, including the relationships between levels of responsibility and management, the roles played by various actors (such as managers, physicians and local institutions) and the balance between economic constraints and the principles of universalism and equity of access. The resulting reform extended the regionalization process, making clearer the division of responsibilities among levels of government. The regionalization was completed by the Legislative Decree 56/2000 prescribing the abolition of the National Health Fund to be replaced by various regional taxes. Regions unable to raise sufficient resources will receive additional finding from the National Solidarity Fund. These will be allocated

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annually based on criteria recommended by the government and the Standing Conference on the Relations between the State, the Regions and the Autonomous Provinces. As regards health and hospital assistance, the autonomous regions and pmvinces exercise the legal and administrative h c t i o n s not specifically reserved to the State. After the publication of the national health plan, the regions adopt the regional health plans. These plans must be standardised with the national health plan by defining the organisational models of the services. The regional health plans are the instrument through which the regions attain the objectives of the national health service. Among the competencies attributed to the regions are: - the organisational directives of the services; - the organisation of the health protection activities; - the financing criteria of the Local Health Agencies (ASLs) and of the hospital structures; - the control of the health care provided and the evaluation of the quality of the providers chosen by the ASLs; - the elimination of the disparities in the health care services at the local level. Recent national legislation has defined a new local unit, the “local health agency”, and has provided general managers with more autonomy, which mainly materializes in the power to define their agency’s mission and objectives through a 3-year strategic plan, consistent with the recommendations of the regional health plan. The number of ASLs has decreased considerably; today, there are 230 as compared with 65 1 USLs in 1978. As far as the introduction of competition models is concerned, the regions have a free choice. However, it is possible to distinguish three potential models: the single contract model, the preferential health provider model, the activity plan model. In the first model, the patient is entirely free to choose his health care provider, public or private, affiliated to the national health service. The local health care Agency (ASL) acts simply as a paying organisation. In the second model, close to the current British system, the ASL negotiates specific contracts with some health care providers. Patients are entirely covered when they choose these health care providers with a preferential status. If, on the other hand, they choose to go to a non-preferential institution or practitioner, they must advance the payment of their health care cost and apply for a refund. Refunds are allocated on the basis of rates set by the region. In the third model, each ASL negotiates an annual activity plan with its hospitals and ambulatory care centres or with private health providers. Theoretically, the district provides basic health care and co-ordination of the ASLs. Districts are defined by the regions and are urged to favour the integration of basic health care with ambulatory care, and of health education with epidemiological follow-up. In the absence of a precise rule at the national level, some regions, particularly in the south, have decided not to put these institutions in place. The national health service employs approximately 700 OOO people. Doctors make up approximately 13% of this, nurses and midwives approximately 37%. Selection for entering medical schools was only recently instituted. Italy has the highest rate of unemployment amongst doctors within the European Union. The development of primary care was one of the main objectives of successive reforms. In 1995, there were 5 1 000 general practitioners, which corresponds to a density of 1 per 1 000 inhabitants. The number of paediatricians (6250) is largely insufficient since their density is 0.6 per 1 000 children. There are noticeable disparities in the distribution of general practitioners over the national territory. Their density is higher in the south. These first contact doctors are still outside the mainstream in the national health service; they have no real participation in the ASLs and rarely co-operate with specialists. They are remunerated on a per medical act basis.

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A number of specialised doctors are employed by the national health service to provide ambulatory care. Three types of institutions co-exist: public polyclinics, public and private hospital dispensaries. Most of these institutions were established by the mutual benefit insurance funds prior to the creation of the national health service. Specialists within the national health service may practice in several hospitals or work only on a parttime basis. They are remunerated on an hourly basis. Their activities outside of hospitals are essentially related to diagnosis, although they may carry out minor operations. Specialists affiliated with the system with an external practice work in private individual offices or in clinics. They are remunerated on a medical act basis according to an agreed set rate. Private individual offices are more prevalent in the south. In principle, access to a specialist is subject to a referral from a general practitioner. Patients may go both to the public and to the private sector that is part of the general agreement, as a result the private sector is increasingly playing a supporting role. A patient may even go to a private institution that employs a practitioner he would have consulted in a public sector. There are approximately 1 000 public institutions and approximately 650 private clinics which are part of the general agreement. Furthermore, there are 68 psychiatric hospitals that outlived the law requiring their closure. 60% of the hospitals are institutions of less than 200 beds. 70% of all beds are in medicine or surgical Agencies. The density of beds is 6.7 per 1 000 inhabitants. There are notable regional disparities: 5 beds per 1 000 inhabitants in Campania to 8.3 per 1 000 inhabitants in Latium. Patients tend to go to private institutions more often in the south or the Latium region than in other regions. Patients’ migration is more important from the south to the north. Although disparities are shrinking, hospitalisation still occurs at unequal rates in different regions and social classes. Within the public sector, and since 1995, hospitals have been turned into autonomous institutions that manage their budgets freely, with financial and technical autonomy and a governing structure of hospital trusts mirroring that of local health agencies. Public hospital trusts provide highly specialized tertiary hospital care (inpatient and outpatient). Since 1997, hospital funding is carried out on the basis of specific tariffs according to a classification of patients in homogeneous groups (DRG). Approximately 80% of the budgets of autonomous hospitals is covered by the regions on per patient quotas. The remainder is covered through the agreements with the ASLs that act as reference centres across the country. Other hospitals are integrated with ASLs in terms of funding and management. 560 000 people are employed by public hospitals; of these 17% are doctors and 44% nurses. Although prospective payment remains the main source of reimbursement, Legislative Decree 229/1999 states that providers are to be paid based on a global budget negotiated yearly by the regional health departments, local health units and trusts. Private accredited providers provide ambulatory, hospital treatment and/or diagnosis services financed by the NHS. The regional health departments regulate this participation through the authorization and accreditation system. Doctors who work in the public hospital sector are salaried. Over half of them work on a full-time basis. Doctors who work on a part-time basis are allowed to work in private clinics. Within the private hospital sector, doctors are remunerated on a per medical act basis. In private practice, full-time doctors represent only a quarter of the total number of doctors. The organisation and the funding of the pharmaceutical sector are overseen at the central level. Authorised medication is registered on a list. The purchasing of drugs is covered by the national service but only partially, depending on three levels of therapeutic importance. The flat rate contribution of the insured may vary from one region to another. The increase in these flat contributions has led to a decrease of drug per capita expenditures

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of approximately 33%. Drug consumption is higher in the south; so are the number of prescriptions and the per capita expenditures. According to the D. P. R. of December 24th 1992, all the Italian citizens registered with the NHS are entitled to health care, as are political refugees and the stateless. Health care is also guaranteed for certain categories of foreign citizens: those residing in Italy with a resident’s permit and an Italian work permit, the unemployed registered with the employment ofice, those voluntarily registered with the NHS, refugees and nomads. Portugal

The Portuguese Health System: Portugal’s National Health Service (NHS) was created in accordance with Law no 56/79, which was passed by the Parliament. It comprises a number of organisations and services whose aim is to provide the entire population with global and integrated health care services, including health promotion and protection, disease prevention and diagnosis, and the treatment of the sick as well as their medical and social rehabilitation. This law makes provision for the existence of authorities whose role is to ensure the rational distribution, the technical hierarchical organisation and the overall functioning of the health care services, as well as ensuring that they are complementary. They must also promote the decentralisationof decision-making and the participation of the beneficiaries in the organisation and management of services. These authorities are being developed at central, regional and local levels and may have a consultative, instrumental or executive function. The 1979 legislation combined the system’s two main institutions: the social security and the public health services. The social security ceased to play a direct role in health care. However, some health insurance plans remained unchanged: those for civil servants, bank employees, insurance and public companies, the army. Although the 1979 legislation guarantees universal coverage, approximately a quarter of the Portuguese are inadequately covered by the NHS. Patients affiliated to insurance funds are free to choose where they wish to be treated. Most of them choose the private sector or accredited doctors. for ambulatory care, and the national service, for hospital care. The NHS is essentially funded through the budget of the State. The State owns the majority of the hospitals and the primary health care network of the health centres. it is the role of the central authorities to examine and propose health policy. They are responsible for: - planning and evaluating services and activities in the health sector, - developing norms for the functioning of institutions and services, - carrying-out technical inspections and evaluating their results, - taking the decisions necessary for the organisation and hnctioning of the NHS. - co-ordinating the various sectors of activity, - drawing-up model contracts with those bodies not integrated into the NHS and for signing contracts at national level, - participating in inter-ministerial activities, - training and research in the health sector, and for - the protection and financial support of private activity in the health sector. Theoretically, the National Health Service provides fi-ee cafe accessible to all. However, dysfunctional institutions, a financial burden impelled by the development of medical activities. along with political changes have all lead to an amendment of the original principles.

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In 1989, a new constitutional amendment re-established a patient financial contribution to the NHS. Patients are free to choose their health providers. However, their choice is often curtailed by the geographic context of their health care centres. Except for emergency cases, they may consult a specialist only after referral by a general practitioner. It is often impossible for them to find certain services. These factors lead to increase of agreements between regional administrations and the private sector. In the absence of such agreements, patients may pay a doctor in private practice for treatment, and then apply for a refund. The portion of health care funding borne by the patients has reached approximately 38%, half of which goes to paying pharmaceutical bills. Besides the health care protection offered by the NHS, a number of health insurance plans were maintained, as mentioned above. These plans have their own administrative structure. The types of care they cover are provided 6y health services, which they manage, or by public or private health care providers with whom they have signed a general agreement. The people they insure enjoy the coverage of their health care expenses and have access to their health care institutions, in addition to access to the NHS. Approximately a quarter of the population is covered by these plans. Major health care funds cover the civil service and the military, i.e. 18% of the population (those which cover private or nationalised companies were privatised, along with the branches with which they were associated). Salaried workers pay very small contributions,the rest of the funding comes from the employers or the State. Approximately 700 000 people subscribe to mutual benefit insurance funds which provide their members with various types of coverage. Private health insurance companies have expanded since 1980, and now in 1998, about 10% of the population. In order to encourage people to seek the services of the private sector, premiums have been made tax deductible. Close to thirty insurance companies with a private and commercial status now operate in Portugal. Subscribers to public or private health insurance funds are fiee to seek treatment wherever they wish. Some health care plans offer access to their own health care system. Organisation and delivew of health care: The Ministry of Health is in charge of the organisation of hospitals, primary care and public health programmes. The central administration oversees the regions and the districts, assisted in this task by the National Institute for Public Health. An Economic and Social Council acts as an advisor on issues of public health. Five autonomous health care regions have been in place since 1993. The Regional Health Administrations are responsible for the local implementation of the national health policy objectives. They co-ordinate all levels of health care and allocate resources to hospital and health centres. Regional health centres are associated with hospitals in so-called health care units. Each has a planning and co-ordination committee. Within the NHS, primary care is organised by the eighteen districts managed by commissions monitored by the regional boards and the Ministry of Health. The impossibility of access to certain health services has led to the gradual development of agreements between regional health care administrations and the private sector. In the absence of such agreements, patients may be treated by doctors in private practice and apply for a refund of expenses incurred. Primary care is organised by district. These Health Centres provide a wide range of services, primary health care, health promotion and protection, as well as prevention, diagnosis and the treatment of disease. They employ physicians (particularly general practitioners and public health physicians) along with social workers, psychologists and nurses. Each Health Centre reaches an average of 25 to 30 000 people. In 1996, there were 2043 health jobs and 382 Health Centres. General Practitioners work with a system of patient lists, on average approximately 1500 patients.

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Hospitals are institutions providing specialid health care services. The objective underlying the organisation and administration of hospitals is the provision of medical, curative and rehabilitative care to the population; they are thus equipped with the means to accommodate patients and to provide appropriate diagnosis and therapy. It is also their responsibility to make a contribution in the fields of disease prevention, teaching and scientific research. In 1996, there were 21 1 hospitals, of which 122 were public. There were 39 212 beds which gives a rate of 4.1 beds per 1.OOO inhabitants, one of the lowest in Europe. The NHS hospitals are divided into four different categories: central (14), specialid (14), district (39) and district -1evel-one (26) hospitals. Many of these institutions are small, mainly the districtlevel-one hospitals. 773% of all hospital beds are found in the public sector. The distribution of these institutions over the national territory is not equitable. They are mostly concentrated in the areas of Oporto, Lisbon and Coimbra. The NHS also covers the autonomous regions of the Azores and Madeira, although both have their own qualifications. Control of health care services falls to the Regional Secretariats for Social Affairs of the governments of the autonomous regions. Services are not equitably distributed over the national territory. The importance of the private sector has never ceased to increase since 1970, even after the creation of the NHS. This growth has been favoured by the tax system since 1990, and was strongly encouraged by the 1993 reform. Thus, over 80% of dental consultations, 70% of laboratory tests, 50% of X-rayexaminations, 16% of the medical specialists appointments and 14% of the general practitioners appointments occur in the private sector. The NHS is predominant for hospitalisations, general medicine services, as well as maternity and nursing care. Dental care is mainly provided in the private sector. Some new dental health programmes, for children, are now being started in some of the Health Regions. Human Resources in the NHS: 110 OOO people were employed by the NHS in 1994. 35% of health professionals are involved in primary care,61% work in hospitals and 4% in teaching, research or administration. Doctors may have more than one specialty (including general medicine). The percentage of doctors who are general practitioners was 35% in 1996. In 1996, there were 29 OOO doctors, i.e. 1 physician per 340 inhabitants (one general practitioner per 530, one specialist per 1 120 inhabhnts). Half of all physicians work in hospitals and over a quarter of them in health centres.Doctors who work within the NHS are salaried. Their salaries in health centres depend, in principle, on the number of patients registered on their lists as well as various compensations, for instance, for rural practice. The 1990 legislation allows salaried physicians of the public sector to have a dual private-public practice (since 1993, even if they are employed on a full-time basis). In fact, the vast majority of doctors work in both sectors. Because of a lack of public investments, low salaries paid to professionals, and a certain measure of leeway in the regulation, doctors are pushed to provide minimal care when they work for the national service, in order to increase the potential market share of their private practice. There is a shortage of nurses in the country. Most of the nurses work in central or district hospitals (74%). In 1995, there were 3,38 nurses per 1.000 inhabitants. Some hospitals are contracting foreign nurses, mostly from Spain and Brazil. The ratio of dentists is relatively low - 0,26 per 1.OOO inhabitants - compared with other countries. There is a large proportion of foreign dentists in the country, especially Brazilians. In 1995, a total of 120 0oO employees were employed by the NHS, mostly in hospitals. Health Expendituressand NHS Financing: At 8.2% of GDP in 1996, total health spending is close to the OECD average, but e x d the EU equivalent by 0.5 percentage point. Scaling the expenditure share by per capita income shows Portugal as a country with a relatively high spending level. High and rapidly growing overall health-service resource demandsare associated with an atypical mix of public and private health care provision. While

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outlays on health, at almost 5% of GDP, are marginally lower than the OECD average, private spending, at 3.3% of GDP, is more than twice as high surpassing all other OECD countries except the USA. Operating parallel to the NHS, the separate health insurance sub-systems cover 25% of the population and have autonomous administrations. Health care is provided either by their own services or by contract with the private or public health institutions. Mirroring this rise in spending, health outcomes improved vastly over the past 20 years. The infant mortality rate was reduced by four-fifths, and the potential life years lost for males was cut by nearly one half. Nevertheless, in absolute terms Portugal's health outcomes are still below those of other countries. Comparatively low levels of education attainment and the persistence of extreme poverty in some areas have certainly contributed to these results. Hospitals of the NHS have a global budget that is mainly based on historical data. However, there is in fact an open-ended budget, because the State will cover all the expenses with supplementary allocations. At the beginning of the 1990s, hospital budgets were starting to be established on the basis of cases treated the previous year assembled in homogenous groups of patients. There are few incentives to encourage cost-containment, which has been promoted since 1993. . In public hospitals, patients are fully covered. However, a co-payment may be required of them, depending on their level of income. Health Centres are financed through the district level of the health regions. The budget is constructed based on historical financing. As far as drugs are concerned, only listed products are covered. There are two levels of financial contributions: 60% for most medications, 30% for the rest. Medication for chronic diseases is entirely fiee. Programmes to assess the quality of health care have also been established. The final objective is to allocate resources to the regions according to their needs. The Actual Reform and the Future: In 1996 the Minister of Health set-up a Commission on the fbture of the Portuguese health care system, to put forward health policy recommendations up to the year 2000. Among other reforms, the Commission allowing health insurance beneficiaries to opt-out of the NHS. A National Health Strategy was elaborated in 1998. It set out a coherent plan for health with measurable targets. It gave precedence to health gains and focused less on the economic constraints in which health care services must be provided. This document has five goals: - to obtain health gains for the Portuguese; - to develop local health systems gathering all local resources towards better health; - to invest in the training of health personnel; - to promote new models of financing in health care; - to have a European vision of health and establish close links with Portuguese-speaking countries. The objectives of some of the most recent reforms included: promoting incentives for cost containment and improving efficiency - by commissioning the heath services at a regional level; improving health care management - by creating autonomy in hospital services and departments, and autonomous Health Centers, allowing private management models in public hospitals; improving health gains - by promoting local health systems. A system based on private health insurance companies

Switzerland

Switzerland is a federal state made up of 26 cantons, with just over 7 million inhabitants, traditionally known as a rich country (in 1999 the GDP was evaluated at 27 902dollars per inhabitant). However, from 1991 to 1997, the unemployment rate at the federal level went from less than 1'YOto more than 5%, however it stabilised at 1.9% in 200 1. Even though this

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country is still one of the richest States in the World, during the 1990s poverty rates and the number of persons living in precarious conditions clearly increased, and are respectively evaluated at 15% and 30% according to certain studies (Source: L'exclusion sociale, leX partie. Rapport d'experts au Conseil economique et social du canton de Geneve) There are also major disparities between cantons, both as regards statistics (the unemployment rate in the canton of Geneva was 4.2% in 2001)and as regards legislation. While the federal law regarding health insurance prevails throughout the country, each canton can improve its content, though this improvement must be submitted for the approbation of the Federal Council. Switzerland does not have a national health system. As regards health insurance, the social security applies the indirect grant system. Each person registers with private health insurance funds, subsidised by the State, which guarantee payment or pay directly. Up to December 3 1'' 1995, health insurance was optional and individual, but certain cantons had made it obligatory for their entire population or for certain groups (civil servants, school children, and employees below a certain income threshold). Since January''1 1996, the application of the 1994 health insurance law (LAML),has made it obligatory at the federal level. The notion of daily indemnities insurance for salaried employees has remained optional with the new LAMAL. Afiliation can be individual or collective (by means of the employer), any person between 15 and 65 years old, residing in Switzerland, with a paid activity, can subscribe. The insurers have the right to exclude from the insurance the illnesses which the insured person has at the time of admission, and also prior illnesses. if a relapse is possible. Invalidity insurance (AI), and accident insurance (LAA) are also liable to provide direct payment in the case of certain medical treatments. The A1 intervenes in the treatment of congenital infirmities, and in the case of measures directly necessary for occupational readaptation. The LAA is managed by the Swiss national insurance fund in the case of accidents and by the private accident insurance companies. It guarantees medical treatment for injuries resulting from an accident or an occupational disease, or from a nonoccupational accident, for all salaried employees. Finally, military insurance allocates funds when a disease or accident is related to a person performing his military service. or assimilated. The social protection system is relatively old in Switzerland, as the first federal health insurance law dates from June 13' 191 1. However, until 1964, health insurance legislation was limited to subsidising. From 1965,the law prescribed numerous minimum norms: notably the fact of not being able to refuse a candidate in view of hidher poor state of health with, however, the possibility of issuing conditions. The law imposed the observation of these norms on the recognised health insurance b d s , in exchange for subsidies. Since January''1 1996,the LAMAL has made health insurance obligatory for all the legal residents in Switzerland (Swiss and foreigners with a valid residence permit or working papers, in the 3 months following their establishing residence or being born in Switzerland). Affiliation is obligatory, but not automatic: the person concerned must be insured but, if necessary, the canton authority will affiliate them as a matter of course. Insurance is always individual: the notion of "entitled to" does not exist, however rates for children are reduced. The insured person has freedom of choice regarding the insurance company. It is possible, on condition of giving advance notice, to freely change insurance companies, the law thereby favouring competition between the companies. For the "basic" services, the insurer cannot make any conditions. Maternity care is also covered by this system. but there is no specific maternity scheme. As for those persons who do not

Part 1. An Overview On Europeans' Health Care Systems

53

have accident insurance (mainly non-salaried persons), the LAMAL takes charge of this eventuality. To be recognised by the Confederation the health insurance f b d s must fill the following conditions: - either be recognised by the Federal Department of the Interior - or be private institutions submitted to federal insurance law, and authorised to .practice by the Federal Department of the Interior The collaboration between the health insurance funds and the care providers is ruled by fee conventions, agreed at the canton level. The insured person's free choice of doctor is guaranteed in that the doctors' fees are government regulated. However, in exchange for a decrease in the monthly payments, certain funds offer those they ensure affiliation to "care networks", in which the choice of doctor is limited or even imposed (gatekeeper of the HMO systems). Since the year 2000 affiliation to an HMO system insurance is tending to become obligatory for asylum-seekers. Since this date, the Federal Office for Refugees is heavily inciting the cantons to establish this kind of insurance for financially assisted asylumseekers; this measure will be obligatory by the end of 2003. Access to the specialist depends on the gatekeeper, and the gatekeeper's choice is limited to a closed list. It must be noted that dental care is excluded from the field of the LAMAL, except if it has been caused by a "serious and unavoidable illness of the mastication system or by another serious illness or its sequels". In certain cantons, dental treatment effected on children within the framework of "youth dental clinics" is subsidised by the State, and the parents are billed according to family income scales. The insurer only pays for services provided in the insured person's canton of residence, except for specific medical reasons. The scheme is mainly financed by the insured persons' contributions (premiums). The employers' participation to the contributions is minimal, or nil. In addition, the insured persons must participate in the costs of the services, by paying a monthly fee, and a share of the costs. The public subsidies (Confederation and cantons) are targeted for lower income persons, according to precise scales. For 1998, the franchise was 230FS for an adult (there is no franchise for children under 18) and the share paid by the insured is fixed at 10% of costs (including hospitalisation costs), up to a maximum amount of 600FS for an adult and 300FS for a child. In case of hospitalisation, apart from the share of costs, the insured must also pay a contribution towards hostelry costs of lOFS per day. Persons sharing housing with one or more members of their family are exempted from this contribution, as are women in the case of maternity services. The insurance fund cannot demand any participation for maternity costs. In exchange for a reduction in the monthly fees, the insured can choose a franchise higher than the legal one. With the new LAMAL, the insured can oppose the health insurance directly by letter. The decision taken in answer to this opposition can be attacked by resorting to administrative law at the cantonal insurance funds court, and then, if necessary, at the federal insurance funds court. Doctors enjoy complete fieedom of prescription and in setting-up a practice. The 1996 health insurance legislation re.quires that doctors ensure that the interest of their patients and the quality of the services they provide are not compromised by the cost reduction measures they may take. Doctors must seek the prior approval of the medical advisor of the insurance fund for certain particularly costly services. Patients are free to choose their doctor. Rates are set by agreement between doctors' federations and insurance funds' federations. These agreements must be approved by the cantons. Rates are also set by agreement between

54

Part I . An Overview On Europeans' Health Care Svstems

federations of insurance funds and representative bodies of professional groups. In the absence of agreements, the rates are set by the canton. There are two types of hospital institutions: public hospitals and non-profit private clinics. Cantons and communes oversee the management of public hospitals that they subsidise. Non-profit private clinics also receive subsidies fiom the cantons. Rates are set by agreements between the institutions and the Canton Federation of InsFunds. These rates may thus vary fiom one institution to another for the same service. Rates for laboratory tests are set by the Federal Department of Internal Aff'ars. The European health care systems confronted with the principle of equity

Beyond naturaI differences, which are perceived as inevitable, the debate is open to point-out "avoidable and unjust'' inequalities related to society's mode of operation. This debate takes a different course according to social context, national wealth, social protection systems, but also according to scientific knowledge. For instance, the major social determinants of mortality are, nowadays, clearly established. Equality in respect to health care is a major objective of the health care systems; it is important to define the issues that smund it, its ambitions and the means it requires. All the countries on which we focus in this report adhere to the 1986 WHO "Ottawa charter for the promotion of health". Amongst others, they have made a commitment to "reduce the existing health condition discrepancies and ofer to all individuals the same resources and possibilities for them to reach theirf i l l healthpotential". The concept of equality at the time when the major health insurance programmes were introduced, consisted in making all the services deemed appropriate by the medical profession accessible to all. "Today,a health system is deemed equitable ifit opens to all an access to health services which contribute, in space and time, to the betterment of health and to an equalisation of the health conditions of the individuals in a given society" (Contandriopoulos,Quebec, 1991). Thus, health policy must have the ambition of achieving the best balance between offer and demand. The challenge is to define criteria and principles of equality in a context of increasingly precise constraints, in particular financial. We shall retain the usually accepted principle that a system is deemed equitable if it allows all individuals, with equal morbidity, to receive the Same quality and quantity of health care. It is essentially on the social character of health care inequalities that health care and social protection systems will be able to act. This definition urges the health care systems to act upon health care inequalities even though the heafth condition of individuals is largely the responsibility of social and economic policies. In reality, theses links between the economy, social policy and health policy call for a coherent implementation of the objective of inequality reduction, the policy to bring expenditures under control and the health care system regulation. In spite of all this, all the reforms have been guided by efficiency criteria and are, thus, not necessarily neutral fiom the point of view of equality. Do the reforms undertaken in most European countries shake up the historical foundations of European democracies (the establishment of the Welfare State)? Do they allow our health care systems to adapt to economic constraints in order to safeguard the principle of equality? We shall examine these issues in a following chapter (see Trends in European health care systems). Bibliography

Abel-Smith. et al, eds. Choices in health policy, an agenda for the European Union. Dartmouth, Aldmhot. 1995.325 p.

Part I . An Overview On Europeans' Health Care Systems

55

Alfonso Sanchez JL,Del Ban0 MJ, Cortina Greus P. Spain: an explanatory model of supply and utilisation of human resources of the health care system. Cah Sociol Demogr Med 1995; 35: 227-261 . Ambrose P. Health system reform and the rise of family medicine in Spain. J Am Board Fam Pract 1996; 9: 6063. Berthod-Wurmer M, ed. La santk en Europe. Paris, La Documentation Franpise, 1994,367 p. Bertinato L, Mazzeo MC, Pocetta G et al. The organisation of health promotion and education in Italy. Promot Educ 1997; 4: 19-22. Boerma WGW, De Jong F, Mulder PH. Health care and general practice across Europe. Utrecht, Nivel, 1993, 126 p. Bourdelais P, Gaullier X, Imbault-Huart MJ, Olivennes D, Poursin JM, Stasse F. Etat-providence : arguments pour une rkforme. Paris, Gallhard, 1996,4 18 p. Brotons C, Iglesias M, Martin Zurro A, Martin Rabadan M, Gene J. Evaluation of preventive and health promotion activities in 166 primary care practices in Spain. Fam Pract 1996; 13: 144-15 1. Carbonin P, Bernabei R, Zuccald G, Gambassi G. Health care for older persons, a country profile: Italy. J Am Geriatr Soc 1997; 45: 15 19-1 522 Chauvin P, Lebas J. La problkmatique pr6caritb et santb, un symptbme des dysfonctionnements de notre systkme de sante. In: Lebas J, Chauvin P, eds. Prtcaritk et santk. Paris, Flammarion, 1998 : 3-22. Collectif InCgaIites, santd et exclusions. Prhenir 1995 ;28 : 7-92. Commission europdenne. L 19emploi en Europe I997. Luxembourg, Oflice des publications officielles des Communautes europdennes, 1997, 144 p. Commission europdenne. Population, mknages et logements en Europe. Luxembourg, Oflice des publications oficielles des Communautbs europdennes, 1996,256 p. Commission europdenne. Portrait social de 1 'Europe. Luxembourg, Oflice des publications oficielles des Communaut& europeennes, 1995,262 p. Contandriopoulos AP. Coiits et Bquit6 des systbmes de santd. Communication au stminaire "La santk internationale ;un champ d'ktude et de pratique professionnelle", Qu&ec, mars 199 1 . Dagum C, Lemmi A, eds. Income distribution, social welfare, inequality, and poverty. In: Slottje D, ed. Research on economic inequality. Greenwich, Jai Press Inc, 1995, ~016,405p. Danzon M, Poitrinal P. De 1'Est d 1'Ouest de 1'Europe: la sant6 malade de I'dconomisme. Le Monde Diplomatique 1996; 3 : 1 1 . Darioli R. Enseignement de mtdecine des assurances. Genbve, Institut de Mddecine Sociale et Mventive, 1996, 41 p. Deleeck H, Van Den Bosch K, De Lathouwer L, eds. Poverty and the adequacy of Social security in (he EC. Aldershot, Avebury, 1992,20 1 p. Do Rosario Giraldes M. Portugal: current distribution and development of the human health resources. Cah Sociol Demogr Med 1995; 35: 343-360. Duriez M, Lequet D, eds. Les rkformes des systkmes de sante. Specificit& et convergences. In: Actualitk et dossier en santkpublique. Paris, HCSP, avril 1997,32 p. Duriez M, Lequet D. Convergence des politiques de maitrise des dbpenses de sante et risques d'inegalitds d'accb aux soins. Belgique, Italie, Luxembourg, Pays-Bas. Rapport pour la Commksion des Communautks europbennes, DGV, 1 99 1 . Duriez M, Lequet D. Desengagement des institutions dans le fmancement de la protection sociale et inegalites d'accbs aux soins. Espagne, Grande-Bretagne, France, Republique Ftktdrale d'Allemagne. Rapport pour la Commission des Communautis ewopkennes, DGV, 1990. Duriez M, Lequet D. Les syst2mes de santk de I'Union europtenne. Paris, PUF, coll. que sais-je ?, Paris, 1997, 127 p. Elola J. Health care system reforms in western European countries: the relevance of health care organization. Int J Health Sew 1996; 26: 239-5 1

56

Part I . An Overview On Europeans’ Health Care System

ENSPIMIRE. Les trmfwmations des syst&mes de s M I p en Europe : vers de nomeam c o m m e m e prestataires,payeurs et pouvoirspublics ? Rennes, Editions ENSP, 1995, 175 p. Federal Ministry for Health. Health care in Germany. Bonn, Federal Ministry for Health, 1997.69 p. Ferrera M. The rise and fall of democratic universalism: health care reform in Italy, 1978-1994.J Health Polir Poli~yLUW 1995; 20: 275-302. Greber PY. Cours d’introduction au &oit suisse de la secwitk sociale. Univenitt de Genkve, Facultd de Droit, edition 1997-98. lglehart JK. Health policy report: Germany’s health care system. N Engl J Med 1991 ; 324 : 503-508, 1 750- 1759. Institut de I’Humanitaire. Sante, precaritP. vunerabilite en Europe. Rhumks de la I“” conference internationale u Paris, 15-16 novembre 1996. Paris, Institut de I’Humanitaire, 1996.

La CIC. Guide social et prutique, Hospice Gdndral, Service d’information sociale et juridique, ddition 1996. Lagasse R, Humblet PC, Lenaerts A, Godin I, Moens GF. Health and social inequities in Belgium. Soc Sci Med 1990; 3 1: 237-248. LardeIli P, Blanco JI, Delgado-Rodriguez M, et al. Influence of socioeconomic and health care development on infant and perinatal mortality in Spain.J Epidemiol Communiry Health 1993;47: 260-264. Le Goff J. Crise et indcuritd sociale : traitement de choc pour la sant6 europknne. Le Monde Diplomatique 1997; 7: 25.

Lequet-Slama D, Parayre C, eds. Donnkes sur la situation sanitaire et sociale en France en 1998. Paris. Ministkre de 1’Emploi et de la Solidaritd, 1998,245 p. Light DW. The real ethics of rationing. BM 1997; 3 15: 1 12-I 15. Ludvigsen C,Roberts K. Health care policies and Europe: the implications for practice. Oxford, ButterworthHeinemann, 1996,272 p. in Italy: an empirical Mapelli V. Health needs, demand for health services and expenditure across social WDS investigation.Soc Sci Med 1993; 36: 999-1009. Navarro Rubio MD, Jovell AJ, Schor EL. Socioeconomic status and preventive health-care use by children in Spain. Am J Prev Med 1995; 1 1 : 256-262. OCDE, La riforme des Vstkmes de santi. Etude de dix-sept pays de I’OCDE. Etudes de politique de s u n t i nos. Pans, OCDE, 1994,370 p. OCDE. Etudes des politiques de santk n08. La riforme des systsmes de santi, la volonti de changement. Paris, OCDE, 1996, 158 p. OFS. Mbmento statistique de la Suisse. Beme, ORce fadral de la statistique, 1997, 33 p. Ott N, Wagner GG, eds. Income, inequaliw andpoverry in Eastern and Western Europe. Heidelberg, Physica-

Verlag, 1997,253 p. Perneger TV, Etter JF, Rougemont A. Switching Swiss enrolees from indemnity health insurance to managed care: the effect on health status and satisfiction with care. Am J Public Health 1996; 86: 388-393. Pijxmo A, Di Orio F. Social differences in health and utilization of health services in Italy. Soc Sci Med 1990; 31: 305-312 Rehfeldt U . Effiitement du madtle social europtkn. Le Monde Diplomatique 1994; 7: 25 Roncaglioni MC, Bertelt V, Pan@ J, Santom L, Tognoni G. Health inequalities in Italy. Collaborative Group of the Primary Prevention Project. Lancet 1997; 350: 1557-1558 Saltman RE3, Figueras J. Analyzing the evidence on European health care reforms. Health Aflairs 1998; 17: 8510s.

Schneider-BunnerC. La justice sociale duns les syst2mes de sunti euroeens. Paris, Fuwible, septembre 1995. SESl (FranceyDIRIS (Qukbec). Indicateurs sociosanitaires, comparaisons internationales, kvolution 19801994. Paris, Ministh de I’Emploi et de la Solidaritd, 1995,308 p. Townsend P. Davidson N, eds. The Black Report. London, Penguin Books, 1982, I85 p. Van der Stuyfl P. Woodward M. Amstrong J, De Muynck A. Uptake of preventive health care among Mediterranean migrants in Belgium. J Epidemiol Communic Health 1993: 47: 10- 13

Part 1. An Overview On Europeans’ Health Care Systems

57

Waddell C, Petersen AR. Just health: inequality in illness, care and prevention. Melbourne, Churchill Livingstone, 1994,424. Weissman JS, Epstein AM. Falling through the safety net. Baltimore, John Hopkins University Press, 1994, 185 p. Zenker HJ, Mohammadzadeh Z, Hilbert T, eds. Asylum seekers / refugees and health in the nineties. Proceedings of an expert meeting in Bremen, 9-10 May 1996. Bremen, Public Health Office, 1996, 1 19 p.

Table 1. Comparative data regarding the 8 European countries participating in the EUROPROMED project

r

1

population millions % '

undei 25 years old

10 2

58.3

XI.0

10.5

57.2

98

39 7

31 I

34.9

28.2

32.6

30.0

3s 0

34 2

7.2

17

1996

13

1997

15 6

11.1

15.2

15.0

16.0

I4 2

I4 8

14.8

13

1997

35 9

43.5

38.9

36.7

43. I

445

31

6

54.6

17

1995

181

2.13

1.65

1.91

1.70

192

1 84

1.73

9

1995

births outside marriage (per lo00 births)

113 1

332. I

148.8

26.4

67.8

I609

100 I

62.2

9

1992

(h urbdn population

97 0

72.8

86.5

65.2

66.6

35 6

76 5

60.8

2

1995

% foreigners

91

6.2

8.5

I .4

1.1

16

1 1

18.5

8

1994

4.3-13.9

6 7-46.0

2 5-3 2

5 8-126

ttal: 117.8

20

1994

8.21

21.1

10.014

14.141

39.048

%' >= 65 years old (h

d ~ t i v epopulation

tinal demndants for women born

in

I957

foreign immgrants EU, non EU (thousands)

GDPlinhab: thousands US$

27 0-28 9

24.336

11.3-52.8 167.6-627.4

25.19

26.885

consumption: ppdadult equivalent

8619

9940

9384

mean salary: elcapita

10653

1049 1

I2302

39.3

41 .9

49.1

(',m. no

per 100 inhab.

6587

17.6

6064

5978

3712

4812

20452

17

1 995

48.8

18.3

36.2

45.7

I1

1991

- 47

1.9

1.4

I .2

0.9

1.4

I .5

1.1

I .4

10 2 - 12.4

h 3 - 10.3

7.8 9.8

9.4 - 12.1

4.0 7.3

17 7 - 22.7

iineinployment rate: % ' 15-24 years old

22.9

28.9

9.6

31.0

33.S

16.7

41.9

temporary employment: 5% salaried employment

13.1

21.5

11.1

I8

10.9

16.1

povcrcy ratc: % ,

6.1

14.0

10.8

20.6

20.6

25.2

16

21

13

31

23

42

% t~ou~cholds with 3 housing problems o r inore

1988

4742

6.7 - 12.9

~

1996

7x55

uncmployrnent rate: n/r 1992 - 74- 1996

dependency ratio (ratio inactivdactive pop.)

1 9

~

13

1997 1992-96

12

1996

39.5

3

1995

16.7

9

1988

28

14

I 994

65 61

Greece

46 104

33 23

105

49.9 30

Spain

151

Portugal

38

Italy

98

20.9

11.4

20.6

56

6.6

39

27.2

9.7

13.8

49

8

25

2.5 20.9 64.0 3.6

8.2

5.8 34.2 40.1 5.2

963

15

59 13.4

10.0

20.7 42

8.0

18.1 26.0 42.6 1 .I

7.8

I000

76.3

56

Switzerland

9 19

source

1992

1995

1991-JV

year

87.7

80.7

78.3

69.9

59.8

76.3 32.4

5

19

1988

1990

1991

1995

1994

1

1991

17

17

5

9

2248

19

4,9

9.7

1 .I

8.0

8

21

I000

21

7.8

963

Germany

71

70 83

18

49 16.3 7.6 17.1

3.4

7.6

59.8

8.2

1402

z

1402

7.6

654

France

116 23

21 33.6

8.5

25.2

i$ f 69.9

17

5.9

I990

Belgium 65 57

13.3

55 4.7

2.7 14.9 66.8 I .2 5.9 654 82.9

17

10.5

I833

National data

93

17

18.8

10.5

78.3

I990

17 9.6

1549

Education

% of 18 year olds at school Secondary level of education (% 25-59 year olds)

24

17

no of post graduate women for 100 post grad. men higher level of education (% 25-64 years old)

% 25-29 year olds living with their parents

27.1

13.5

9

1.3

4.7

9.2 27.0 41.2 7.6

55 1.3

28.4

single parent families: 'YOfamilies 15.4

3.5

80.7

9

3.5

single person households: % households

poverty rate among single parent families: % 23

14

9.6

8. I 26.2 43.7 9.6

1 1.O

2.6

% 16-29 year olds in households with economic pb % of households with >= 6 persons

distribution: %

24.7 44.2 8.1

I833

7.9

87.7

1549

unemployment health elderly families

health care expenditudinhab: € pps

health care expenditure: YOGDP

health care expenditure: % of public expenditure

23

2.6

9.7 7.9

health care expenditudinhab: € pps

82.9

42

8.0

14

YOof households with >= 6 persons

18.1 26.0 42.6 1.7 9.2 27.0 41.2 7.6

39

6.6

1.7 25

3.4

% 16-29 year olds in households with economic pb

5.8 34.2 40.1 5.2 8. I 26.2 43.7 9.6

20.7 27.2

2248

lhealth care expenditure: % GDP

health care expenditure: % of public expenditure

7.6

2.5 20.9 64.0 3.6 2.7 14.9 66.8 1.2 1 1.O 24.7 44.2 8.1

unemployment health elderly families distribution: %

1991

8.5

2905

1994

5

13.3

205 1

19

13.5

4143 1562 5298

1988

9.7

16.3

20.9 17.1 25.2

11.4

21

33.6 single parent families: % families

18.8 15.4

13.8

17

27.1 % 25-29 year olds living with their parents

521 1

1990

9

20.6

24

28.4 single person households: % households

4834 lsocial assistance allowance per inhab: € pps

4,9

9 8.0 poverty rate among single parent families: %

59 49 56

49

10.0

1991

4 1995

5

e

19 32.4 13.4

year source Switzerland Spain

Portugal

Italy Greece

Germany France Belgium

National data

4

e 9

INatlonal data

Belgium

France

Germany

Greece

Italy

Portugal

Spain

Switzerland

source ~

_

year _

_

healfh care sysrem

no of physicians per I0 000 inhab.

37.4

28.5

32.8

38.8

physician consultations: annual meadinhab hospital beds: n"/l 0oO inhab. (X public)

8.0 7.6

6.3 9.0(64)

12.8 9.7(48)

5.0

22.8

19.9

hospital admission rate: YOinhab. national health system insurance system (Social secunty, private insurance)

29.3

(40.8)

31.0

1994(93)

-- 3.5

17 15

11.0 6.5(77)

3.1 4 3 (81)

6.2 40(83)

5.5

17

1994

13.5

16.0

11.5

10.0

16

1994

no

no

no

Yes

Yes

Yes

Yes

no

yes ( S S )

yes (SS)

yes (SS)

no

no

no

no

yes (pnvate)

1993

healfh profection system ~

~~~

health protection: YOpop. covered - YOreimbursement all medical care

99.0 - 85.0

99.5 - 73.9

92.2 - 91.0

100 88.0

-

100 - 75.0

100 -

99.5 * 90.0

99.5 - 90.0

17

1995

ambulatory care

94.0 - 72.5

98.0 - 57.0

92.2 - 90.0

100 - 85.0

100 - 73.0

100 - 100

99.3 -

99.5 - 78.0

17

1995

medicine

94.0 - 50.0 98.0 - 54.0

92.2 - 48.0

100 - 74.0

to0 - 65.0

100 - 65.0

99.3 - 75.0

99.5 - 43.0

17

1995

hospital care

99.0 - 92.0

99.5 - 92.0

92.2 - 98.0

100 - 95.0

100 - 85.0

100 - 100

99.3 - 100

99.5 - 100

17

1995

private insurance: YOtotal health expenditure

1.8

3.3

5. I

3.2

1.1

17

1993

private consumption of medical care and goods: Yoof total household consumption

12.1

10.3

3.5

4.4

7.2

5.2

4.9

11.1

17

1993

73.1 - 79.8

73.2 - 81.4

72.6 - 79.1

74.6 - 79.8

73.6 - 80.3

70.7 - 78.1

73.3 - 80.5

74.5 - 81.3

36.6 - 15.4 34.8 - 14.4

36.6 - 15.7

16

181

7

healfh data

life expectancy at birth: males, femalcs

36.3 - 16.2 35.0 - 14.6 37.3 - 16.1

male life expectancy: at 40 years, at 65 years tuberculosis mortality ratio

61

97

84

121

12.1

9.3

9.0

80

92

97

84

I 00

I29

88

33

41

32

40

32

26

36

30

9

21

10

potential life years lost before 70 years old by tuberculosis among men (per 100 000) utcrinc cancer mortality smokers

I5 years old: YO

regular alcohol consumer ( > I /week): % I I - I 5 ycars measlcs vaccinai coverage

I03

313

9

51.3

2.0

14

7

7

25

29

10

I2

66.6

77

70

76

so

96.4

88

17 7

1

3 1980. 1984

1992

lWl

Local data

Brussels

Paris

Bremen

Athens

Calgari

Lisbon

Valencia

Geneva

(Region) [Belgium]

(Ile de France) [France]

(Region) [Germany]

(Attica) "kxxel

(Sardaigna) [IblYl

(Region) [Portugal]

(Community) [Spain]

(Canton) [Switzerland]

2.1 (10.9)

0.56 (0.68)

(3.5)

(1.65)

(3.3)

(4.03)

0.4

(161)

(156)

(73)

(78)

(87)

(73)

495 13

19.1 (14.8)

(9)

(10)

(9)

(10)

(10.5)

4,13

(9.57)

4

Sources

demographic data ~~

population: mi I I i ons GDPhhab: pps (% EU mean) birth rate: per 1000 mortality rate: per 1000

8.9 (7.0)

unemployment rate: %

(10.7)

(11.4)

(11.9)

(21.8)

(8.9)

(2 1.5)

unemployment rate c 25 years: %

(24.7)

(1 5. I )

(34.3)

(49.3)

(21.5)

(39.3)

13

% single parent families

(3 1.7)

(1 8.3)

(1 8.7)

(1 5.6)

(1 4.2)

5

% population living with welfare allowance

8

13

2.1 (1.4)

8

(3.6) (8.3)

(4.4)

(6.0)

(1.8)

(4.0)

(3.9)

13

(10.5)

(7.2)

(6.0)

(4.3)

(3.2)

13

4 -

no doctordl OOO inhab. hospital beds/l 000 inhab.

f3.61 (8.7)

2 z lbreast cancer screening coverage: % targeted women

immigrants: % total population

(40)

(10)

(1 2.9)

15

(2.6)

illegal immigrants: no refugees: no homeless: no - % total population Roma: no drug abusers: no

(0.3)

(1.7)

[3500001 6 000

I

(65)

1.5

37

(1 2 500)

???

[50 0001

3 000 - 7.5

[8 0001

I5 000 - 7.1 I 000 - 1.79

( 1 million ?)

[ 120 to 250 0001

[400 0001

(31 525) 100 000

(53 400)

5

t Q\ 4

Sources

1 : Atlaseco, Paris, France, 1997.

2: OMSNHO, Geneva, Switzerland, 1996. 3: Enquete europkenne sur les conditions de travail, Luxembourg, 1996. 4: INSEE, Paris, France, 1995. 5: Eurostat. Annuaire 1996, Luxembourg, 1996. 6: OCDE/OECD, Paris, France, 1993.

7: Holland W.European community atlas of avoidable deaths, Oxford, UK, 1991.

8: Offrce Ftdtral de la Statistique, Berne, Suisse, 1998. 9: Eurostat. Portrait social de I'Europe, Luxembourg, 1995.

10: Centre International de Recherche sur le Cancer, Lyon, France, 1993. 1 1: International Road Federation, Geneva, Switzerland, 1992.

12: Commission Europeenne, Emploi 8c affaires sociales. L'emploi en Europe, Luxembourg, 1997. 13: Eurostat. Annuaire statistique des rtgions, Luxembourg, 1997. 14: Eurostat. Panel de menages de la Comunautt euro@enne, 1994.

15: OCDEIOECD, Paris, France, 1997.

16: OECD. Economic surveys: the health care issue, Paris, France, 1998.

17: OCDEIOECD-CREDES, Ecosantt (CDRom), Paris, France, 1998. 18: SESVDIRIS. Indicateurs sociosanitaires,Paris, France, 1995.

19: Eurostat. Les jeunes de 1'Union Europknne, Luxembourg, 1997. 20: Eurostat. Statistiques sur la migration, Luxembourg, 1996.

2 1 : Eurostat. Les femmes et les h o m e s dans I'Union Euro@enne, Luxembourg, 1995.

9

Part 2

Europeans’ Experiences

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Part 2. Europeans ' Experiences

65

Illegal immigrants in Spain Amparo Shchez Maiiez, Ma Luisa Dorado Garcia and Juan MonlCon Garcia Introduction

Over the last few years Spain has gone from being a country of emigration to one receiving immigration; the Moroccan trend is one of the most recent, the one with the fastest continuous growth, and one most generally undertaken clandestinely. This migratory flux, and in general that of Africans, primarily responds to escape factors related to the country of origin (political situation, poverty and health problems), rather than to attraction for Spain factors. However the economical and social development of Spain also helps this immigration, in particular that from Morocco, which is closely linked to work in the agricultural sector of the Mediterranean coast, and certain services. The information obtained from various publications and studies of these groups highlights the actual difficulties which they encounter, as well as the difficulties in attaining a satisfactory degree of integration. Some of the indicators of this conflictive situation in the migratory process are: - The high percentage of persons not regularised, neither as residents nor as workers. - The abundance of precarious marginal employment, which implies high residential mobility. - The difficult housing conditions. - The high percentage of immigrants with insufficient schooling. - The little, or no, attention paid to their professional training and learning Spanish. - A latent and at times manifest social rejection. Their arrival, as stated above, is not motivated by the employment attraction of Spain (with a high rate of unemployment), but rather they are pushed by the difficult situations created in their countries of origin. The balance of the adversities suffered on one and the other sides, incline these groups, in particular those from African countries, to opt for staying indefinitely in Spain. Nearly every day one can read newspaper reports of the tragic adventures of the "pateras" (rafts), in trying to cross the Straits of Gibraltar; or of traffic accidents with a high number of deaths because of overcrowded travelling conditions, or travelling in subhuman compartments prepared in the back of trucks and vans. The reports and studies undertaken of immigrants in Spain, corroborated by the official statistics available, show that the Moroccans are the community which is increasing the fastest and the most regularly. Their arrival being in general clandestine or irregular, their appearance in Spanish statistics is due to two extraordinary processes of legalisation of foreigners in 1985-86 and 1991. Thus, according to the Spanish Labour Ministry, there were 65 847 Moroccans residing in Spain in 1992, of whom 50 950 had work permits. However, these figures were inferior to the estimations made by the Ministry of Moroccan Foreign Affairs Abroad which estimated at 90 000 the Moroccans residing in Spain at that time. To the Moroccan workers with work permits must be added: the inactive (children and people over 65, who represent 18.5% of the total of the census) and those who recently acquired Spanish nationality. There is also a large group of workers who remain in an

66

Par? 2. Europeans ' Experiences

"illegal" situation and mainly work in agriculture on the Mediterranean coast, this group is constantly added to by other clandestine arrivals. The Department of Human Geography of the University of Alicante interviewed SO0 Moroccan and Senegalese immigrants, in order to determine their demographic characteristics and study the migratory process, it was observed that 56% came from cities of the ex Spanish Protectorate, close to Ceuta and Melilla. The impossibility of reaching other European countries of traditional labour immigration is a determining factor among 79% of the Moroccans interviewed who chose Spain as their first country of immigration. 86% of the Moroccans who were legalised in 1991 entered Spain as tourists, and only 4.8% did so with a working visa. The criteria for choosing Spain are accessibility factors, such as geographical proximity (30% of the Moroccans surveyed), ease of entrance, and the possibility of clandestine work, particularly in temporary agricultural work on the Mediterranean coast. Also, in comparison with other European countries, there are probably fewer controls on the part of the authorities. Another important motive in choosing Spain is the presence of family members, also workers, particularly for the Senegalese (46%). In fact 56% of the Moroccans and 64% of the Senegalese declared that in Spain they had family or friends who provided them with information or help for their emigration. As regards the groups of immigrants attending the Social and Health Care Centre (CASSIM) of MMicos del Mundo in the Valencian Community, they mostly stated financial causes as the main reason for emigrating fiom their country: - financial reasons 48.5% - family regrouping and financial reasons 20% - political reasons 17% - political and financial reasons 5% - health problems 6% The majority of the immigrants work in activities rejected by the active native population, because of the precarious working and payment conditions; these are activities on the outer fringes of the labour market, proper to the submerged hidden economy. There is a significant distance between professional qualification and the job performed in Spain by Moroccan women, Filipino women, and men fiom the Central African countries. The Filipino women, who make up 80% of the Filipinos in the city of Barcelona, are teachers, nurses, or matrons, and despite having higher education or technical certificates, they are in domestic service as "permanent maids" in the homes of the prosperous in Barcelona. The socio-demographic characteristics and problems vary greatly according to the country of origin. While a large group of South Americans declares university level professional qualifications, Central Americans declare the opposite professional category. The groups from Africa and Asia are characterised by living with others from their country of origin and also by their place of residence in Spain (Moroccansin Catalonia and Madrid, Filipinos and Chinese in Madrid and Barcelona, Indians in the Canary Islands, etc.). These are the largest groups of immigrants, with the greatest number of illegal or clandestine immigrants. As regards their housing conditions, the group of Third World immigrants presents a certain residential stability as regards the region or the city. The main reason for this is their low income level whether living alone (most of the Central Africans), or as families (the North Africans tend to emigrate with their wives and children, or send for them later). Another reason is the social rejection with which they are faced when they wish to rent housing belonging to a Spaniard. There is often a negative response to allowing North Africans. Central Ahcans or Pakistanis to move into apartments in well-to-do

Part 2. Europeans' Experie,nces

67

neighbourhoods, apart from these normally being inaccessible for the immigrants. Rents are in general very high in relation to the average incomes of these people. All of this means that they mainly live in the most degraded areas of the cities, occupying housing whose conditions are really unworthy, both as regards overcrowding and the conditions of the housing itself. Nearly all the housing rented to this group does not have a housing certificate (the technical and administrative certification awarded by the town-halls), as it does not meet the necessary hygiene-health conditions to pass the inspections of the relevant organisations. Despite this the rents are exaggeratedly high. There therefore exists an indirect but manifest complicity of the native population in housing speculation acts, bordering on criminal, by refusing to rent apartments to immigrants without objectivejustification, or by charging abusive rents. As regards their type of housing, among the population attended at the CASSIM, the following data were collected: - 43% live in rented housing - 27% live in the homes of family or friends - 15% live-in at their place of work - 7% live in NGOs or the administration's reception centres - 3.5% live on the street - 3% live in temporary housing Slightly less than 1% are in prison, in "third degree" situation (i.e. allowed out to work during the day). Health data: morbidity

The attended morbidity does not differ from that encountered among the rest of the general population, apart from the lower incidence of chronic disease, most probably due to the average age of this sector of the population, considerably younger than the national average. During 1997, Medicos del Mundo attended 799 persons in the city of Vaiencia, which generated 3 61 1 consultations. The pathologies diagnosed in this population are reported in Table 2. The Madrid Red Cross Programme for Refugees has performed a study of the prevalence of contagious diseases among asylum and refugee status seekers in this community. 1 280 persons were screened using tuberculin reaction, chest X-ray, and dual microbiology of sputum (microscopic and culture) among those presenting radiological alterations compatible with TBC, obtaining 0.56%of active pulmonary TBC among the 15 to 40 age group (a much lower prevalence than that found among the general population, which is 26-27%). Socio-demographic data

The foreign population of legal residents increased steadily between 1982 (200 91 1 residents) and 1991 (360 655 residents, National Statistics Institute, ME). For 1995 the INE logs 499 773 foreign residents, of whom 200 130 are from Third World countries. This statistic does not include the under-age dependants of adult residents, nor persons without legal status, nor students. Moroccan immigrants are, at present, the most numerous foreign colony: 65 843 on December 31" 1993, of whom 42 193 held valid working permits, and 23 650 did not.

Part 2. Europeans’ Experiences

68

Table 2. Distibution of the diagnosis reported in patients attending tbe Maicos del Mundo clinic in Valencia, Spain, in 1997. Diagnosis

Diagnosis

Infectious and parasitary diseases

I Yo

Genito-urinary apparatus illnes (incl. breast)

I%

TBC

1 Yo

Urinary appamtus illness

3yo

Endoc., Nutrit., Metab., Immun. diseases

1 Yo

Male genital organs

1 Yo

Blood and hematopoyetic organ diseases

1 Yo

Female breast and genital organs

2% 6%

Mental illness

3Yo

Menstrual changes or gynaeco. complaints

Nervous system disorders

3 yo

Pregnancy

3%

Eyes

3Yo

Family planning

7 OO/

Ears

1 Yo

Voluntary interuption of pregnancy

2%

Circulation problems

1 Yo

Skin and subcutaneous tissue

6?’0

HTA

4%

Locomotive and connective tissue

9%

Respiratory illness

1 Yo

Undefinsigns, symptoms and pathologies

IO h

Respiratory infection

7%

Poisonings, accidents and violence

1 Yo

Digestive system ilness

9%

Surgical pathologies

1 010

Oral Droblems Source: Memoria CASSIM 1997 Mkdicos del Mundo Comunidad Valenciana

4%

According to the November 1997 Mkiicos del Mundo report, it is estimated that, in Spain, there are at present more than 100 000 illegal immigrants, mainly h m Afiica (Northern and Sub-Saharan), Latin America and Eastern Europe. We do not have recent or precise demographic data, but the survey of 500 immigrants performed by the Department of Human Geography of the University of Alicante, coincides in that it is a young group, 77% are between 20 and 34 years old, and more than a third are between 25 and 29 years old. 62% are single as opposed to 36% living as couples, though both groups maintain their families in their country of origin; 69% of the spouses and 77% of the children are in the country of origin. Madrid, and in second place Barcelona, are the main enclaves of immigrants in irregular situations, (leaving aside Ceuta and Melilla which would probably be the cities with the highest migrational density: 34% of the population, if the North Africans without a National identity card were counted as immigrants in irregular situations). Mddicos del Mundo is carrying out a social and health care programme for immigrants without income throughout Spain (CASSIM) and, in 1996, 7 577 persons attended the Centres in Madrid, Seville, Valencia, Gij6n and Oviedo. Most of these people are men, except in the Madrid centres, where the majority are women. The average age is between 20 and 39 years old. In 1985 the government passed a law which included the immediate performance of an extraordinary regularisation of the insufficiently documented foreigners, this was requested by 43 815 immigrants. This figure was considered very insufficient compared with the estimated volume of insufficiently documented foreigners, as it represented only 18% of all the foreigners living in Spain. The 1991 regularisation of foreign workers and their families produced more satisfactory results than the previous one. This was not only due to the experience acquired before but also to the government’s media campaign supporting regularisation, and the activities of the NGOs that help immigrants. In total 133 328 requests for regularisation of workers were presented. Of these 108 321 were accepted. and 22 085 refused (because the persons making the request could not prove that they had been living in Spain since before

Part 2. Europeans' Experiences

69

May 15th 1991). The remaining requests were filed as they were from EEC citizens for whom this regularisation was not necessary. More than 5 000 residence permits were awarded to family members and dependants, living in Spain, of regularised workers. The greatest number of regularised workers were immigrants of Moroccan origin: 48 240 which corresponded to 45% of the total, as was the case in 1985. Refugees and asylum seekers are the foreigners for whom there are the most specific and official services. On July 22nd 1978 Spain adhered to the United Nations protocols regarding refuge and asylum. At a later date the Spanish State promulgated a norm of its own, Law 5/1984, regulating the right to asylum and to the condition of refugee in Spain. Apart from the legal privileges which the above mentioned norm regulates, refugees and those awarded asylum receive some health, educational and social services. The latter consist of temporary housing and maintenance, information and assistance. These services are provided by the National Institute of Social Services (INSERSO) and, in a concerted regime, by the Red Cross, the Comision Espanola de Ayuda a1 Refugiado, and the Asociacion Comision Catolica de Migracion. Foreigners who have not been awarded the special condition of refuge or asylum not only do not receive private attention; they do not even have the right to use the public services that the nationals are entitled to. In reaction to this circumstance two assistance initiatives have been undertaken. On the one hand, certain voluntary entities such as Asociacion Comision Catolica de Migracion, the Asociacion de Solidaridad con 10s Trabajadores Inmigrantes (ASTI), the Movimiento Andaluz Pro-Inmigrante (a programme of Andalucia Acoge), certain Diocesan Migration Delegations, certain Diocesan Charities, Sindical Organisation Services, and, since 1994 Medicos del Mundo with the CASSIM programme of socio-health assistance for immigrants in irregular administrative situations. On the other hand, the immigrants themselves, on occasion in collaboration with Spanish citizens, are creating mutual assistance or ethnic solidarity associations. Children, thanks to Law 1/96 of January 15th 1996, have the right to public education, and the social security's general scheme, whatever their legal and/or administrative situation.

Bibliography Actis W, de Prada MA, Pereda C. La inmigracihn extranjera en Catalunya. Barcelona: Institut Catald d'estudis Mediterranis, 1993. Anonymous. Dossier "Les marocains duns le monde". Rabat, Rivages, 1993. Anuario Instituto Nacional de Estadistica 1996. Arag6n R. Hacia una politica activa de inmigracibn. Revista de Economia y de Sociologia del Trabajo 1991; 1 1: 97-108. Blanco Ferndndez de Valderrama C. The new hosts: the case of Spain. International Review 1993;32: 12191227. Gonzalvez Perez V. lnmigrantes Marroquies y Senegaleses en la Espaiia Mediterranea. Vaiencia, Generalitat Valenciana, 1995. Leman J, Gailly A. Therapies intercuturelles.Bruxelles, De Boeck-Wesmael, 199 1, Lluch J, Serra L. Fuentes de datos y sistemas indicadores en la Comunidad Valenciana.Valencia, Generalitat Valenciana, 1995. Marrodtin MD, Prado C. Las migraciones: su repercusibn en la sociedad y en la biologia de las poblaciones humanas. Madrid, Ed. Universidad Autbnoma, 1994. Marrodiin MD, S b c h e z And& A., et al. La mujer inmigrante en Espaila. Caracteristicas epidemiolbgicas y factores de riesgo. In: Nuevas perspectivas en Antropologia Biolhgica. Granada, Diputaci6n Provincial, 1995.

70

Part 2. Europeans' Experiences

Solas O., Ugalde A. Inmigracibn, salud y politicas sociales. Granada, EASP, 1997.

Tanner JM. Hormonal, genetic and environmental factors controlling growth. Oxford, Oxford University Press, 1988. Tapinos GP. Immigration fiminine et statut des femmes Ptrangsres en France. Paris, lnstitut National d'Etudes Demographiques, 1990.

Part 2. Europeans’ Experiences

71

Tuberculosis in an Indian community in Lisbon Rui Gentil Portugal The Indian Community

In the centre of Lisbon there is a large community of Indian people living in a slum at Alto do Pina. This community started in 1975, just after the Portuguese revolution and African de-colonisation. Around 1 million Portuguese arrived in Lisbon from 1975 to 1977, mainly from the Portuguese colonies of Angola and Mozambique. This latter country had developed a very close exchange with people from the Indian Sub-continent, thus many of the Portuguese who requested to come to the mainland during de-colonisation were of Indian origin. This community was traditionally involved in trading. On arrival in Lisbon, the country did not provide lodging for everyone, people therefore started to build their own houses in very deprived conditions and without authorisation. The last census done in that area was in 1994, of a total of 4 000 inhabitants 41% were of Indian origin. The other inhabitants were mainly people from Africa ethnically classified as either Europeans or Africans. Today the population is being re-housed in new flats in the Lisbon area. A survey was performed of the housing conditions and found the following characteristics: 90% had electricity, 88% had running water, 77% had sewage services and 90% had a kitchen. Literacy was discovered to be very low in this population and a substantial number did not speak or understand Portuguese. The houses of the Indian population had a high occupancy rate with a very high density and were often shared by different families. At present there is a new immigration movement of male construction workers. One of the houses visited had rooms of no more than 10 square meters (without windows) occupied by eight men! (Some of them are not allowed to work or live in Portugal). The Indian community has its origins in DidFudam a Portuguese ex-colony characterised by a doubIe immigrant movement, from India to Mozambique and from Mozambique to Lisbon. The Indians are mainly Hindus, but some are Catholics (those from Goa) and some others Muslims. It is interesting to see that their names are like fingerprints of their religious origins. The Hindu population is predominant and maintains its culture and language (Gujarati). There are two different Indian populations: the first which came after the revolution and the independence of Mozambique, and a more recent one which immigrated for economic reasons but has strong ties with the first community. The latter population does not usually have Portuguese nationality but this is a minority. Tuberculosis in Alto do Pina

Health Authorities in Portugal have the duty to monitor the infectious diseases for a particular region, using compulsory declaration of infectious diseases. There is a list of 42 different diseases including all forms of tuberculosis. The Health Authority of Alto do Pina verified that the number of cases of tuberculosis for a particular area was 4.2 times greater than in the rest of the region. It also appeared that almost all the patients had Indian names. It was therefore decided that for a preventive intervention in tuberculosis the population of Alto do Pina was the priority. Note that the incidence rate of tuberculosis at that time (1994), in the Lisbon region, was over 55 per 100 000 inhabitants.

72

Part 2. Europeans ' Experiences

Tuberculosis prevention guidelines were in practice at a national level. and these were implemented in this area with a natural specificity of the population. The main objectives for prevention at a national level are: - vaccination of all new-born babies; - screening for special populations, including direct contacts of patients; - adequate treatment; - declaration of the disease to the Health Authority; A number of intervention activities were planned in order to identify new cases of tuberculosis and to have a more effective preventive strategy for the disease in that particular area. These activities were: - public health surveillance of tuberculosis in Alto do Pina; - tuberculosis vaccination in Alto do Pina - health education in tuberculosis - medical training in tuberculosis - mass screening in tuberculosis - diagnosing new cases of tuberculosis Community Participation

In order to put this plan into practice, prior contact was made with the leaders of the Hindu community to explain this population's greater risk as regards tuberculosis. These contacts were made with the help of the municipality leaders: "fieguesia". Their support was crucial in the discussions of what to do to prevent tuberculosis, and in order to perform mass screening. Posters and pamphlets in Gujarati and Portuguese were distributed, talks took place in the cafe with the leaders, and mass screening was performed in one of the Hindu houses of the area where 70% of the estimated Indian population lived. The screening project was a tremendous success as regards adherence. The Hindu community, which has a very strict hierarchy, obeyed its leaders in an astonishing way. Without them the project could not have been undertaken. Every new member of the community arriving fiom India was invited by the community to go to the health services for tuberculosis screening. As a result, 10 of the 1 300 persons screened were diagnosed as having tuberculosis. Half of them were persons living in very densely occupied houses (> 15 personshouse) and most of them where illegal immigrants. The cost for the health service for each patient diagnosed was about 8 10 €. This project produced some indirect impact with the organisation of the health centre. After that programme, doors become much more open and that population started to have a positive discriminative attitude fiom health professionals regarding their access to the health centre.

Part 2. Europeans' Experiences

73

The Bremen Health Programme for Asylum Seekers and Refugees Zahra Mohammadzadeh

Introduction In 1996, war refugees in Germany numbered 340 000, most of them from Bosnia, while there were 120 000 asylum seekers from a variety of African, Asian, Latin American, and Eastern European countries; in 1997, 103 000 new applications were added to this number. Of these new applications, as well as of any number of newly arriving war refugees, the Free Hanseatic City of Bremen, as the smallest of the federal states, is taking 1%, according to a quota agreed among the sixteen states. Thus, in 1997 1 030 new asylum seekers were added to the roughly 6 000 asylum applicants and war refugees already living there. Currently, it is difficult to give an exact figure for the size of this population group. The number of war refugees, mostly Bosnian, in Germany is changing at present because a portion of them is being repatriated, if at a slow rate. Some of these, however, are returning to Germany because of lack of subsistence in former Yugoslavia, while others are reentering Germany as asylum applicants. The number of asylum seekers is changing, too, both because of turned-down applications and subsequent deportation or voluntary departure and because of new applications. The rate of new applications has gone down in comparison with former years, due to harsher legislation. Therefore, although the exact number of new applications for 1997 is known, it is not straightforward to state how many asylum seekers have left the country since then. Also about 20% of what are called 'hew applications" in official statistics are really babies born to asylum seeking parents in Germany. The number of people staying in Germany as illegal residents poses another problem: the so-called illegal immigrants. There are no official figures but it can be assumed that a high percentage of rejected applicants and Bosnians to be repatriated remain in the country illegally. In the context of the Bremen Health Programme for Asylum Seekers and War Refugees, only people in mass accommodation are relevant. Taking November 1997 as an example, the number of asylum seekers in Bremen hostels amounted to 1 638, while 812 war refugees were housed in this type of accommodation. The Bremen programme started in 1993. Its main components are: - in the case of asylum seekers, using the "first contact" medical examination required by paragraph 62, Asylum Procedures Act, to check their general health status and diagnose any traces of specific diseases and disorders; - for both asylum seekers, and war refugees, follow-up checks and doctors' advice both on health problems and on health-relevant factors such as accommodation, nutrition, hygiene etc. - if diseases or disorders are diagnosed, immediate treatment in minor cases - in case of more severe symptoms, referral to general practitioners, specialists of public health facilities for the appropriate treatment or further diagnostic measures; - the scientific evaluation of the examination procedures and results. In Germany, health provisions for asylum seekers and war refugees are fairly restricted. A special law, the Asylbewerberleistungsgesetz(Asylum Seekers Social Benefits Act) proclaimed in June 1993 but made even more restrictive since, reduces medical care for these groups to acute diseases and painful conditions, plus some provisions for pregnant

74

Part 2. Europeans' Experiences

women and mothers with new-born babies as well as for immunisation measures. In Bremen, however, a health programme has been designed for these people on the basis of another law, the Asyherfuhrensgesetz (Asylum Procedures Act). This requires migrants living in mass accommodation - as they are obliged to do at least in the first year of their stay and sometimes longer - to undergo a medical check for infectious diseases. But the Act leaves the scope of the examination to the responsible Federal State authority. Between June 1993 and the end of 1997, more than 7 000 consultations were carried out in the programme, with almost 4 000 people consulting the physicians providing consultations, on a voluntary but reguIar basis, both in the reception centre for asylum seekers and in the refugee hostels. Acceptance of the programme in the hostels varies between 60 and 70%. Most of the people consulting the programme have been in Bremen for less than one year. Those undergoing the first-contact check-up in the reception centre have been there, as a rule, for less than six weeks. This means that the diagnoses observed only disclose part of the real problem, as the statutory asylum procedure occupies the applicant to such an extent in the initial months that certain health problems may well be suppressed during this period. In any case diagnoses leading to referral are considered preliminary, as further diagnostic measures are taken by the physician or public health facility the patient is referred to. There is at present no systematic evaluation of what happens to the patients after referral but the hostel doctor does receive and file the reports from the doctors reterred to. The sex ratio of asylum seekers and war refugees consulting the programme has remained roughly 8 to 2 throughout the programme. The distribution of age groups for 1996 (which is roughly representative for the total period in which the programme has been operative) shows that the vast majority (68.3%) is concentrated in one age group, the seventeen to thirty-four year olds. Adding this to the next largest group, 35 to 50. 8 1.6% are between 17 and 50, and only 13.8% are youths or children. There were very few patients in the over 50 bracket; this is a realistic reflection of the age structure of the total group of refugees. The scope of the programme does not allow for a detailed medical history of the patient to be compiled. Only in some cases, when a certain context is quite obvious. physicians will register a problem going back in the patient's past. For instance, alcoholism and smoking are grave problems, especially in certain groups, for instance, those coming from Eastern European countries. This general observation was also underlined at the "Third Federal Congress on Poverty and Health,Mental Health and Migrants Section", held in Berlin from December 5th to 6th, 1997 (Table 3). Previous traumas occur, we know. at a much higher level than the 2.3% stated in the following table. One problem is that our physicians are not really able to diagnose the sequels of torture or other experience of violence unless they are very obvious (wounds, scars etc.); according to all experts, this requires special qualifications and experience. Secondly, the consequences of traumatic experiences -just like many mental problems - often only become manifest at a later stage, while most of our patients consult the programme, as was said, in the first year of their stay. In other years of the programme - these data are taken from 1996 - traumas or their sequels were observed in up to 5% of the patients, even without systematic diagnosis. At an international expert meeting organised by the Bremen Public Health Ofice on "Asylum Seekers, Refugees and Health" in May 1996, participants reported estimates of up to 25% for traumatised patients in certain groups such as refugees fkom former Yugoslavia. A Bremen refbgee mental health counselling service (Refugio) reported a growing number of consultations between 1994 and 1996, with 85% of traumatised victims of torture and other organised violence.

Part 2. Europeans' Experiences

75

Table 3. Distribution of health problems reported in the population attending the asylum seekers and war refugees programme in Bremen, Germany, in 1996. Diagnoses

No

YO

Respiratory system Digestive system

453

70.0

207

32.0

of which: dental problems Unclear symptoms Mental disorders Factors influencing health Musculoskeletal system Skin Injury Infections and parasites Circulatory system Eye and adnexa Genito-urinary system of which: kidneys, urinary female organs male organs External causes Ear and mastoid process Selected infectious diseases* Torture sequelae, trauma Nervous system Endocrine diseases Pregnancy Blood and blood-forming Malformations Neoplasms

66

10.0

175

27.1

125

19.3

111

17.2

95

14.7

70

10.8

70

10.8

42

6.5

42 38 33 21 9 3 31 23

6.5 5.9 5.1 3.3 1.4 0.5

15

498 3.6 2.5 2.3

13

2.0

12

1.9

16

9

1.4

5

0.8

1

0.15

1

0.15

* This category was specially formed for the evaluation, extracting some selected infectious diseases from ICD category A00-B99. They are those diseases playing some part in the public debate about health risks claimed to be imported by migrants. Thefigure presents confirmed diagnoses only. We have little knowledge of cardiovascular problems in this group, other than the 2.5% shown in the table. It is generally known, though, that migrants tend to display a higher rate of cardiovascular disturbances than the indigenous population. One weakness of the programme under the circumstances is the lack of insight into chronic conditions and diseases in our patients, who usually do not stay with us long enough for relevant data to be compiled. Drug abuse, again, is not systematically diagnosed, but we do know that it is a sizeable problem with certain groups. No HIV tests are performed in the Bremen health programme, so our figure for sexually transmitted disease (1 % in 1996) does not include that. This percentage is part of the 6% for "selected infectious diseases" presented in the previous table, as is tuberculosis where 52 people (8%) were found to have symptoms indicating they might have the disease. None of these, however, were confirmed in the subsequent diagnostic procedure. The Bremen experience does not confirm the assumption of a generally high prevalence of infectious diseases, especially tuberculosis (Table 4), in asylum seekers, reported elsewhere. According to our data, only certain groups are apparently higher risk

P a n 2. Europeans’ Experiences

76

groups, such as the Bosnian group. After a number of cases of confirmed tuberculosis were observed among refugees in a hostel not participating in the health programme (see following table), a TBC prevention programme was designed for Bosnian refbgees in Bremen, in which 428 persons were examined. No additional positive cases were found, however. As for AIDS, 4 persons consulting the health programme in 96 asked for special advice on HIV and AIDS. On the subject of prevention, the health programme cannot include systematic measures in the course of consultations at the hostels. Advice is, of course, given by the physicians in individual cases, especially on women and children’s health, dental care etc. In addition, an AIDS prevention project was recently organised in one of the Bremen hostels.

Table 4. Tuberculosis data for migrants according to status of residence, Bremen,Germany, 1996. Status

No

YO

Asylum seekers

8

19

War refugees Eastern European Germans

6

14.3

8

19

OtherRJnknown

20

47.6

No systematic procedure has yet been developed for systematic immunisation, although allowed for by the Asylum Seekers Social Benefits Act, mainly for financial reasons. However, children of migrant mothers who take part in the regular paediatric prevention system (U1 - U9) will receive the usual vaccinations from the paediatrician. Similarly, refbgee children who go to regular schools will benefit from the Public Health Office’s school medical service. There are no provisions at present for nursing care regarding this group. A special problem is posed by unaccompanied youth. About 300 of them live in a separate Bremen hostel with special social care for juveniles offered by a welfare organisation. There is no specific health insurance for asylum seekers and war refbgees in Germany. The cost of medical care for these groups is covered by funds of the Federal State authority responsible. In Bremen, this is the Senator of Women’s Affairs, Health, Youth. Social Affairs and Environment.

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Evaluation of the impact of trauma and torture on asylum seekers: the Geneva experience Louis Loutan

Background The 26 cantons of Switzerland enjoy autonomy as regards the reception and the medical assistance of asylum seekers. Since 1996, the major "common denominator between the 26 cantons is that all the asylum seekers have access to medical insurance, which gives them the same access to health care as the Swiss or other legal residents. The reception and organisation of medical care varies from one canton to another. In Geneva, the medical policlinic (Department of Community Medicine, University Hospital of Geneva) is in charge of performing the medical entrance examination of asylum seekers (over 17 years old) assigned to the canton within 15 days of their arrival. Progressively, doctors and nurses realised that the sequels of violence were not uncommon among asylum seekers, impairing their ability to adjust to the new environment and leading, in the most severe cases, to repeated, ineffective hospitalisations for somatic complaints. It was then decided to conduct a systematic investigation of exposure to trauma among the newcomers. There were two objectives: a) to document the prevalence of severe trauma among asylum seekers, and their symptomatic profile; and b) to evaluate whether asylum seekers exposed to torture had more severe psychological sequels than those who had not been exposed. 'I

Methods Over a 9-month period, 573 asylum seekers were interviewed shortly after arrival in Geneva, using a questionnaire to collect information on physical and psychological symptoms and previous exposure to traumatic events. Before starting the study, a number of instruments measuring the psychological impact of trauma were considered for possible utilisation. However, such questionnaires were too long and complex to be easily administered in a general practice setting, considering also that no additional resources (in terms of personnel, interpreters, etc.) were available to conduct this survey. Accordingly, a short questionnaire containing questions on traumatic events and current symptoms was developed, and tested at the Policlinic for a few months. The questionnaire in its final form contained three main sections: 1) basic demographic and social information; 2) a list of 16 physical and psychological symptoms that the person may have experienced in the last week; and 3) a list of 8 traumatic events that the person may have experienced before his or her arrival in Switzerland. Many of the items in Sections 2 and 3 were selected from two instruments measuring anxiety, depression, post traumatic stress disorder and traumatic events, the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25, while others derived from the clinical experience of the staff working with asylum-seekers. The sixteen symptoms composing the questionnaire were the following: stomach pain, headache, back pain, joint pain, pain in the thorax, palpitations, shortness of breath, dysuria, lack of appetite, being anxious or irritable, difficulty concentrating, loss of memory, sadness most of the time, insomnia, nightmares, and recurrent and involuntary memories of past events. The symptoms were rated in three categories: "absent" (score=O), "a little or sometimes" (score=l), and "extremely or very of'ten'' (score =2).

78

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Eight traumatic events commonly experienced by asylum-seekers and refusees covered a range of events from detention, severe beating, torture and loss of family members. The events were rated as experienced or not experienced. A trained nurse administered the questionnaire, as part of the medical entrance examination. The interview was conducted in the language most familiar to the asylum seeker out of the five spoken by the nurses (French, English, Italian, Spanish and German), because interpreting services were not routinely available. The checklist was easy to administer and it usually required 15 minutes per person. Before the interview, the purpose of the checklist was explained, and the voluntary nature and confidentiality of the information were stressed. For the purpose of the analysis, only symptoms rated as having been present to an extreme degree or very often (score=2) were considered. Differences between subgroups of asylum seekers exposed and not exposed to torture were measured by chi-squared test. All p-values reported are two-sided. Results

From May 1 1993 to January 3 I " 1994, the checklist was administered to 573 consecutive adult asylum seekers attending the Medical Policlinic for the medical entrance examination. Of these only two refused the interview. The main sociodemographic characteristics of the sample are summarised in Table 5 .

Table 5. Main socidernographic characteristics of the s t u d y sample (573 asylum seekers in Geneva, Switzerland, in 1993B4) Age median 25th percentile 75th percentile Other characteristics gender female male education illiterate primary education secondary education university marital stahis single married divorced widower religion muslim Christian other continent of origin Africa Europe Asia Americas other

YearS

27 22 33 no.(%) 208 (36%) 365 (64%) 70 ( 12%) 150 (26%) 279 (49%) 74 ( 13%) 3 13 (55%) 230 (40%) 9 (1%) 21 (4%) 375 (66%) 134 (23%) 64 (1 1%) 250 (44%) 2 10 (37%) 9 8 (17%) 10 (2%) 5 (4%)

Table 6 summarises the type of traumatic events reported by the sample interviewed. Overall, 353 persons (62% of the entire sample) reported having experienced traumatic events, 20% only one, and 42% two or more. Imprisonment, murder of family members, severe beating and lack of shelter, food or water were the events most frequently reported. Torture was reported by 18% of the sample (27% of men and 3% of women), often in association with other traumatic events. in particular severe beating (in 90% of

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asylum seekers who reported torture), imprisonment (87%), and lack of shelter, food or water (69%). Self-reported health status was considered poor by 17% of persons who did not report any traumatic event, by 35% of those who reported at least one, and by 38% of those who reported torture. Table 6. Traumatic events reported by asylum seekers in Geneva, Switzerland, in 1993/94. Taking part in or being exposed to war actions Imprisonment Lack of shelter, food, or water Severe beating Torture Rape/sexual violence Murder of family members Disappearanceof family members %

No

YO*

66 186

12

147 173 104 13 178 95 * more than one event could be reported by each subject.

33

26 30

18 2 31 17

Over one third of the sample (37%) reported having experienced at least one symptom of severe intensity over the previous week; in almost three quarters of the cases, the symptom(s) were exclusively of a psychological nature. Out of the somatic symptoms, headache was the most commonly reported (9%), followed by stomach ache (4%) and loss of appetite (4%). Of the psychological symptoms, sadness most of the time (1 l%), insomnia (1 1%) and anxiety (10%) were most frequently mentioned. We further explored the symptoms profile of persons who reported having been tortured, because of the extreme nature of the trauma, and of the simultaneous exposure to other traumatic events. Overall, persons who reported torture had a higher fiequency of psychological symptoms than those who did not ( 5 1% versus 2 1% respectively, p 75 ml./day). Synthesising the data from this study we find that: 42.3% did not consume any drug. 36.5% consumed one, 14.0%consumed two and 7.2% consumed three or more. The type of drug consumed varies widely depending on the pattern of consumption, for example heroin users generally consume various substances. whereas when only one substance is consumed it is generally tobacco. The characteristics of the results of this study would be that: - Men are the biggest consumers of various substances: tobacco. alcohol. cannabis, heroin, cocaine and synthetic drugs. - Women consume more psycho-pharmaceuticals though we must also take into account the daily smokers (26.3%)and the excessive drinkers (4.7%).Tobacco and alcohol consumption reach high percentages, close to those of the men. among young women, and the 15 to 18 year old group smoke and drink excessively, even more than the men. - Tobacco consumption peaks between ages 25 and 34 and alcohol between 19 and 34. - Cannabis, synthetic drugs, heroin and cocaine are basically consumed by young people. - Psycho-pharmaceuticals are basically consumed by slightly older persons. - Tobacco, alcohol, cannabis and synthetic drugs are widely used among all social classes in the Valencian Community. Cocaine in the middle and upper classes, heroin in the lower or middle-lower classes, and psychotropes in the lower classes and all the strata of the middle classes. In 1997 MDM published a study of 821 substance injectors in Madrid. Seville and Valencia, which confirmed that high percentages of drug abusers have several years of experience in injectable consumption, low educational levels, and precarious financial situations. In Seville there is a greater prevalence of crack use among IVDA (which has

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I 05

been linked with a greater frequency of high-risk sexual behaviour) and sexual relations with non-IVDA than among IVDA in Madrid and Valencia.

Health data The social security’s general system cares for the general pathology, and that derived from consumption, of drug abusers, as for the rest of the population. We have no data regarding morbidity among this population, other than Aids data. It must be remembered that Spain is the European country in which the Aids epidemic linked to drug abuse was the most intense. According to the National Registry of Aids cases, 32 903 cases of Aids related to drug abuse had been diagnosed in Spain by the end of June 1998; this represents 64.15% of all the Aids cases diagnosed up till then. In the MDM study it appeared that more than 86% of the IVDA had had some test to detect HIV antibodies, the prevalence of seropositivity varied from 30.1% in Seville to 43.2% in Madrid. A major problem linked to HIV infection and IVDA is tuberculosis (pulmonary or disseminated). We have no data of its prevalence among the IVDA group, but we do know that it is present in 40% of the diagnosed Aids cases in this group. Its fiequency increases if only IVDA who have been in prison are analysed. A study of 126 IVDA in the city of Barcelona shows that the prevalence of tuberculosis infection was 39% and HIV infection was 64% with a co-infection of 29%, chemoprophylaxis compliance was 67%. According to a 1996 study of heroin consumers in treatment, it is estimated that 61.7% of heroin consumers admitted to treatment were infected at that time by the Hepatitis C virus, and 45% by the Hepatitis B virus. Table 8. Substance motivating admittance to outpatients treatment for abuse of, or dependency on, psychoactive substances, Spain, 1996 Substance motivating admittance to treatment Heroin Other opiates Cocaine Amphetamines MDMA and other feniletilaminederivatives Other psychostimulators Barbiturates Benzodiazepines Other hypnotics or tranquillisers Hallucinogens Cannabis Volatile inhalants Other psychoactive substances Total

No. 47148 795 2 992 317 226 16 15 171 19 74 1598 19 19 53 409

YO 88.3 1.5 5.6

0.6 0.4 0.0 0.0

0.3 0.0 0.1 3 .O 0.0 0.0 100

The use of illegal drugs (in particular injected heroin), is at present one of the main causes of death among the young in the big cities in Spain. The two main causes of death of opiate and cocaine consumers are Aids and acute reaction after consumption. According to the State Information System on Substance Abuses, in 1996, 53 409 persons were admitted to outpatients care for abuse of, or dependency on, substances other than alcohol or tobacco. Of these 39.4% were admitted for the first time, and of all those admitted 50 935 (95.4%) were for opiates or cocaine dependence.

Part 2. Europeans' Experiences

Table 9. Admittance to treatment for abuse of, or dependency on, psycboactive substsncts: substance, average age at start of consumption, proportion of women, Spain, 1996.

Substance motivating admittance to treatment Heroin Other opiates Cocaine Amphetamines MDMA and other feniletilamine derivatives Hypnotics or tranquillisers Cannabis Hallucinogens

Average age on admittance 29.3 31.5 29.3

Proportion of women

20.6

Average age at start of consumption 20.6 22.3 22.3 19.5 18.1

35.3 24.7 23.3

26.4 17.0 17.5

44.6

24.5

(YO)

15.6 21.0 14. I 23.5 19.5

11.3

15.1

Source DGPNSD State Information System on Substance Abuses (SEIT,,

Socio-demographic data

Approximately four out of five opiate consumers are men. Most of them are single, but the proportion of legally separated or divorced consumers is relatively high, particularly among women (18.3% of the women and 9.3% of the men). 38.9% has at least one child (61.3% of the women and 34.2% of the men). In general, they have a low educational level, only 14% completed secondary education or university studies. Most of the users of MDM's Syringe Exchange Programme are unemployed men; their average age is 29.3 years old; 86.2% lived with their family the year preceding the treatment. During the month preceding the treatment 58.90h were unemployed. The majority is self-employed, mainly in illegal activities. Main activities of the Secretariat of the National Aids Plan in relation to IVDA

In order to increase and diversifl the risk prevention programmes, destined to diminish HIV transmission among IVDA, 15 collaboration covenants were signed with 15 Communities; 45 million pesetas were allocated to this activity. The programme of financial aid or subsidies to NGOs for the prevention and control of HIV/Aids has two sources of funding: - The Ministry of Health and Consumption which, through the order of March 28' 1996, allocated 150 million pesetas to the 139 HIV/Aids prevention programmes of 78 organisations. In this fiamework it defined IVDA as a priority, subsidising 25 projects aimed at this group, to the amount of 36.5 million pesetas. In 1998, the subsidy was of 85 million pesetas, allocated among the Autonomous Communities, according to the number of AIDS cases. - The Ministry of Labour and Social Affairs which subsidised 19 entities and 23 programmes for the creation and development of reception houses and home help for Aids patients, many of them drug abusers, at a total cost of 385 million pesetas. An Aids prevention campaign was carried out in the major media with a budget of 225 million pesetas. Detoxification and methadone programmes have also been developed within the penitentiary system.

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The advisory service on sexually transmitted diseases in Bremen Gabi Siebenmorgen Introduction

The legal basis of the advisory service on STD at the Bremen Department of Public Health is the 1953 Act on the Prevention of Sexually Transmitted Diseases. In 1962, the advisory service was restructured. The aim was to use a certain freedom to interpret existing regulations in order to abolish mandatory checks and other police measures against male and female sex workers. At the same time medical care offers were extended. In addition to the typical range of sexually transmitted diseases included in the legislation, medical checks and, if necessary, treatment can now be provided for all important sexually communicable diseases according to individual needs. An important task of the advisory service is STD prevention. Information programmes are developed specifically for each group addressed. In this way, the information medically required can be integrated into the special psychosocial framework of the group concerned. The people concerned are thus more likely to accept the changes in sexual behaviour necessary for prevention. Personal advice is offered both in the centre and in the form of street work, as the clients’ needs may suggest. The formulation of standards for advisory activities has facilitated access to individual clients. All the activities of the advisory service are anonymous and fiee of charge. Advisory service in cases of unknown residence status

As the anonymous character of the counselling is safeguarded, people can resort to the advisory service on issues of sexuality and sexually transmitted diseases without having their residence status questioned. In the case of diagnosed STD, it is of essential importance that the medical check and the treatment be free of charge, as most of the patients concerned do not have the financial means to cover the costs. Thanks to the fact that fears of police measures are largely reduced, the number of clients is constantly growing. The reasons for which migrant women are working as sex workers in Germany are manifold, and so are the conditions in which they are doing this. Cases range fiom the selfconfident sex worker who is striving for better possibilities to e m money than she can obtain in her home country, to serious traficking. The advisory service has so far not been able to register grave cases of this kind of slave-trade as the victims will probably not get the opportunity to come to the centre. The situations in which most clients find themselves are shown in Table 10. The special situation caused the advisory service to formulate specific standards for the counselling of this group, these are flexible and can be modified according to the client’s individual needs. If necessary, interpreters can be employed in the counselling.

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Table 10. Situation analysis: migrant sex workers witb unknown residence status, Bremen, Germany, 1997. Information on their situation as sex workers Residence status

usually outdated tourist visa Immigration

in most cases by means of trafickers

no idea of prevention

strong deficits regarding. - STD

- HIV - contraception - condom use

Dependence

most women know on entry that they will work as sex workers most women work as sex workers for the first time little confidence in official facilities

Table 11. Special standards for advisory activities: migrant sex workers witb unknown residence status, Bremen, Germany, 1997. Initial counselling

prevention of STD and HIV contraception sexual hygiene information on sexual organs (anatomy etc.) use of condoms advice on handling customers Health insurance

individual advice on the availability of a health insurance suitable for the situation Criminal offences

free legal advice from a female lawyer (through a Bremen self-help organisation for sex workers) for sex workers involved in a criminal offence there is a link with the police Assistance in case of disease

the whole medical programme of the advisory service in case of other acute or chronic diseases, the service co-operates with the social welfare ofice to obtain nonbureaucratic assistance.

Migrant women with unknown residence status form the largest group of clients who come to the advisory centre. Their number is growing constantly. The number of consultations by target groups is shown on Table 12.

Table 12. Client contacts by target groups, Bremen, Germany, 1997. Target groups migrant women (with unknown residence status) other sex workers drug abuserddrug-abusing sex workers general public persons frequently changing sexual partner other target groups (e.g., refugees, asylum seekers)

No. 221' 108 98 178 95

I52

* I n 1997, I48 migrant sex workers came to the advisory centre On average, each of these women came one to five times per year The age of the women is between 18 and 26 j e o r ~ older women only come occasionally The maximum age was 33 years

The majority of women with unknown residence status come from Eastern Europe and Thailand. For 1998, a decline in the number of Thai women was predicted. while the number of Eastern European women keeps rising.

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Table 13. Migrant sex workers by country of origin, Bremen, Germany, 1997. ~~

~

Country of origin Poland Thailand CIS Czechia other

No. 70 69 62 19 1

Counselling Subjects

Communication with people with unknown residence status is frequently difficult. The greater part comes to the advisory centre because of an acute STD or an unwanted pregnancy. In the countries of origin, they were usually confronted by official facilities in terms of instruments of repression. They are therefore remarkably intimidated and uncommunicative. Even after a lengthy contact, there is hardly any information on their real situation to be obtained from them. The low level of knowledge on prevention, contraception, and sex work is reflected in the data on the subjects broached during the counselling (in these figures, counselling on different subjects in the course of one contact has been counted separately). V

Table 14. Counselling subjects for migrant sex workers with unknown residence status, Bremen, Germany, 1997. Subjects STD including HIV and advice on immunisation (prevention) contraception and sexual hygiene (prevention) partner problems/particular sexual practices special advice on sex work issues of social assistance mediation with other institutions/facilities

No. 22 1 22 1 95 74

21 19

The advisory service compiles separate diagnostic data on migrant sex workers with unknown residence status, which are the basis for formulating standards for preventive advisory activities (see Table 14). They also facilitate the adaptation of the medical programme to existing needs. Imrnunisation for migrant sex workers with unknown residence status

Immunisation measures for the prevention of hepatitis B are fairly difficult. The clients have great reservations regarding vaccination. On the one hand, they nurse irrational fears of negative side effects. On the other hand, they are scared of losing their anonymity when the required immunisation document is issued. Moreover, many women do not know how long they will stay in Bremen, and the offer of an anonymous and free hepatitis B vaccination cannot be found in many cities. Influenza immunisation is only carried out with clients in a bad general condition, but as it tends to be known in the countries of origin, it is better accepted on the whole. Smears for cancer detection are only taken in the case of a clinical finding (positive iodine test, erosion of the portio not healing after therapy, sub-clinical HPV infection). In the case of 9 Pap tests undertaken, no finding occasioned further diagnostic measures.

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Table 15. Diagnoses for migrant sex workers with unknown residence status, Bremen, Germany, 1997. Diagnoses No. Basic screening gonorrhoea 1 acute syphilis 3 anamnestic syphilis 4 vaginitis (Gardnerella infection) 45 vaginal thrush (candidiasis) 23 trichomonas 4 removal o f foreign body 3 unspecific cystitis 5 Specific vaginitis ureaplasma urealyticum 20 mycoplasma hominis 14 hemolytic streptococci group B 1 chlamydia 2 intestinal bacteria 2 other 5 Parasites scabies 6 body lice 11 head lice 9 Hepatitis acute hepatitis B 2 hepatitis C / positive HIV test * 1 Genital herpes I1 8 Condyloma acuminatu m Subclinical HPV 2 *HIP’ testing is performed on the clienl’s explicit demand and only afier detailed counselling. Whenever possible, a female interpreter is included in the counselling on the test and its implications &

Conclusion

In summary, the health status of migrant sex workers with unknown residence status who came to the advisory centre was considerably poorer than that of other sex workers regarding STD. Migrant sex workers suffer from STD and parasites much more frequently. Preventive measures such as the use of condoms and checks on the customers for visible symptoms of STD clash with the interests of both pimps and customers. As most women are living in financial dependence, they feel urged to accept the customer’s offer to pay more if intercourse is without a condom. The general health care system cannot be used by the women, most of whom are illegal immigrants. As a rule, they come to the advisory centre with already extensive symptoms. Unwanted pregnancies are frequent, as many women reject the pill as a contraceptive on religious grounds. Most abortions are performed in their home countries. often after the twelfth week and in a situation of extreme need. It is difficult to make a precise analysis of medical and psychosocial demands as complete data on the number of people with unknown residence status in Bremen are lacking. Detailed information about the life that these people are forced to lead is also lacking.

Part 3

Health Promotion

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Public Health and Health Promotion Paolo Contu

Concepts and definitions The state argues that its responsibility is to protect people’s property rights. For most people the only property which they possess is their health; therefore the state has a responsibility to protect people’s health. Neumann, 1847 At least I know this, that if a person is overworked in any degree they cannot enjoy the sort of health I am speaking of ; nor if they are continually chained to one dull round of mechanical work with no hope at the other end of it; nor if they live in continual sordid anxiety for their livelihood; nor if they are ill housed; nor if they are deprived of all enjoyment of the natural beauty of the world; nor if they have no amusement to quicken the flow of their spirits from time to time; all these things, which touch more or less directly on their bodily condition, are born of the claim I make to live in good health. Morris, 1884 Public health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the education of the individual in principles of personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. Winslow, 1920 Health is more than the absence of disease, it is a complete state of physical, mental and social well-being. World Health Organisation, 1946 Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, and social wellbeing, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to wellbeing. First International Conference on Health Promotion, Ottawa, 1986 Health is the extent to which an individual or group is able, on the one hand, to develop aspirations and satisfy needs; and on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living; it is seen as a positive concept emphasising social and personal resources, as well as physical capacities. University of British Columbia As the previous statements show, public health has assumed different aspects and priorities during the last 150 years.

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I840 Health concept The public health movement arose in Europe around the idea that overcrowding in unsanitary conditions was at the root of the epidemics that afflicted the cities, and stressed the need to develop a locally based sanitation action (housing, safe water and sewage disposal) supported by legislation. According to Wirchow, who was a member of the Berlin city council, medicine, in order to fully achieve its goals, needed to involve itself in the political and social life, and highlight all the obstacles that prevent a normal life cycle. The legislation of most of the European countries (1 848 English Public Health Act. 1888 Italian health legislation) was inspired by this philosophy. During this period major health status improvements were related to improvements in the overall standard of living, a composite of nutrition, education, housing, income, public health measures and health services. In the European cities the sanitary structures (aqueducts, sewage disposal, public housing, wash houses, slaughterhouses...) and public health organisation were dramatically improved between 1820 and 1920. At the beginning of our century the cities were radically transformed. This sanitation was more and more supported by health education oriented to personal, home and food hygiene and by social measures (free school meals, community services). The advances in bacteriology made it possible to target individual problems both for prevention and for treatment. , I920 Therapeuticperiod The breakthroughs in pharmacology with insulin (1921), the sulphonamides (1938), and penkillin initiated the therapeutic model of medicine which started to dominate educational and scientific thinking, and medicine focused more and more on the individual patient. As a matter of fact, as McKeown confirmed through his research, the major health status improvement during the last century was related to the improvement in the overall standard of living and health services. In order of importance the major contributions to improvements in health in England and Wales came from limitation of family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences), and specific preventive and therapeutic measures. In particular after the Second World War, resources were more and more allocated to the curative system, with escalation in costs in part a consequence of technological innovation and an apparently limitless demand for medical care. I970 New Public Health In 1974, the Canadian health minister Marc Lalonde presented "A new perspective on the health of Canadians" which introduced the health field concept. It stated that in order to achieve better population health five groups of determinants must be addressed: biological factors, the physical environment, the social environment, lifestyle factors and health care services. The Lalonde report underlined that many of the factors determining population health were outside of the scope of the health services. In 1986 the Ottawa Charter for Health Promotion changed the face of health promotion world-wide. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identifi and to realise aspirations, to satisfi needs, and to change or cope with the environment. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Health is, therefore, seen as a resource for everyday life,not the objective of living. The Health for All document, elaborated by the WHO, was a revolutionary statement on development. It saw health status as an outcome of development. It set global goals and targets for population health gain and proposed the key strategy with which to advance: the primary health care strategy.

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The original goal of Health for All is that we should act upon health determinants and known health risks so that all people have the opportunity to lead a socially and economically productive life. This goes beyond the focus on individual behaviour oriented to persuade or coerce individuals into adopting healthy lifestyles, which will lead to the prevention of diseases. The health promotion movement asserts that the social environment (negative aspects of urbanisation, bad housing, unemployment and social exclusion) is the most important health determinant, particularly for those living in deprived areas. To concentrate on lifestyle is to blame the victim while ignoring the social circumstances that are responsible for the disease. Health promotion is therefore the process of enabling people to increase control over, and to improve, their health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies. As the debate has proceeded it has become ever clearer that health is not only an outcome of development but also a significant input to development, and the government of British Columbia proposed a new definition. "Healthis the extent to which an individual or group is able, on the one hand, to develop aspirations and satis@ needs; and on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living; it is seen as a positive concept emphasising social and personal resources, as well as physical capacities."Good health is a major resource for social, economic and personal development and an important dimension of quality of life. The health sector is expected to move in a health promotion direction, and to embrace an expanded mandate that supports the needs of individuals and communities for a healthier life. Equity is the key issue for health promotion. The message encompassed in the "For All" means that health policy has as its key goal reducing the health gap, whether between countries, or between individuals. It aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. Health promotion is not just the responsibility of the health sector. A modem health policy is therefore much more than a policy for managing, organising and funding medical services. Health promotion is not just the responsibility of the health sector, but demands co-ordinated action by all the sectors concerned. The "settings projects" encourage organisations to set their own targets and to develop integrated mechanisms to achieve these as part of a social project for health. Intersectorial collaboration refers to joint working between government, business community, church, health authorities, higher education, community groups, media.. . Strategies need to be found to motivate a multitude of participants with different aims around a commitment to health. The local action is far removed from any "big government" approach - it is built on motivation, incentives, energy, creativity and partnerships. It explicitly starts by strengthening the health potential within each setting. The focus of health promotion is a complete and effective community participation in setting priorities, making decisions, planning and implementing strategies. However, a strong commitment at the governmental level is essential to define criteria and to ensure resources for the local actions. The European Union with decision no 645/96/EC of the European Parliament and the Council adopted the Programme of Community action on health promotion, information, education and training within the fiamework for action in the field of public health (1996 to 2000). Pursuant to Article 3 of the Treaty, the European Community action must include a contribution towards the attainment of a high level of health protection. The actions must be

Part 3. Health Promotion

1 I6

undertaken within the fiamework for action in the field of public health, and take into account other actions undertaken by the Community in the field of public health or having an impact on public health. The objective of the programme shall be to contribute towards ensuring a high level of health protection and shall comprise actions aimed at: - encouraging the "health promotion" approach in Member States' health policies by lending support to various co-operation measures (exchanges of experience. pilot projects, networks, etc.), - encouraging the adoption of healthy lifestyles and behaviour, - promoting awareness of risk factors and health-enhancing aspects, - encouraging inter-sectorial and multidisciplinary approaches to health promotion, taking account the socio-economic factors and the physical environment necessary for the health of the individual and the community. especially for disadvantaged groups.

The European Community included health promotion, education and training among the priority areas for action; emphasised that certain eating habits, the uncontrolled use of some chemical substances and medicines, drug abuse, smoking and environmental pollution have a harmfhl effect on health, also bearing in mind the problems of safety and accident prevention; underlined that the promotion of a healthy lifestyle as regards nutrition is vitally important to enable people to make the necessary choices to ensure appropriate nutrition in keeping with individual needs; identified school as a vital setting for systematically developing a healthy lifestyle at an early age that would enable sickness and accidents to be reduced; considered that there were a variety of other settings such as local communities. homes, workplaces and hospitals, in which health education had a central role: encouraged action for the prevention and fiuther study of the risk factors for cardiovascular diseases; recognised that socio-economic conditions such as urbanisation, housing. unemployment and social exclusion have to be taken into consideration in the promotion of health, particularly for those living in deprived areas A ct ivities 1. Support for integrated health promotion measures and projects relating more specifically to groups which are disadvantaged as a result of their vulnerability or social exclusion, of social and cultural differences or of living in unfavourable areas or environments. together with measures to combat exclusion and precarious situations.

2. Examination of the role of nutrition and other life-style factors in the aetiology of diseases and information of the public to improve understanding of basic nutritional principles and of new techniques and methods of presenting and preparing foodstuffs. 3. Promotion of analysis, evaluation and exchange of experience and information and support for actions in respect of innovative measures for the prevention of cardiovascular and cerebro-vascular diseases, taking account of the risk factors for such diseases.

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4. Support for exchanges of experience and information concerning the rational use of

medicines, in particular generic medicines and self-medication, in co-operation with general practitioners and pharmacists. Exchange of experience on providing the public with information on the use of medicines, in particular medicines available without prescription. 5. Promotion of examination, assessment and exchanges of experience and support for actions concerning measures to prevent alcohol abuse and the health and social consequences thereof.

6. Support for measures to promote regular physical activity and to reach sound physical and mental hygiene practices.

7. Support for studies on ageing populations in the European Union and promotion of exchanges of experience and information on the prevention of age-related illnesses in conjunction with the other specific programmes. Community Participation

Perhaps no other development concept has been more thoroughly, consistently and fervently advocated than that of "community participation", which is currently one of the most frequently used terms in the field of health promotion. As a result of this, the last decade has seen a massive surge in the number of programmes advocating this community approach. Rifkin defined community participation as a social process whereby specific groups with shared living needs in a defined geographical area actively pursue identification of their needs, take decisions and establish mechanisms to meet these needs. The concept of "community" can be enlarged to include a group of people not living in a particular area, but with shared values, interests, cultural patterns or social problems. A true participation should be active, and involve choice, with individuals having the right, responsibility and power over decisions. Citizen involvement can range from manipulation and tokenism (a level whereby the community are given a taster, while professionals still remain in ultimate control of the programme) to actual control. During the last year we developed a short tool to measure the level of community participation, which is described at length in a following chapter (see the Healthy School Programme at Sant 'Elia, Cagliari, Italy). One of the aims of health promotion is to strengthen and increase participation to a point where the community takes control of a programme. There is no guarantee all participants want to reach this stage of self mobilisation, or that all are able to cope with the responsibility that a partnership would bring. Some professionals think the ultimate level of Participation is the level that should be aimed for, and that it would be the best for both professionals and community members. Others feel that a professional impetus is essential and necessary. However, it cannot be said that a programme with a high level of participation is better than one with a lower level of participation. It is important to define the level of participation desired, community based or community orientated. The difference here is that community orientated programmes are programmes where professionals define what they think is the best way of improving the community's health, and community based programmes involve citizens in all aspects of the programme.

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Resistance to Community Participation

It is difficult to find a health promotion project, which does not mention participation, empowerment or one of the other terms customarily used, and advocate this approach, but often health promotion priorities have continued to be professionally and medically defined. Participation, in its very essence is a challenge to a traditionally professionally dominated field. It requires new ways of thinking and of acting that challenge consolidated models. In fact the Alma Ata statements lie right at the centre of professional values and beliefs and therefore pose a real threat, for some the temptation to dismiss participation as irrelevant, too political or too difficult, is strong. The old mystique which often surrounded health matters, where only professionals had the knowledge and skill, is slowly eroding and this in itself is a threatening thought for some. The transition fiom filial passivity to a partnered advocacy represents a value change that is quite difficult and dramatic, and this inevitably causes conflicts and fears. Limits and challenges of Community Participation

The whole idealism of community participation was often called into question. It could be said that too much idealism and too many sentiments surround the principles of participation. While community participation is now sought after in the majority of health promotion programmes emerging today, there is also growing criticism surrounding this concept coming to light. Of course the rhetoric of participation is much easier than the practice, and problems and dilemmas arise when people start to be involved in programmes. Heterogeneity within the community

It is important to recognise the diversities existing within communities in which a wide variety of social dynamics exist. The communities are not cohesive and integrated entities fighting for justice against powerful external forces, this is more romanticism than a serious analysis of community life. A community can be made up of many different groups of people, and not all these groups share the same goals and motivations. Often their interests and demands are different and sometimes opposite, and consequently groups of citizens are often in combat with one another. The lack of common interests between the different social groups is maybe deeper than 150 years ago, when the self-interest of the middle-class in recognising their vulnerability to cholera spreading fiom the poor neighburhoods generated revolutionary actions to improve the health of the cities. When most of the diseases involved young workers and the low social classes included most of the population, good health was seen as a major resource for the social, economic and politic development of the nation. Not because they were more altruistic or moral, but because health improvement was a gain not only for the poor but also for the upper and middle classes. According to Dahrendorf, today the position of the deprived groups can get worse without any disadvantage for the rest of the population. They are not a productive or revolutionary force, the rich can get richer without them, the government can be elected without them, the gross national product can increase without them. The lack of a unifying explanation for deprivation does not lead to a wide social movement aiming to change society, but to an individualistic rehsal of the healthy and ethical rules (alcoholism. drug abuse, violence. ..). The competition between different social groups is not equal. Participation is more effective among people who already have experience in community leadership. who are often from higher socio-economic groups. So the situation of marginal groups is a weak

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spot in community participation, as they are in a weak position. Participation, which should aim at improving the chance of individual self-realisation, could become more corporatism with stronger groups using it to defend their own interests. This situation is very common when the aim is to improve the health situation of Roma, asylum seekers, sex workers, and drug abusers... The "normal" citizens do not consider them as "unlucky people", whose health has to be improved, but as a danger, that has to be kept as far as possible from healthy society. When the government decides to open a centre for drug abusers or a camp for Roma, local citizens stand up and organise groups and actions to fight against this decision. In this case community participation mostly leads to more exclusion. This is important when remembering that most health promotion programmes have to reach and work with disadvantaged groups and those lower down the socio-economic scale. Community participation is valid, only when the interests and the goals of all the members of the community are taken into account on an equal basis. Otherwise, in order to guarantee the social and civil rights of marginal groups, the governmental agencies must overcome the unwillingness of the majority of the local community, and take decisions, which may not be popular with everyone. As Neurnann highlighted in 1847, the state is responsible for protecting people's health, the only property of disadvantaged people. In this case professionals and public authorities will have full control over the programme, planning and organising activities (passive participation), and citizens will just be informed of plans. Forcing the community?

Another dilemma could be encountered when a community does not want to become involved in the programmes. Participation is easier when the issues emerge from community concerns, rather than being established by professionals. If the issue being dealt with is one that many people in the community feel strongly and are concerned about, there should be little problem in citizens participating. If the community members do not see the issue as a priority in their lives, they would be less likely to have the same motivations to participate, than if the issues being dealt with were important factors in their everyday lives. For many people health is not something they see as a priority, it is something they just have. For them it is often just not a factor in their everyday lives, no matter how important we, as professionals think (and know) health is. In deprived communities poverty, unemployment, shelter are the issues in the forefront of people's minds, and "healthy behaviour" (for example eating a low fat diet and reducing the risk of heart disease) is not considered a major factor of influence in their lives. The habits of some deprived groups are far from a healthy lifestyle. Roma children are not expected to attend school but to contribute to the family income, some immigrant communities want to preserve their traditions (infibulation, nutritional behaviours). What does participation mean for groups that have other desires, such as drug abusers? Again with the health damaging behaviour of social risk groups a passive participation is common and NGOs, professionals and public authorities will have full control over the programme, planning and organising activities, and citizens will just be informed of plans. Starting Community Participation and fostering self-worth

Community Participation, if not directly requested by the community, will require some kind of access point and penetration. Professionals need to access the system, to know the key people and where they are, to know the structure of the system and how it operates. Low self-worth and skills within the community can represent an additional problem. Individuals who believe they are in control of their lives and actions, and that the latter can

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influence their lives, are more likely to participate. Those who believe their lives and actions are influenced by fate, chance, destiny or other people, and that there is no point in making healthy decisions as they will not affect their health, would be less likely to participate in a health promotion programme. The creation of inter-sectorial steering groups and citizens groups carrying out transitional projects (functional participation) can help to foster self-worth and then participation. Evaluating the progress of the programme, in terms of participation and changes in attitudes, allows community members themselves to understand how they are progressing and are involved in the process, and to recognise their own strengths and weaknesses.

Bibliography Ashton J, Seymour H. The New Public Health. Buckingam UK: Open University, 1988. Ashton J. Inaugural lecture "A vision of Health for the North West". Liverpool, 30 January, 1995. Bury J. Inventory of public health and health promotion training in the European Union, 1997. Cosmacini Storia della medicina e della sanita in Italia. Editori Laterza, 1987. Cosmacini Storia della medicina e della sanita in Italia. Dalla "Spagnola" alla 2a guerra mondiale. Editori Laterza, 1989. Dahrendorf R. Economic opportunity, civil society, and political liberty. UNRlSD Conference "Rethinking Social Development", 1995. Kickbusch I. Keynote address presented on the occasion of the Healthy People 2000 Consortium Meeting "Building the Prevention Agenda for 20 10: Lessons Learned" New Yo&, 1996. McKeown T. The Role of Medicine. Dream, Mirage or Nemesis? Nufield Provincial Hospital Trust, 1976 Taylor CE. Measuring community participation and changes in health behaviour in a health promotion programme in Sardegna Italy, Dipartimento di lgiene e Sanith Pubblica - Cagliari. 1997. World Health Organisation, Health and Wevme Canada, Canadian Public Health Association. Ottawa Charter for Health Promotion. Copenhagen: WHO,1986.

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Definition of target groups for health promotion or preventive programmes: the example of migrants Zahra Mohammadzadeh and H.-Jochen Zenker

Introduction One of the tasks of the public health service is to organise or provide special attention in the form of health care, health promotion measures andor prevention programmes for those population groups which, for whatever reason, are on the fringe, excluded, deprived or exposed to specific health risks. This is the point of departure used for defining target groups. The following criteria could be used to define a target group eligible for such concentrated attention, or inclusion, in specially targeted public health programmes. Some of the factors influencing the health situation of any observed group may occur under more than one set of criteria (e.g. cultural background can be considered among access criteria or among communication criteria). In some cases it is also important to note that problems may become serious because of the combination of several criteria (e.g. gender plus cultural background). 1. Status Criteria

Legal status The legal status of a group, for example as refbgees, asylum seekers, or as a national minority. Residence The length of residence in the country, but also the stability of the right to stay. Health insurance status Are members of the observed group insured for health risks like any other citizen? Type of health care funding Do they receive health care under the same financial conditions as the regular population, or is there special funding? Special laws governing social servicesfor that group E.g. the Asylbewerberleistungsgesetz (Asylum Seekers Social Benefits Law) in Germany. Degree of integration The degree to which the group is generally integrated into the system of social and health services.

2. Social Criteria Income Income level, but also the question whether this is a regular income, in what periods it is received, and whether it is reliable. Relative poverty The means of livelihood as compared to the rest of the population. Acceptancehejectionof the group by the population at large Acceptance or rejection by the social environment will have an influence on the psychosocial situation, but this factor can also play a role in emergency situations,

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for example homeless people are often considered "just drunk" when they are in fact in need of help. Possibilities of particeation in social activities or public lye A factor predominantly bearing on the psychosocial situation, but if defined in a wider sense for example political participation such as voting it becomes a civic rights question implying the degree to which the group is able to voice its own health needs. Likelihood of psychosocial problems Is either the internal structure of the group or its relationship with the social environment such that psychosocial problems can be expected? 3. Access Criteria Cultural Background The question as to access criteria should be posed as widely as possible; it is not just about purelyformal rights of access to the different levels of the regular health care system. Although the group may formally have access, numerous factors may render access difficult or prevent it. Cultural background may be one of them. Language Language may be a communication problem, but even before a patient-provider situation occurs, the mpecZed language problem may prevent the patient from seeking the help of the health care system. In fact it may prevent the health care system from including this group in its programmes in the Same way as others are included. Likewise, the need to employ interpreters - with financial resources not available - may work as a mechanism to lower the level of inclusion into the services of a health facility. Exclusive regulations In some cases there may be legal restrictions preventing the target group from access to a certain health service, for example rehgees who are due to be deported will not be treated for certain health problems. Lack of knowledge In this case, "lack of knowledge" refers to the level of information the health care system maintains regarding the health risks and needs of the target group. Rejection by medical personnel The attitude of medical staff and social and health providers in general towards that group. 4. Gender or Age Group Criteria

Problems specifc to gender Problems specific to youth Problems spec@ to children Problems specific to the elderly The problems of women and girls come more easily to mind, but it should also be remembered that the typical male education and set of attitudes include some aspects which may lead to deficits in the person's health-related behaviour.

5. Epidemiological Criteria Specific health risks of the group

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This criterion concentrates on the obvious specific health risk an observed group may have, such as drug abusers. Nutritional status This does not only refer to the standard discussion of nutritional problems. For example, in the case of migrants, the kind of food available to the group may play an important role in the psychosocial situation and mental health status of its members. Hygiene This aspect will usually be connected with the general standards of living, accommodation, job situation etc. available to the target group. Prior health care An especially important aspect in the case of migrants, as the health care systems in the countries of origin may be quite different fiom those in the host societies. But even in the individual case, the circumstances in which the person lived in his or her home country may have restricted possibilities of prior health care. Traumas Is there a probability of an above-average number of traumatised persons in the group observed? This may for instance be the case in certain refugee groups. Traumas are sometimes difficult to diagnose, they therefore require special attention. Exposure to organised violence This aspect has been added to the previous one because it may also be very difficult to diagnose except when the health problems connected with it are very obvious. Patients who have suffered torture, systematic rape or other forms of organised violence are usually very reluctant to talk about their experience. Special training is usually needed to record the patient’s history and to decide the correct way to proceed to more detailed measures of diagnosis and therapy.

6. Communication Criteria Language problems An obvious set of problems in many cases of migrant groups. Cultural communication barriers Cultural communication includes more aspects than just language problems. Therefore the barriers caused by difficulties of communicating across cultural barriers have been added as a separate aspect in addition to the language problem. Trans-culturalmisunderstandings If the group comes from a different cultural background to the general population, the question of communication is made more difficult even than it seems on the surface. In some cases the patient and the provider may think they understand each other, while really being victims of a trans-cultural misunderstanding. This aspect is also typical of the problems of migrant groups. Patient-provider relationship Are there structural difficulties in the patient-provider relationship between members of this group and health staff! Such difficulties may be found in their attitudes towards each other, but also in different conceptions of health and disease, different reactions to the diagnosis, different understanding of how treatment should be handled etc.

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7. Education Criteria

Literacy Lack of schooling Lack of health information Attitudes towards health, sickness, disease prevention etc.

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Prevention and health promotion among populations in precarious conditions: a critical approach Anne Vincent and Pierre Ryckmans Introduction Prevention and health promotion among populations in precarious conditions is a formidable challenge: these groups already have dificulties, not only in obtaining care but also in finding care. Prevention goes one step fiuther since it implies a specific attitude or a change of behaviour regarding a health problem, which has not yet arisen, or is not yet directly perceptible by the persons themselves. At first sight it is obvious that undertaking prevention will take time. All the participants in the field are aware that some medical problems are simply the manifestation of social problems. A part of primary prevention must therefore take place elsewhere than in a medical consulting room. Even if poorer people do not have diseases specific to them, there is a higher frequency of certain problems, which can be more or less clearly linked to life style. Thus, one notices pulmonary and dermatological problems (precarious housing conditions), digestive (nutrition), psychological (unstable employment, family situation, housing) dental (nutrition), injuries (housing, conflicts), dependencies (stress). Housing, employment and income are the foundations of truly efficient primary prevention, but cannot mask the entire behavioural and psychological dimension of precarious conditions. A more specifically medical prevention policy probably requires two conditions: a direct link with curative care, and an adapted language or technique. The direct link with curative care is indispensable, as it is illness, and not health, which links those living in precarious conditions to the health workers. It is the illness that, often too late, will create the contact. The patient requests access to care, whereas the medical personnel requests access to the patient and his family. It is probably also the illness, which, by bringing the patient to where he knows he can be treated, will provide the minimum of continuity necessary for health education. Curing the illness, or an improvement in the symptoms, will give the care provider the credibility and authority necessary to be heard. However, the messages are not always understood, in fact non-communication seems to be the rule. This is when the importance of a specific technique, or language, comes into play. To provide a realistic solution and an adapted message the care provider must be able to read the meaning, or meanings, behind the complaint, and even the cause of the present situation. As for the patient he must explain the problems, dare to share his fears, his vulnerability, and his weaknesses. The care providers must make an effort of comprehension and adaptation, which is generally under-estimated. The form, the language, the terms, and the content are each points where communication can break down. The very person of the care provider is important: a care provider fiom a poor background will understand and transmit more easily, because he will express himself better and be better accepted.

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The prevention institutions in Belgium In Belgium, the Communities are in charge of prevention, whereas curative care is a Federal prerogative. According to our information the total prevention budget represents 1 to 2% of the Federal health budget. Prevention among the French community The main prevention organ is the ONE, with about 90% of the community prevention budget. The main tasks of this organism are prevention among mothers and small children, help for children in difficulties, and the supervision of the reception centres. Prevention among mothers and young children is performed through prenatal consultations, infant consultations, and consultations for children under six. These consultations are entirely fiee, a factor which favours access for the more destitute. Other than their obvious preventive role, they also plan to be a privileged moment and place for social aid. Their big weakness is that they are strictly separated fiom curative care, which greatly diminishes the attendance of the population most at risk, for which a consultation without medication is not a real consultation. Another reproach is that the constraining timetables and lengthy waits reduce access. Integrated social aid is viewed by some as a double-edged weapon, which can dissuade certain families. for example out of fear that the children will be put in foster homes. The subsidised reception structures supervised by the ONE are mainly the day nurseries, the reception centres for children and the centres for mothers in difficulty. These are the activities of 26 396 structures in the French community. Though indirect, this is an important prevention activity. The SOS-children teams offer assistance and protection against child abuse, they are the final branches of activity. Apart from the ONE, prevention is, in general, mainly left to the initiative of various associations, which can be an enriching and diversifjlng factor but also one of dispersion. The major prevention campaigns (breast cancer screening, Aids, etc.) only marginally affect the destitute, and it is precisely the small better-target& and adapted field initiatives which can make the difference. For the moment, it is difficult to see the whole picture of what is being done. In any case the lack of means to support these projects makes the whole not very credible on the long-term operational level. But this does not prejudge the quality of the programmes that are effectively developed. As a result of a recent decree in the French community, prevention will henceforth be organised by a superior health promotion Council. It will be in charge of defining the main priority lines and the strategies regarding health promotion and preventive medicine. It will be assisted logistically and methodologically by the community health promotion Services. At the local level, local health promotion Centres will be mandated (one for each of the ten sub-regions in the French community) to co-ordinate the establishment of the programmes. The centres will associate in their midst the authorities and private associations. Special attention is planned for the populations in precarious conditions, but for the moment it is impossible to have a precise idea of the changes that this could bring to the field. The local dimension of prevention is however at the forefiont, and therefore the necessity of adapting message and even content to the local context. The efficiency of this policy will of course also depend on the means with which it is provided. Prevention among the Flemish communiw The situation is practically identical in the Flemish community. A new prevention plan to develop a multi-sectorial prevention policy structured at the local level has recently been proposed. The emphasis here is clearly on the role of the general practitioner. The local structures would be flexible associations of all the participants in the field in a given entity. This would concern prevention in general, but the projects targeted at underprivileged populations would receive particular attention.

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An interesting peculiarity of the Flemish community is that it has an instance in charge of preparing and evaluating the policy of the battle against poverty. Its areas of action are numerous and the battle against poverty takes place at multiple levels. As regards health education, discriminated initiatives in favour of the underprivileged exist; as in the French community they are also the work of various associations. Since 1991, Kind en Gezin, the Flemish speaking counterpart of the ONE, has undertaken a massive task, that of identifying and targeting the underprivileged families: definition of the criteria of poverty, identification of the families, identification of the underprivileged neighbourhoods, etc. On the basis of these data, accompaniment work (home visits) is undertaken, this serves as the basis of long term social work; in addition to this preventive care centres have been opened in the underprivileged neighbourhoods. They integrate prenatal consultations, and health education workshops. The prevention activities of the health professionals The prevention sector is not in general well valued in Belgium, and few activities are organised to train personnel in prevention among groups in precarious conditions. The existing training courses are perhaps too axed on the doctors, without taking into account the other participants. In prevention in general, but even more so in the context of precarious conditions, the information must be channelled by different participants, and provided at different times and in different places. The adult education possibilities are not well known by those for whom they are planned.

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Integrating prevention and health promotion practices into primary care for deprived populations Nassera Mezatfa and Pierre Chauvin Introduction

Health inequalities are linked to many factors, among others access to care, access to information, life-style, living and working conditions, and socio-economic situation. Socioeconomic inequalities can be defined "as systematic dzflerences between the emergence of health problems among individuals with a high economic status and those with a low socioeconomic status, the notion of socio-economic status referring to the socio-professional position, the level of education, the income level, (. ..) ". Socio-demographic conditions such as age, sex, and other factors such as affiliation to additional health insurance, housing conditions, an individual's social network etc. should also be included. Deprived populations can be identified by using an approach based on all of these determining factors. The problem lies in the fact that there is no homogeneous population identified as a deprived population. Individuals classified in this category in fact constitute heterogeneous groups that are often hard to define objectively and institutionally. though this is sometimes possible by means of institutional mechanisms. such as the minimum integration income. In order to reduce inequalities several kinds of interventions can be undertaken in different areas, in particular on living, housing or working conditions, on income levels. access to care, etc. Prevention and health promotion programmes specifically aimed at the deprived populations are another kind of intervention liable to ensure a decrease in social inequalities as regards health. The problem in setting-up these policies as a whole, whatever they may be. resides in the difficulty of evaluating their efficiency, as the relative share of each factor determining the inequalities is not known. Each determining factor's actual causal link with the health inequalities observed would have to be known. Before undertaking prevention and health promotion it is necessary to differentiate between primary, secondary, and tertiary prevention. The stakes are not the same if one wishes to limit the consumption of tobacco and of alcohol, to screen for cancer or hepatitis. or to limit the risks of contamination in the case of tuberculosis for example. Therefore. depending on the types of prevention undertaken, the obstacles are not the same, the cost elements to be taken into consideration can differ considerably. and the participants are not necessarily the same. This document proposes several themes and questions relative to the role of primary care professionals in prevention and health promotion for deprived populations. We will identie the so-called primary care structures, before defining the general practitioner (GP) as being one of these structures. We will then try to identify the obstacles to GPs adopting a practice aimed at prevention and health promotion. Identificationof prevention and health promotion structures.for deprived populations: what health promotion structure(s)for deprived populations?

What is needed, particularly in the case of deprived populations, is a global care structure which would take all their problems into account, and which if necessary would refer the patients to other structures adapted to their specific problems. This is part of so-called

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primary care medicine, practised by GPs. In view of the one-on-one relationship that he has with his patient, the GP holds a privileged position as regards prevention and health promotion. Thanks to his knowledge of the patient's medical history, life-style, risk factors, family, and perhaps professional environment, living conditions, perception of health, the GP has, during the consultations,the opportunity to promote health and prevent disease. This structure is therefore totally adapted for certain health promotion actions, not only within the framework of the consultation itself, but also by means of the information with which the patient can be supplied, in particular by posters in the waiting room andor the consulting room itself. A general practitioner's consultation is thus a privileged place for prevention and health promotion. However when undertaking these activities the GP is faced with a certain number of problems and questions. We must also add that, whereas we mainly take into account GPs in their prevention function, other professions are of course liable to undertake and promote such activities. They are defined and identified according to the health problem and the population concerned (see Paolo Contu text). For example, as regards smoking, it is important to identify those persons who can participate in the fight against cigarette smoking. These persons are not exclusively health professionals, but also all the professionals whose work brings them into contact with pre-adolescent and adolescent populations, as these are the age groups liable to take-up smoking. Studies have shown that, among others, financial resources, social environment, employment status, and housing conditions, are determining factors of health inequalities. Health is a multidimensional concept, determined by different types of factors. There can therefore be an interrelation between the physician in charge of prevention and other professionals, appropriate to the situation concerned, such as dieticians, social workers, etc. The link between what is medical and what is social must be functional, and health promotion activities must award a privileged status to teamwork. This need for team work is also encountered through the concepts of care networks channels and managed care (based on health professionals integrated in different types of structures), established in several countries, which stress a global multidisciplinary approach, centred on the patients' needs. This kind of organisation is particularly well adapted for chronic diseases, accessible to primary and secondary prevention measures, such as asthma, diabetes, certain cancers, AIDS, Alzheimer's disease, depressions and psychoses, cardiovascular diseases, pain management, hepatitis C, etc. Access to care: an important problem

If one considers that health promotion is the role of the general practitioner, he must be able to be in contact with the target population (the socio-economically deprived population) by means of consultations or visits. However, a real contact problem exists between the general practitioner and certain patients belonging to these populations. In effect, certain studies have shown, in particular one undertaken in France in 1993-1994, that a large part of the population classified as deprived and identified as such according to a certain number of criteria, has no family physician and never consults a GP. In this case the emergency departments are the only service of the health care system which are used, thereby becoming primary care structures. This situation is particularly true among certain fringe populations such as substance abusers and sex workers who use the emergency departments and classical hospitalisation services for problems that are more social or primary care than specialised hospital medicine. However, the objectives and the organisation of hospitals (both in classical hospitalisation and in the emergency services) cannot respond to this type of demand. These structures can neither ensure health promotion, nor ongoing care, nor the patient's

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global care, as by definition they will only treat the patient for the problem that led him to the structure. The factors that explain why the deprived populations use the emergency services as primary care facilities are multiple. They can be related to the perception of health among these populations. The attention given to health and the body is not the same for all and the adoption of preventive behaviour, in particular by means of regular consultations, cannot be presumed. The level of knowledge and the information necessary for individuals to care for their health, and to formulate their expectations regarding the health care system, are not always sufficient. Also, the populations' choice of structure depends on the organisation of care, the welfare system and the reimbursement rates (for insurance-related systems). When hospital care is better reimbursed by health insurance, as is the case in the example chosen here, economically weak populations will more easily choose this type of structure. It would be advisable to promote schemes for an optimal usage of the care system, as this varies according to the patient's socio-economic category. The emergency services are in fact used for motives qualified as non-urgent, since these structures appear to be the only resort for the populations in question. The populations qualified as deprived are characterised by precarious housing conditions (or even homelessness), a difficult employment situation (unemployment, unstable employment), the absence of health insurance in those countries with a Bismarckian tradition (these populations are either not entitled to it or have not claimed it), etc. In fact, the persons who are in need of the prevention services and, in view of their socio-economic situation, have limited access to care, rarely or never consult privately, and if they do so it is belatedly. Our efforts should be focused on promoting the access of the populations excluded fiom the care systems, to the structures specifically for them. Several studies have in effect shown that the efforts made to improve the health of the general population, despite a constant increase in health care expenditure, do not reach those who are most in need of them and contribute to the health inequalities which persist in most European countries. The question of access of the so-called deprived populations to primary care medicine is therefore hdamental in that the general practitioner has been chosen as one of the main figures in charge of health promotion for this group. In order to establish policies to reduce health inequalities, the structures liable to be in sufficiently regular contact with the target population must be identified. Choosing suitable momentsfor promoting health: the place of prevention in the GP's medical practice.

Though it has been clearly shown that the introduction of prevention and health promotion in medical practice is necessary, it is not easy to decide the place which it should be awarded and arbitration between the curative and the preventive can be problematic. Choosing the right moment in which to provide prevention services is therefore important. These acts should not only take place during check-ups or visits for this purpose (vaccinations...). The general practitioner must try to include them as tiequently as possible in other consultations, even if the patient is consulting for other reasons. However this cannot be systematic, in that the patients are not always receptive to preventive recommendations, in particular if at that moment they are wonied by the problem that motivated the consultation. It can then be useless or inefficient to bring up primary prevention questions (tobacco, alcohol, or others) with a worried patient who is not receptive to this type of consideration. The general practitioner must adapt to the situation of the moment and choose the right context.

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It is obvious that the generalist can neither say nor do everything as regards prevention and health promotion during just one consultation. He can, and should, while taking into account the context, complete the prevention message during the following consultations. The best principle would be an annual routine examination, even for those persons who are in good health. The content of this routine examination would be adapted for each patient according to his personal risk factors. It would be a purely preventive examination, which would not impede the generalist from also regularly promoting health in the course of other consultations. This kind of approach, in particular as regards adolescents, is advised in the recommendations of the American Medical Association and other learned western medical associations. Periodical examinations performed by a general practitioner are a good opportunity for him to adopt a preventive practice, but two questions immediately arise. The first concerns the content of these examinations. It is necessary to define the most adapted acts, the share of primary prevention, that of secondary prevention, etc. The second question is that of the frequency of these examinations: sufficient scientific data are not available to determine an optimal frequency. It is important not to separate the curative from the preventive in the definition of medicine. For this reason prevention acts should take place even within the framework of a curative consultation. Medical practices must tend towards an integration of these different components.

The obstacles to general practitioners adopting preventive practices The ability of the professionals concerned to integrate prevention and health promotion into their activity constitutes another problem. The question of their training is also raised. As seen previously, we theoretically consider that primary care medicine is ambulatory general medicine. It is important to identify the obstacles that impede or make difficult the introduction of prevention and health promotion activities within the framework of general practitioners' exercise. Even though all the reasons and justifications exist for these activities to be part of medical practice, the studies show that in general, whatever the country concerned, they are often insufficiently integrated. Payment One of the arguments resides in the absence of payment for this type of activity; it would appear that the general practitioner considers that only the curative activity is paid for. Thus, the real question to solve is that of the definition of medicine; should prevention be an integral part of medical practice in ambulatory general medicine even though prevention is primary care medicine. The question of payment for prevention activities is raised in all the countries. Where professionals who receive a salary for a specifically preventive medical activity (occupational medicine for example) are concerned, the question is obviously not posed. However, in the case of liberal practitioners, generalists or specialists, exercising in the ambulatory sector, where payment is per act, we are faced with a problem in that no valuation exists for the acts linked to prevention and to health promotion. When practitioners are paid per capita, the question of payment appears simpler to solve. The objectives and the content of this non-curative practice must be defined (it cannot be, with a fixed payment, extensible ad infinitum). Time Time also constitutes another argument. General practitioners very often do not have enough time, during their consultations and visits, to undertake prevention and health promotion. Here again, the consultation is solely curative and it is often difficult to take into account the patient's possible problems, other than the one for which he is consulting. This

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factor has been particularly well studied in the United Kingdom and certain Northern European countries in numerous studies describing the determinants of GP's workloads and job satisfaction. General practitioners 'perception of medical practice In most countries, specifically oriented prevention structures, such as occupational medicine, already exist. The perception that GPs have of their profession can then partially exclude prevention activities, reserved for other kinds of practitioners and other structures. The generalists' perception of their own role in the health system is thus fundamental in explaining the more remedial or more preventive nature of their practice. Studies of GPs have been undertaken in several European countries, in the form of questionnaires, both on completing their medical studies and also later during their professional lives, in order to discover their perception of medical practice, and to evaluate their prevention practices. These studies were undertaken in order to ascertain whether these professionals are aware of playing an important role in the matter.

The guidelines The question of providing health professionals with training in prevention and health promotion activities is fundamental. The practitioner is often perceived through his therapeutic role, thus ensuring a strong link between treatment and sickness. However. the practitioner's role is also to avoid the risk of illness and avoid aggravations in the case of diagnosed diseases. Our vision of medicine, which up to now was remedial, must now incorporate preventive medicine, with a greater role and wider objectives for the general practitioner, who must develop a privileged relationship with the deprived populations. The general practitioner must thus leam to identify deprived populations, to know the specific problems these individuals are liable to encounter, and to supply a service corresponding to their prevention and health promotion needs. The need for guides for these GPs has become widely accepted. It can in fact be interesting to systematise this type of activities through the elaboration of guidelines, authentic care protocols which provide an answer and a standard procedure when faced with a given problem or situation. Such guidelines have already been established and used in certain countries. Elaborated for the health care professionals, they provide recommendations for clinical practice and prevention practices for a certain number of diseases, or more generally, for questions relative to individuals' health. The guidelines: protocolar and evaluated care The guidelines are developed according to the results of the studies evaluating the efficiency of the prevention acts Concerned. The criteria defining a prevention act as efficient vary according to the act concerned. For example, a screening test must be able to detect the patient's status regarding the disease concerned with enough precision to avoid the greatest number of false positives and false negatives. The sensitivity and specificity of the tests are therefore the essential criteria to evaluate the efficiency of the acts. The efficiency of prevention measures is evaluated by specific studies. at best controlled and comparative, but this is not always the case. In particular, the efficiency of health promotion can be evaluated through cohort studies of a sample of patients regularly consulting a general practitioner. These studies have been undertaken in certain countries. They have enabled the impact of the information provided by the GPs to be studied, thanks to certain indicators, such as the number of persons who stopped smoking. or drinking alcohol, or who modified their eating habits. On the one hand, the results have shown that the general practitioners' capacity to induce behavioural changes among their patients was not substantial. There may be a certain reticence on behalf of the patients to accept, and put into practice. advice from their

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general practitioner. On the other hand, the interpretation of the results provided by this kind of evaluation must be subtle and relative, in that several factors can be taken into account in the behavioural modification decisions taken by the patients. It is difficult to presume the intensity of the existing correlation link because not all these elements can be imputed only to the GP's intervention. Globally, the studies show that preventive practice in general medicine is still insufficient to be satisfactory, in particular among deprived populations. The results of these evaluations must enable the elaboration of clinical practice prevention recommendations for general practitioners, by identifying the most efficient acts. However, their efficiency depends on several factors, and is not the same among all the populations. The content of the guidelines sometimes needs to be adapted in function of the populations targeted. One can try to identify the difficulties in applying the recommendations, this has been done in certain countries. For example, in Spain the Spanish Society for Family and Community Medicine has set-up a prevention and health promotion programme, in order to disclose the possible difficulties in putting into practice the preventive recommendations, concerning children and adults devoid of any particular symptoms, within the framework of first contact medicine. Elements other than efficiency also come into play. In particular, cost considerations are widely taken into account, through cost-efficiency or cost-benefit studies. In view of the cost of screening equipment it is particularly important to identify the populations at risk. The Same is true of the vaccination programmes. Both efficiency and cost condition the practices chosen and recommended to the general practitioners for preventive practice in consultation. The cost of elaborating the guidelines themselves must be taken into account. There is a real need to extend this system and to invest in research of prevention and health promotion means and methods, in order to systematically include this dimension in the practice of ambulatory medicine. The system based on clinical practice recommendations has grown considerably in the last few years. The use of guidelines also reduces the disparities in practice between the general practitioners. On the macro-economic and purely financial level these guidelines, if well applied, will provide general practitioners with good practice recommendations, which should entail mastering health expenditure by avoiding inappropriate and costly usage of the technologies. Mastering costs and greater equity of the health systems are therefore stakes and objectives which cannot be disassociated from the programmes, undertaken in most European countries, to master health expenditure. Different types of guidelines according to the approach adopted To elaborate the guidelines the necessary combination of two types of complementary approaches must be taken into account. Both an approach by population (categories by age, income, etc.) and an approach by disease, whether clinical or social (for example, guidelines can be developed for the treatment of alcoholism, or the screening and treatment of HCV). These two approaches must be combined. One can thus find two types of guidelines: guidelines centred on the categories of population (for example, guidelines providing recommendations for preventive care for adolescents) and guidelines centred on a particular health problem (for example, guidelines for the treatment of asthmatics). However, in order to be usable and operational, guidelines centred on a category of population must contain information on the prevalence of diseases among this population (to return to the example of the guidelines for the care of adolescents, for example STDs). Also, guidelines with an approach by disease must contain information on the different types of population which could be concerned (to return to the example of the guidelines for the care of asthmatics, the recommendations must take into account the exposure factors

134

Pan 3. Health Promotion

specific to certain p u p s ) . Certain guidelines can be elaborated by simultaneously adopting both lines of attack . The behavioural dimension: a firndamentalfactor The general practitioner has a role in prevention and health promotion, but the patient, without whose collaboration any action in the domain is doomed to failure, holds the lead role. Whereas in the remedial domain one is often faced with a passive/active patienvpractitioner relationship, in the domain of primary prevention the patient holds the main role: he is responsible for his state of health. One of the GPs roles is to ensure that during the consultations the patient receives information and advice suitable to his individual behaviour in order to reduce the risk of disease or health alterations. As regards prevention, the patient must be aware of the link between behaviour and state of health. Establishing this link, by means of comprehensive. adapted, and accessible information, must be the first step. The GP must explain to the patient in comprehensible terms that certain factors, or the combination of certain factors, can increase the risk of disease. The accessibility of the GP's language or the adaptation of this language to each patient is fundamental. Behavioural factors concern different aspects of life. Certain substances, such as tobacco, alcohol, drugs, are clearly identified as dangerous to health and perceived by all as such. Primary prevention efforts must therefore be applied to $ese elements, taking into account the specific conditions of deprived populations in that environmental factors (social, familial, professional etc.) heavily condition this kind of consumption. Eating habits is another area of competence of health promotion; they can also have an influence on the development or aggravation of certain diseases, in particular if age and environmental factors are added. Certain studies have in fact shown that the question of nutrition is a growing problem among the deprived populations when compared with the socio-economic privileged populations. The quantities of calcium, iron, magnesium. vitamin C, fruits and vegetables consumed are insufficient whereas the consumption of certain fats is too high. These nutritional imbalances have been analysed as risk factors in particular for problems such as anaemia, asthma, eczema, premature births, and certain cancers. Promoting better nutritional habits can therefore notably improve the state of health of these populations. There is most probably a link between eating habits and income level, but other socio-cultural factors must also be taken into account. Physical activity or inactivity must also be taken into account by the GP in preventive practice. Combined with other risk factors, physical inactivity can be at the root of an alteration in health, the GP must therefore be able to provide his patient with comprehensive and comprehensible information on the subject. Information regarding STDs must also be provided, the means of prevention must be presented, explained, and promoted. The patients' sexual behaviour also requires information regarding contraception and the appropriate method adapted to each person's needs. Other kinds of behaviour are approached in certain guidelines, concerning questions that are more social than medical, such as conjugal violence. These problems, while not reserved to deprived populations, are among them more specific and often more problematic. Prevention is not limited to the protection of the patient's health. In certain cases, it is necessary to protect the family or social circle. For example, in the case of intravenous drug users several levels of health promotion exist: the GP must try to refer the patient to addiction treatment structures, but he must also avoid the transmission of infectious 'See for example a guideline edited in Spain on tuberculosis among the homeless. Diez E. et al.. Tubercle and Lung Disease, 1996. "Evaluation of social health intervention among homeless tuberculosis patients". pp. 420-424.

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diseases (in particular HCV and HIV). The GP must therefore be familiar with syringe exchange programmes or similar activities. Thus, the behavioural dimension does not concern only the area of primary prevention. General practitioners will also tend to raise questions relative to health promotion and prevention with the patients showing particular interest and asking questions on the subject. However, it is often those who ask no questions who are most in need of health information and education, in which case the GP must take the first step. A necessary knowledge of the patient The GP must be abble to identify risk factors and the insuing diseases. The elements which he must take into account are described under the generic term of life-style, and include nutritional habits, physical activity, substance abuse such as alcohol, tobacco, and drugs (taking into account both frequency and amount), sexual behaviour, protection practices regarding sexually transmitted diseases, contraceptive practices, vaccinal status, etc. The association of "high risk" behaviour (for example oral contraceptives-tobacco) must also be identified. This list is not exhaustive but gives an idea of the elements which the GP must know and which he must try to modify in the case of "high risk" behaviour. It is important to clearly identify the risks to be prevented. In the case of primary prevention, all the diseases are involved, and more generally all the problems associated with "high risk" behaviour. In fact it is not necessarily diseases in the clinical sense of the term, but also diseases classified as social, for example undesired pregnancies, or family violence. The prevention needs of the deprived can be divided into two groups: needs related to physical problems (vaccination, etc.), and those related to psychosocial problems, such as suicide, violence, the consumption of alcohol or tobacco, substance abuse, etc. Are there healthproblems specific to deprivedpopulations? There is a close relationship between "social" and "clinical" diseases, in the sense that action on one of these elements cannot be disassociated from action on one of the others: for example, one cannot fight certain cancers without acting against tobacco consumption. In the same way, one cannot fight cirrhosis without acting on the consumption of alcohol. The very name of the phenomenon shows this tight interweaving: for example alcoholism is, in itself, defined as a disease. It is nevertheless a heavy risk factor for other diseases. Not only is the consumption of alcohol a determining factor in the development of certain diseases, it is also an aggravating factor for the complications of certain others (for example, hepatic carcinoma complicating infection by HCV). When considering prevention and health promotion for deprived persons, one must try to identify the problems specific to them in order to direct the measures towards the particularly worrying questions. In fact certain studies have shown that some of the clinically identified diseases are most frequent among the poor populations. These must therefore receive very special attention from the GPs. Tuberculosis, which is recognised as a poverty-related disease, must receive particular care, both as regards treatment or secondary prevention (screening) and primary prevention (vaccination). In this case, the environment and the living and working conditions are factors to be taken into account. The general practitioner, who practices local hands-on medicine is in a privileged position and his role is essential for screening and therapeutic observance of tubercular patients. As we have seen, the deprived population constitutes neither a social category, nor a homogeneous group. For example if one considers intravenous substance abusers, one is confronted with diseases such as HIV infection, or viral hepatitis (hepatitis C or hepatitis B). These diseases must therefore be the object of particular guidelines, specific to the populations concerned. As regards regular consumers of alcohol, one is faced with hepatic diseases. In this case the GP, in his preventive practice, must consider several questions. In particular the question of whether screening for cirrhosis would be wise according to the

I36

Part 3. Health Promotion

age, the quantity of alcohol regularly consumed, but also possible blood test results showing abnormalities. The GP must also act in the health promotion area by attempting to modifL the patient's behaviour. Mothers and children pose problems specific to this group and must also be the object of particular care. The follow-up of pregnancies, the prevention of "high risk" behaviour during pregnancy, the detection of malformations, and the screening of possible diseases of the new-born, must receive specific care particularly among patients from deprived populations. Here also it is a question of primary and secondary prevention. The GP can thus find in the guidelines, a list of the diseases that he must more particularly look out for among certain categories of the population. However, as we saw previously, the concept of deprived population does not cover a homogenous social reality. but rather a myriad of groups concerned by specific problems. Thus, the guidelines can be general, and concern for example tuberculosis in general (screening, care, etc.), or adopt a more specific and detailed approach, by elaborating recommendations on tuberculosis among the aged in institutions, which is a more specific approach to the problem. One should also note that the modes of prevention and care of a same disease can differ according to the sub-groups of population under consideration. For example, as regards tuberculosis, specific care for the homeless has been widely proposed and evaluated. Ideally, the GP should have access to the data supplied by epidemiological surveillance of diseases, and the results of these studies using a socio-demographic and socio-economic health factors approach. In effect, whereas the incidence or the prevalence of certain diseases provides interesting information, this is insuficient as won as one wants to establish modes of care specific to certain categories of the population. As well as the surveillance date, other indicators must be available to the GP, such as the mortality and morbidity rates by age, by sex, or by social category, or more generally the differences in risk of disease according to the individual's social condition. Feasibility and acceptability of the guidelines One of the difficulties linked to the very existence of these guidelines is due to there being different possible sources. The recommendations can be supplied by governmental agencies, by individual experts, by professional associations, scientific organisations, etc. The multiplicity of the sources can be an impediment in the adoption by GPs of prevention and health promotion practices defined by protocols. In order to elaborate a document for health professionals it would therefore be necessary to obtain homogenous references. resulting from a consensus of the different sources identified. One of the questions fiequently raised is that of lack of time, which we have seen is often invoked by the GPs to explain the lack of prevention in their activity. Here, it is the length of the consultation that is under consideration. This leads us to examine the indicators such as the number of consultations per day and p e r GP, which is linked to the modes of payment in use. The acceptability of such protocols containing practice recommendations is also a hdamental question. One can wonder whether the general practitioners really want to have guidelines, whether they consider them an aid in their practice, or rather as an exterior constraint, and because of this badly accepted. Such a system can be perceived by certain GPs as threatening their fieedom of activity, their freedom of prescription, and the importance of their role in the choice of acts appropriate to their practice. Certain studies have shown that the GPs can consider the guidelines system as a hindrance to their autonomy'. Medical culture, the perception of their role by the GPs, the representation of prevention, of medical practice, are all factors to be taken into account in this area. 'for example Grilli R. et al., Social Science and Medicine, no 8. 1996. "Physician's view of practice guidelines A survey of Italian physicians". pp 1283- I787

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In some countries we are heading towards the practice of a medicine which does not question the GP's freedom of decision as regards diagnosis, therapies or prevention, but which favours a framework of recommendations emanating from the authorities or the organisms financing health expenditure. Apart from the question of acceptability in connection to the concept of constraint, we must reflect on the usability of the guidelines, which is linked to their simplicity and their appropriateness to the situations encountered by the GP. It is important to test the guidelines on a sample of GPs faced with the populations targeted (in this case the so-called deprived populations), before making the protocols general. The acceptability and the feasibility of the guidelines system also depend, probably, on the protocol's object. It's probable that subjects exist on which one observes a greater adhesion of the GPs. Thus, studies are undertaken in certain countries in order to identify the themes on which one is liable to obtain extensive participation from general practitioners. For example, a study undertaken in Italy on a sample of practitioners, generalists and specialists, concerning the care of certain cancers, showed a good acceptability of the method based on the guidelines. Many of the practitioners questioned considered that in general, apart Erom its other advantages the system based on care protocols constituted a guarantee of quality for the patients. Without a doubt, the acceptance of these guidelines by the GPs and their adherence to this systematic approach to prevention and health promotion is linked to their participation in establishing them. If one wishes this approach to appear not as a constraint, but rather as a reaffirmation of professional autonomy, and a redefinition of the professional practices of general practitioners, the GPs (by the intermediary of their representative instances, the learned general medicine societies, etc.) must be associated with the conception, the drafting, the establishment and evaluation of these guidelines. Conclusion

It is important to establish prevention activity protocols within the framework of general medicine, but first and foremost the problem of deprived persons' access to care must be solved. The applicability, usefulness, efficiency of the approaches which we have described could be heavily compromised if it turned out that a large percentage of the so-called deprived populations does not have, for various reasons, access to the structures using these approaches. The question of access to care is therefore one of the preliminaries to establish policies in favour of the financially weak populations. It is also necessary to think about the other structures liable to integrate or to develop the preventive dimension, and to reflect as to the articulation and the collaboration between different structures carrying out similar functions, in order to ensure that they are complementary. In particular, the concept of care networks advanced in a certain number of countries must integrate this preoccupation with both remedial and preventive care of people's health. The system based on the conception of guidelines should be extended in that it enables the GP to have a global and systematic view of the problems and the populations encountered at the consultations, and to propose standardised responses to given situations. This system is far from being general in all the European countries concerned. An effort must be made not only to pursue the elaboration of guidelines in response to particularly preoccupying questions among deprived populations, but also to incite the GPs to use these guidelines. The acceptability of the protocols by these professionals must receive particular attention, taking into account each country's specific conditions regarding initial and ongoing training of practitioners, medical culture, modes of payment,

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organisation of the care system; all factors which can have a definitive role in the applicability of the system. In the hypothesis of choosing guidelines using an approach by population, it is important to make a reasoned and motivated choice of the population, in function of the patient present in consultation. In the hypothesis of resorting to guidelines using an approach by disease, the GP must be sure that the patient’s specific condition, i.e. sociodemographic characteristics, are taken into account in the care protocol. Identifying the diseases proper to the populations which interest us here must take into account the heterogeneity of these populations. One cannot thus consider objectively certain diseases as specific to all the deprived populations. A more subtle characterisation of social determinants of states of health is an area of research to be developed simultaneously (if not beforehand) with these systematic medical approaches. Bibliography Aday LA. Health status of vulnerable populations. Annu Rev Public Health 1994;15: 487-509. Adler M, Foster S, Grosskurth H, Richens J, Slavin H. Sexually transmitted infections: guidelines for prevention and treatment. DFID, 1998, I46 p. Allen JP, Maisto SA, Connors GJ. Self-report Screening Tests for Alcohol Problems in primary Care. Arch Intern Med 1995;155: 1726-1729. American Medical Association. Guidelines for adolescent preventive services (GAPS). American Medical Association, 1997,25 p. Baker D,Taylor H. Inequality in health and health service use for mothers of young children in south west England. J Epidemiol Community Health 1997;5I : 74-79. Calman KC. Equity, poverty and health for all. BMJ 1997;3 14:1 187-1191. Canadian Task Force on the periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121: 1193-1254. Centers for Disease Control. Prevention and control of tuberculosis in US communities with at-risk minority populations: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1992;

41:RR 5. Collectif. La prdvention des conduites A risque et les publics marginalis&. Prdvenir 1997 ; 32 : 103-158. Collectif. Prkvention, midecine ginirale et milieux difmorispS : Ptat des lieux et perspectives, seminaire europien, 23-25 octobre 1997. Bruxelles, Universitt catholique de Louvain, 1996,145 p. Ferris LE. Norton PG, Dunn EV, et at. Guidelines for managing domestic abuse when male and female partners are patients of the same physician. J A M 1997;278:85 1-857. Fontaa V, Senninger JL. Le mkdecin et le toxicomane. Heures de France, 1996,279p. Fries JF, Koop CE, Sokolov J, Beadle C,DeWright D. Beyond health promotion: reducing need and demand for medical care. Health Aflairs 1998; 17:70-84. Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners’ knowledge of their patients’ psychosocial problems: multipractice questionnaire survey. BMJ 1997;3 14: 10 14-101 8. Hamburg MA. Public health and urban medicine. Lancet 1996;348: 1008-1010. Hemmingsson T, Lundberg I, Romelsjo A, Alfiedsson L. Alcoholism in social classes and occupations in Sweden. Int J Epidemiol 1997;26:584-591. Hunter D, Fairfield G. Disease management. BMJ 1997;3 15: 50-53. James WP,Nelson M, Ralph A, Leather S. The contribution of nutrition to inequalities in health. B M 1997; 3 14: 1 545-1549. Klein JD. The National Longitudinal Study on Adolescent Health. J A M 1997;278: 864-865. Lebas J, Chauvin P, eds. PrPcarifP et santi. Flammarion, 1998,299p. Pilote L. Tulsky JP. Zolopa AR, et al. Tuberculosis prophylaxis in the homeless. Arch Intern .h4ed 1996;

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156:161-165.

Samet JH, Rollnick S, Barnes H. Beyond CAGE: a brief clinical approach after detection of substance abuse. Arch Intern Med 1996; 156: 2287-2292. Spence DPS, Hotchkiss J, Williams CSD, Davies PDO. Tuberculosis and poverty. BMJ 1993; 307: 759-76 1. US Preventive Task Force. Guide to clinical preventive services; an assessment of the effectiveness of 169 interventions. Williams & Wilkins, 1989, 335 p.

Volmink J, Garner P. Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ 1997; 3 15: 1403- 1406. Waddell C, Petersen AR, eds. Just health: inequalities in illness, care and prevention. Churchill Livingston, 1994,424 p. Worrall A, Rea JN,Ben-Shlomo Y. Counting the cost of social disadvantage in primary care: retrospective analysis of patient data. BMJ 1997; 3 14: 38-42.

Table 16. Excluded populations, access to care and preventiodhealth promotion in selected European countries. B c I gi u m

France

Gcrmany

Greece

Italy

Portugal

Spain

Switzcrland

I - Arc thcrc any mcdical/surgical proccdurcs cxcludcd from national systcm or public insurancc systcm7

YCS

YCS

Yes

ycs

ycs

YCS

yes

ycs

2 - 110 pcople without lcgal rcsidcnce status havc acccss to

(a) Health Insurancc (HI)? (b) public health sewicc (c) treatment?

no

no

no' no no

no

-

YCS

Y B

YCS

Yes

no no

ycs

ycs

ycs

no no no

(a) Health Insurance (HI)? (b) public health sewicc?

yes ycs

yes' yes

yes8 yes

yes yes

ycs

incomc incomc

no''

no no

no no

25 (06)

0 25 8 E'ld 0 0 0-100"'

0 30 0 0 0 100

0

no

3 - Do young citizens havc acccss to:

4- Arc thcrc any residence conditions (othcr than nationality / citizcnship) to be covcred by to

;:-

HI? no" yes"

havc frce access to drugs?

5 - Which (mean) Yo of cxpcnditure has to bc paid by patients for

h- Arc thcrc mass (public) scrccning programmcs for (if yes frcc of chargc '?)

*GPs consultation? Trcatmcnt (pharmacy)? Hospitalisation? Pregnancy survcillancc~ Childhood vaccination7 Dental Carc?

Breast cancer? (B)

* Cervical cancer ?(C ) * Colorectal cancer 9(R * Tuberculosis 9(T)

t k

tt

...

Pb

ttt

,..

( ( 4

...

Cbb

f

+ttt

.+., * , . I

bbbC

)

25 (10-15") 25 (0 to 100) 5 (1'9 0 0"' 25 (0") no no no + I - (yes)

YCS

40 (O* to 100) 15 f/d (0') 0 40-70

-+/-(yes)

.... no

no no no

no no no""

no no ?

Yes

Yes yes

0 30(0::') 0 0 0 I00

I oBS4 10

60-70

2f 30(0 1060) 0 0 0 100

no no no yes

yes (ycs) yes (yes) +/-(yes) ycs (ycs)

ycs (ycs) yes (yes) no ycs(ycs)

no11:' ycs (no"") no no

0 0 0

0 P

YCS YCS

no

25-40

c

Access to the public health services and to treatment is theoretically possible by means of a Royal Decree of 12112/96 on urgent medical aid But some public health service offer anonymous treatment for HIV, STD and psychosocial problems Unemployed (non-student) young people living alone and < 25 years old have difficulty in obtaining Social security coverage Young people without legal status arc excluded Since January I998 The personal contribution can be paid by the Public Social Aid Centre in the case of minimum income Exceptions e.g. asylum seekers with long term residence permits Specific reimbursement for deprived people Pregnancy surveillance and childhood vaccination are free only in Oflice of Birth and C'hildhood consultations Depending on treatment measures. e p dental prothesis For elderly (> 65 years old) People must pay the first 2.70-to-1500 Swiss Fr on an annual basis Ahovc this threshold. onlv thc given % have to be paid by people (up to 600 Swiss i:r ) Only recommended participation kxcept for asylum seekers in most federal states In some regions only, and only for insured people Only for insured people

10 10

10 1 00

2 2

I-..

s% 5

-tJ

a

if yes: targeted at any of the following populations (A)?

- Homeless (H) - IVDU (I) - Poor (P) - Fringe (sex-workers,prisoners, minorities ...) (Ma) - Migrants (Mi) - "Non speaking" people (N)

Belgium

France

Germany

Greece

Italy

Portugal

Spain

Switzerland

Yes

no

no

yes no no yes no no yes

yes T no no no no no

no

no

Yes

yes Yes no no

no Yes no no

Yes Y* Yes

Yes

YCS

no

no Yes no no

a a+l,Ma a a+I,Ma no a a a no no

a+I,P,Ma,Mi a+I,P,Ma,Mi a+I,P,Ma,Mi a+I,P,Ma,Mi no a+ I, P, Ma,Mi a+I,P,Ma,Mi a+I,P,Ma,Mi a+l,P,Ma,Mi no

1,Ma a+I,Ma a+Ma a+I,Ma a+I,Ma 1,Ma a a a no

a a+A a+/-A a+A a no a+A a a a

yes I Yes yes mostly

Yes H,I,Ma Yes no both

Yes I,H,P,Mi yes(Mi)

Yes H,Mi,N no no public

not specific

for I

I,H,P

T +IT no +/no

Yfew..,.. e no

Yes Yes Yes no

Y e Yes Y e

no a+I,Mi,Ma,P a+P a+I,Mi,Ma I,Ma no no a a+P no

no I a a+I I no a a no no

a a+I a+I+Ma a+I a a a a a a

9- Are there any specific primary care settings for any underserved population (A)? if yes, for whom? still accessibility problem (geographical, language/cultural, financial)? integrated preventive care? publiclprivatefNGO?

Yes I,H,P,Mi yes (I,H,P) no mostly private

Yes I,H,P,Ma,Mi yes no both

Yes I,H,Ma,Mi Yes Y e both

10- Same questions (9) with "mental health" programme

I,Mi

not specific

nottttt

I - Are HIV tests Are HCV tests

free of charge? anonymous? free of charge? anonymous?

Yes

yes

T no YH

8- Does country or region have any health promotiodeducation programme (public or

privateMG0) for gen. population (a) andlor targeted to underserved population (A)? about : - nutrition -H N - birth control - safe sexual behaviour - harm reduction - hygiene - alcohol

- tobacco - accidents (occupational, traffic, home) - domestic violence

*.let

ttttt

HIV and HVC tests are free of charge only for people with health insurance Except some specific clinics for traumatised refugees

yes Yes yes both

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Framework for describing the process of health promotion activities: the "Healthy School" programme at Sant'Elia, Cagliari, Italy Paolo Contu, Federico Argiolas, Gabriella Caria, Valentina Coroneo, Alessandra Mereu, Rita Muscas, SerafinangeloPonti, Josien Prompers, Clare Taylor

Introduction Process evaluation and programme evaluation aim to support and drive the process during its implementation, and later to reflect upon the results in relation to the situation in which the programme is being developed to see if the approach works and if changes are necessary. Process evaluation is the systematic monitoring of the implementation at all levels of programme and project activities. It is a way of learning from experience and using this knowledge to improve current activities and promote better planning by more informed selection of alternatives for future action. It involves collecting information and describing health promotion programme activities while the project is still running. Process evaluation is about how the results or objectives are achieved, in addition to looking at the outcome. These results will provide the information necessary to adapt or change activities before resources have been wasted, as well as highlighting those strengths of the programme that should remain the same. In other words, process evaluation provides ideas that can be used to develop and improve the functioning or operation of the programme. A research tool, conceptual h e w o r k , or evaluation model is not only needed to facilitate the process evaluation; it is also a must for good process evaluation. It helps to ensure that key concepts underlying an intervention, or key elements of the intervention. are measured or documented specifically in a standardised way. This paper will suggest a standard procedure of process evaluation using as example the Healthy School Programme carried out in Sant'Elia - Cagliari. The model is based on a pilot one, experimented in Cagliari in 1997, and includes specific tools for the measurement of community participation and inter-sectorial collaboration.

Situational context 1. Could you briefly characterise the setting? 2. When did the activity take place and how long did it last? Since September 1993 the Department of Hygiene and Public Health has been running a health promotion programme in the neighbourhood of Sant'Elia (about 6 000 inhabitants). An inter-sectorial group met from February to June 1994. Since September 1994 the action involved the municipality, in particular the alderman for social and health services and some inter-sectorial programmes were implemented. The most relevant programme involved the Department of Hygiene, the primary schools (pupils aged 6-1 1). and the most important governmental institutions in the neighbourhood. Since September 1996, these activities were unified in a "healthy school project", financed by the Regional Government, involving students, families, teachers, educators, volunteers in a shared health promotion strategy. This programme is still active, and is linked to some wider European programmes. In this neighbourhood more than 90% of the houses belong to the city council or to the government (a number of dwellings were built to house soldiers and policemen). 52% of the population has not completed compulsory schooling; 38% of the men and 66% of the

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women are unemployed. The dwellings are small (80 m2), normally with a bathroom, and often (57%) with central heating. The population is young (23% under 15) with large families (19% with more than five persons), and a high crowding index (1.05). The neighbourhood lacks services such as pharmacies, health centres, sport centres, a post office, a police station... Juvenile delinquency is higher than in the rest of the city. The experience of inter-sectoriality is very poor. Several institutions operate in the same community at the same time without following any co-ordinated plan. Collaboration often creates defensive attitudes caused by the fear of changing consolidated models, and sometimes by previous personal or political conflicts. The vision of the public management is often hierarchical and bureaucratic, and the citizens shows suspicion towards the institutions. Both public services and volunteer associations are used to working alone and are very secretive about their work.

Objective(s) I . What was (were) the objective@) of the activity? (Objectives must target results and not activities, be based on a need assessment; achievable, realistic, time limited, limited to a target population, clear and specific, measurable) According to the Ottawa Charter, the programme aims to enable citizens to increase control over and improve their health. As far as the neighbourhood is concerned, the main goals are: - To start a process of active participation in the community. - To improve the inter-sectorial co-operation among agencies, services, institutions, volunteer associations. - To improve the population’s health conditions. More specific objectives and activities were defined for the Healthy School Programme: - To foster HP skills among teachers. - To foster HP skills among researchers. - To give pupils better opportunities to develop their full physical, mental and social potential. - To foster community participation & the involvement of the wider community in school life. - To foster collaboration between schools, and between schools and Local Authorities. - To facilitate the opportunities of social aggregation. - To give more visibility to the schools and communities involved in the project. Description of the activity 1. Could you describe step by step how the activity was implemented, in other words what was done? In 1996 the Department of Hygiene and Public Health of the University of Cagliari obtained a 50 000 € grant from the Regional Government for health promotion in schools, the schools of Sant’Elia were selected for this programme. Teachers and researchers identified the objectives at four meetings held in September 1996. Training and planning activities were planned and implemented in order to build a shared vision and a common methodology among the different participants, and to define and monitor practical activities. In total there were 2 planning sessions in September 1996 and September 1997 and 6 or 7 programme meetings each year. For each objective several activities were planned and implemented. Some of these activities are extensively described in papers.

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Table 17. Description of the "Healthy School" programme at Sant'Elia, Cagliari, Italy Objective to foster HP skills among the teachers

to foster HP skills among the researchers to give the students better opsrtunities to develop their full physical, mental and social potential

to foster the community's participation and involvement in school life to foster collaboration between schools and between schools and local authorities to give more visibility to the schools and the communities

Activity planning / evaluation meetings courses (nutrition, infectious diseases) courses (psychology...) readers (nutrition, infectious diseases) building and experimenting education and evaluation tools

Documents Reports Readers Check list, ladder, participation framework Reports

planning / evaluation meetings building and experimenting education and evaluation toots international meetings readers, questionnaires, healthy nutrition: readers, questionnaires, posters, check posters, check lists, food lists, computer game, food letters, letters, journals, game journals, nutritional game, (cards,questions), preparation of carnival costumes, computer game, costumes, film, pupils book parade, table-cloths community analysis: photos, and posters interviews, posters, books table-cloths book, photos, posters infectious diseases: readers, lectures, game emotional growth: posters, books reader, game, film, evaluation, report posters, books participation in the students' costumes, film activities preparation of carnival table-cloths costumes, parade table-cloths report courses for parents report self-help group joint courses between the reports elementary and the high school newspapers participation of the political authorities in the activities newspapers participation in a city parade participation in a health education photos exhibit ion open school days photos newspapers, TV,reports newspapers, TV, etc

Development of participation and collaboration 1. who was involved in the activity (stakeholders)? 2. Describe the organisations and the groups involved in the activity. 3. Describe the stakeholders ' roles and responsibilities (diagnosis,planning, implementation,and evaluation). 4. Describe the decision-makingprocess, in other words by whom and how were decisions made? 5. Mark the level of participation in organising the activity.

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Table 18. A tool to measure the level of participation in the "Healthy School" programme at Sant'Elia, Cagliari, Italy 6

SELF-MOBILISA TION

Professionals take a back seat in the programme. People make independent decisions and develop own contacts. They have full control of planning and implementation of activities. Main funding found by people, who have control over its allocation. 5

INTERACTIVE PARTICIPA TION

People involved in a partnership with professionals in planning and implementing activities. Decisions made jointly and people contribute resources. 4

FUNCTIONAL PARTICIPATION

People more involved in decision-making process. Involved in developing programme and activities. Professionals still have control and make final decisions. 3

PARTICIPATION BY CONSULTATION

People consulted about the programme and their views listened to and acted upon if thought necessary by the professionals. Decision making role lies with professionals.

2

PARTICIPATION BY INFORMATION

People informed about the programme and activities. Involved in asking and answering questions. 1

PASSIVE PARTICIPATION

Professionals have full control of the programme, planning and organising activities, making contacts, and are responsible for the funding. People informed of plans.

0

N O PA RTICIPA TION

People not informed of plans, only of activities in which they are involved. People: This refers to all those involved in the programme other than the programme team.

6. How many programme meetings were organised to discuss this activity? How many people were invited and how many attended these meetings? Is there a written record of meetings? 7. Were all the representativesfree to decidefor their own organisation or did they have to refer to their hierarchy? 8. Who actually tookpart in the implementation (in comparison with what was planned)? Did any new partnersjoin in during the course of action? Did any partners leave during the intervention? Why? 9. Who actually took responsibilityfor the co-ordination of the intervention? Did the co-ordinationrun as smoothly as expected? Are there some aspects that should be modified? The programme, managed by university and schools, involved the pupils, their families and the community in general. The researchers and teachers defined objectives and activities during the planning meetings, on the basis of a joint process of needs assessment. For the strategic decisions the schools were represented by their top management. The operational decisions were taken jointly during monthly meetings, in which both teachers and researchers regularly participated. Researchers and teachers were involved according to their professional role in planning and implementing the activities. The evaluation was planned and carried out by the researchers and by a questionnaire, interviews and focus groups with the teachers. Most of the funding came from the university, but the school financed several activities. Resource allocation was a collaborative process. The collaboration between university and schools is therefore interactive.

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The parents reached a level of participation by consultation. They were consulted over the activities in which they were directly involved (preparation of costumes, parade, preparation of table-cloths, courses), but the decision making lay with the researchers and teachers. In the self-help group the parents implemented some activities. but always strongly supported by the experts. The pupils were involved in practical activities, in the high school they answered questionnaires and interviews, but they were only formally consulted for one project. Resources (persons,funds, services, manpower, technology, materials and equipment) 1. Which resources were used during the steps of the activity?

- Financial resources: amount and origin.

- Human resources:paid by the project, made available by public or private organisations, unpaid. Time spent by the partners on the management of the project. - Material resources: material given or made availablefor the project and origin of the material. 2. Approximately how much did the activity cost? 3. Whofinanced or contributed the resources? 4. Were the resources suficient? Ifnot, why? What other resources were needed? The main resource was the time and the work of the researchers, teachers, parents and children. Some postgraduate public health students and some local and foreign researchers were involved in the programme. Thanks to the regional funds we were able to buy technical tools and books, to give contracts to researchers and educators (18 0o0 € for the regional programme), to support educational activities (10 OOO € for the regional programme). The schools financed some activities: courses for parents and teachers. classroom activities for the children (partially). Development of the activity's process

I . Was the activity implemented as planned? If not, what went wrong? What unexpected (both good and bad) things happened and why? 2. Were any new objectivesformed during the activity? Ifso, what were these? The health promotion approach drove us to privilege flexibility and community participation, and prevented us from carrying out a rigorous control to respect the original plans. Several changes were made to adapt the programme to the needs and the ideas of the community. This programme highlighted the importance of finding new and appropriate indicators to measure some of the main objectives in health promotion. In this programme some indicators were developed and tested to evaluate these important objectives, which were changes in knowledge, behaviour, community participation, and inter-sectorial collaboration. Short-term eflects

1. Do you think that the objective(s) of the activity has (have) been achieved? Motivate your answer. 2. Do you think that the activity involved all the stakeholders (number of persons who attended meetings, read leaflets...)? 3. Do you think all the participants paid attention to and understood the message that the activiw was trying to communicate? Please motivate your answer. .for

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example did they like or enjoy it? Were they interested? Did they actively participate? Were they satisfied with their work? 4. Do you think the target group(s) understood and applied the message that the activity was trying to communicate? Please motivate your answer. 5. What was done to make the activity visible? A stable relationship was established between university, schools and social services: the teachers are more and more actively involved in the health promotion activities, contacts were established with some local authorities and communities, several educational tools (books, games...) were produced. The increasing commitment of the municipality, and particularly of the alderman for social services, is demonstrated by the latest city plans for social care, giving special attention to the neighbourhood, in which new activities are implemented and new resources allotted. The pupils were involved in several activities, and several documents (books, photos, games.. .) were produced with their active contribution. Questionnaires, games, and activities show the improvement of children’s knowledge and interest. As a result of the health promotion intervention some of the observed pupils’ habits changed for the better (nutritional habits, interest in the activities). To a certain degree the mothers participated in the activities, which had never happened before. This was visible in their enthusiasm in helping, and after a while their independence in making arrangements, showing increasing confidence in themselves and their abilities. For some mothers it was also the first time they had been involved in school life, and this enabled them to make new contacts. Good participation in the activities represents an important sign in a neighbourhood with a long history of inaction and frustration. The activities proved highly effective in giving external visibility to the whole health promotion programme, demonstrated through media interest and coverage. The programme was presented at a number of national and international scientific meetings, some papers were submitted to academic journals, some reports and dissertations were written. The results of these two years enabled us to make preliminary contact with a milk company, which could finance health education activities to improve milk consumption among children in the fiamework of the health promotion programme. Progress and future plans

1. In brieJ what are the most important learning experiences to be drawnfiom this activity? What changes or adaptations are needed to improve the finctioning of the activity? 2. What are the major strengths, weaknesses, opportunities and threats (SWOT analysis)? 3. Are you going to, or didyou, do an impact evaluation to assess whether the activity achieved its objective(s)? If so, how? If an impact evaluation was carried out what were the results? The activities with a fun and amusing approach (games for nutrition and infectious diseases), and those which were not limited to the classroom (carnival, table-cloths, community analysis with photos), were fruitful ways of increasing interest and knowledge among the pupils. The most notable were when the wider environment became involved in the activity (carnival, photos). The programme therefore needs to implement more community-wide interventions. According to Hurrelmann successhl health promotion cannot restrict itself to the topics dealt with in class, it has to address not only student’s cognitive development, but their entire ecological, social and emotional experience.

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Practical, short-term activities proved a good way to facilitate the participation of the community and to foster positive attitudes toward inter-sectorial collaboration. The teachers and the school management participated in all aspects of the programme, and wish to continue with it, working at the same level. For them participation in health promotion activities also represents an opportunity to increase their qualification. As does Dwyer, we believe their involvement was greater because the issues being dealt with emerged fiom their concerns, rather than being established by health professionals. The mothers participate in activities that concern their children without needing further incentives. The fathers were not involved, but this can be explained by the fact that most of the fathers consider that only mothers have to take care of the children. The parents need to be more involved in the programme for it to increase its level of community participation. At present they are only involved when invited by professionals and have no say in the actual running of the programme. They could be invited to participate in planning meetings with teachers, to air their views on the children’s needs and help to plan, organise. implement and evaluate the activities. The self-help group highlighted important difficulties in community empowerment. The women who participated in the group were very interested in sharing their personal and family experiences, but, when they tried to implement activities addressed to the wider community, they had to face the opposition of other mothers and some of the teachers. The group was not ready to overcome these problems, and, also because of some personal dificulties, all the participants left. This failure emphasises the need for prudence when asking people to assume control of the planning and the implementation of activities. particularly when their self-worth is still weak. Through the university the programme is related to international research groups, also thanks to the presence of four foreign researchers and students. A number of postgraduate Public Health students are also participating in most of the activities. The regional financing enabled some researchers to be hired. Unfortunately the regional financing has to be renewed every year, making long-term planning impossible. Moreover. the university team is not permanent (postgraduate students, foreign researchers. contracts.. .), which could jeopardise the sustainability of the programme. In the future, if the Sant’Elia programme is to rely less on the university, we need to find alternative resources, as the programme could not be continued without financing. Already, during the second year, a number of activities (courses for teachers and parents, books) were financed by the elementary and the junior high school. The national health system is not participating in the programme. By its very essence the health promotion approach is a challenge to a traditionally professionally dominated field. A major obstacle to community participation being fully accepted by the health sector is that the current health care system would require a massive change. According to Brownlea such a transition, fiom filial passivity to a partnered advocacy. represents a value change that is quite dramatic. The local Public Health approach is more traditional and less participatory, with professionals having full control over the programme, planning and organising activities, making contacts and being responsible for the fimding. A finther difficulty is represented by the conflict between the University and the National Health System, competing for the health education market.

Bibliography Arnstein SR. Eight Rungs on the ladder of cituen participation. In: Vaandrager, HW. Constructing a healthy balance: Action and Research ingredients to facilitate the process of health promotion. Wageningen: Department of Communication and Innovation Studies. Agricultural University. Doctoral Thesis. 1995

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Boonekamp GMM, Vaandrager HW, Koelen MA, Kennedy-Haynes L. Travelling through health promotion land. Guidelines for developing and sustaining health promotion programmes, derived from a European experience. Valencia: Institut Valencia d’Estudis en Salut Pliblica 1995. Brownlea A. Participation: myths, realities and prognosis. Social Science Med 1987; 25: 605-614. CagIiariNageningen: Department of Hygiene and Public Health, University of Cagliari & Department of Communication and Innovation Studies, Wageningen Agricultural University MSc Thesis, 1997. Contu P, Congiu C. Health promotion through community participation: project for Sardinia. Health in cities: a global conference. Research and Change in Urban Community Health: Avebury Aldershot, 1995, 359-376. Contu P. Action research methodologies in monitoring and evaluation: difficulties and challenges. Paper for the International Conference on Health Promotion and Nutrition, Wageningen, The Netherlands, 25/26 January 1996. Contu P. I1 ruolo della scuola nella promozione del consumo di latte. “Latte nascere ogni giorno” Relazione a1 Congress0 Nazionale Straordinario di Pediatria. 1997, 6- 10. Contu P, Coroneo V, Ponti S Un’esperienza di promozione della salute nella scuola. Educazione Sanitaria e promozione della salute 1998; 2 1: 44-53. Contu P. Verso una diagnosi di comunita: Cagliari vista attraverso il censimento generale della popolazione. Piano socio-assistenziale del Comune di Cagliari, 1998. Denman S. Do schools provide an opportunity for meeting the health of the nation targets? J Pub Health Med,1996; 16: 229-224. Downie RS, Fyfe C. Health Education in Schools. Ethics in Health Education, 1990;125-144. Dwyer J. The politics of participation. Com Health Studies 1989; 13: 59-65. Hurrelmann K, Leppin A, Nordlohne E. Promoting health in schools: the German example. Health Prom Int 1995; 7: 53-59. Israel BA, Cummings KM, Dignan MB, Heaney CA, Perales DP, Simons-Morton BG, Zimmerman MA. Evaluation o i health education programmes: current assessment and future directions. Health Educ Quart 1995 vol. 22, no. 3, p.364-389. Kalnins IV, Mc Queen DV, Backett KC, Cutrice L, Currie CE. Children, empowerment and health promotion: some new directions in research and practice. Health Prom Int 1992; 7 : 53-59. Kalnins IV, Hart C, Ballantyne P, Quartaro G, Love R, Sturis G, Pollack P. School-based community development as a health promotion strategy for children. Health Prom Int 1994; 9: 269-279. Kemm JR & Booth D. Promotion ojlzealthier enting. How to collect and use information for planning, monitoring & evaluation. London: HMSO 1992. McGraw SA, Stone EJ, Osganian SK, et al. Design of process evaluation within the Child and Adolescent Trial for Cardiovascular Health (CATCH). Health Education Quarterly, suppl. 2: Process Evaluation in the Multicenter Child and Adolescent Trial for Cardiovascular Health (CATCH), 1994, S5-S26. Pirie PL. Evaluating health promotion programs. Basic questions and approaches. In: Bracht N, ed. Health promotion at the community level. Newbury Park, Sage Publications, 1990, 201-208. Porcu S, Argiolas F, Congiu C, Coroneo V, Contu P, Perrier MP. Building intersectorial cooperation in a lowincome neighbourhood of Cagliari. International Healthy and Ecological Cities Congress, 1995: 13-1 8. Pretty JN. Regenerating agriculture: policies and practice for sustainability and self-reliance. Earthscan Publications, 1995. Prompers J. Nutrition Promotion in Schools. Research to develop and implement an instrument for a process evaluation of activities carried out in schools in Sardinia about healthy nutrition. Ritkin SB, Muller F, Bichmann W. Primary health care: On measuring participation. Social Science Med 1988; 26: 9: 93 1-940. Taylor CE. Measuring community participation and changes in heulth hehaviour in a health promotion progruninie in Sarcfegnu Italy. Dipartimento di Igiene e Sanith Publica - Cagliari, 1997. Vaandrager HW. Constructing a healthy balance; action and research ingredients to facilitate the process of health promotion. Wageningen: Department of Communication and Innovation Studies, Wageningen Agricultural University. Doctoral Dissertation, 1995.

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SMILE: a tooth decay prevention project among children of asylum seekers in Geneva Soph ie Du r ieu x -Pai I 1ard and Francesca Mu rat i -Ross i

In Switzerland, the number of asylum seekers from Bosnia and the Kosovo has steadily increased since the beginning of the war in ex-Yugoslavia. In Geneva, by the end of 1995. these two nationalities represented more than 50% of the 3 500 asylum seekers residing in the canton. Of the remaining 50%, 30% were from Africa (mainly Zaire, Angola and Somalia), and 20% were of various different nationalities. On arrival in Geneva, the phvsical state of health of the asylum seekers is globally correct, particularly among the young adults and the children. However their mental health is fragile, due to the violence and traumas which they have suffered in their country of origin. If necessary, medical and/or psychological care is organised following the screening performed during the border health examination. In the canton, the co-ordination of the health measures for asylum seekers is chiefly ensured, in collaboration, by two organisations. On the one hand the Travel and Migration Medicine Unit (UVM- Department of Community Medicine, University Hospital of Geneva) which ensures border health examination and is specialised in the care of migrants victims of violence. On the other hand, the Migrants Health Centre (CSM-Geneva Red Cross) with a network of nurses ensuring the care of asylum seekers recently arrived at the mass-accommodation centres. At the administrative level two structures ensure assistance and act as the relays of the Federal Office of refugees in the canton: the AGECAS (Geneva Association of Reception Centres for asylum seekers) which looks after the asylum seekers during their first year, and the Refugee Department of the General Welfare Centre which takes over after that period. Since 1996, the asylum seekers are affiliated to an insurance fund on arrival in Switzerland. However, dental care is not included in this insurance. If the asylum seekers do not have funds, the Refugee Office provides a guarantee of dental care which covers treatment up to the sum of 2 O00 FS. The need to set-up a dental prevention project arose from the realisation. in 1992. of the deplorable state of dental health of the asylum seekers recently arrived in the canton. Africans, who were the most common asylum seekers before 1992, traditionally have good dental hygiene practices. However, the ex-Yugoslavs arriving from Bosnia and the Kosovo had serious dental pathologies due to tooth decay and its consequences. even among young children. It was therefore decided to establish a tooth decay prevention programme for the children of the canton’s asylum seekers. A request for financing for this programme was made to the Swiss health promotion foundation in September 1993. The Hans Wilsdorf foundation has also awarded financial support to this project. Thanks to this the initial project, which was simply to develop educational material adapted for foreign children. now includes an epidemiological facet. ,4\this project needed dental health expertise. active co-operation was established with the Department of preventive dental medicine of the Dental medicine faculty of Geneva. ( D r F. Murati. Prof P.C. Baehni).

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Objectives To evaluate the prevalence of oral disease among a representative sample of asylum seekers recently arrived in Geneva, stressing possible geographical differences. To elaborate and set-up a tooth decay prevention programme, for the children of asylum seekers and their mothers.

Methods For the survey of the prevalence of oral disease the WHO standardised method of ''oral studies" was used. The objective was to discover the prevalence of dental damage, among asylum seekers recently arrived in Geneva, and to highlight possible differences according to their geographical origin. It was carried out on a representative sample of 200 persons. The indexes used were on the one hand the DMF index, which gives the average of Decayed, Missing and Filled teeth per group, and on the other the proportion of subjects without decay and those of subjects with active decay. In view of the subjects targeted the prevention programme stressed two angles: play in the teaching material (snakes and ladders, video game, story) and the use of images, the populations concerned being mainly non-French speaking. It was also necessary to train dental health "supervisors". These were from the various linguistic communities, but also spoke French, in order that the prevention message be more interactive during the prevention sessions.

Results Prevalence survey The survey performed in June 1994 on a sample of 200 asylum seekers divided into 3 age groups (5-9, 15-19, 35-44 years old) confirmed the doctors and nurses "clinical impression". On the basis of the WHO norms which evaluate the DMF index as very low if it is between 0.0 and 1.1, moderate between 2.7 and 4.4 and very high above 6.6, one can consider that the dental condition of the adults was mediocre, this was particularly clear among the ex-Yugoslavs. Thus, whatever the age group concerned, the Bosniacs and the Kosovars had two to seven times more decayed, missing, or filled teeth, because of decay, than the Africans. The situation among the children was even more extreme: the milk teeth of the young Bosniac children were 7 times more damaged by decay than those of the African children. The detailed results of the survey are shown in Table 19. Prevention programme In view of the results of the survey and the administrative constraints (dental care for children is subsidised by the State in the canton of Geneva and the sum of 2 000 FS guaranteed by the Refugee Office is sufficient to provide the necessary care), the prevention programme targeted the population of children of asylum seekers, in Geneva under a year. The parents and in particular the mothers were also invited to the prevention sessions. Three young women from different linguistic communities (a Bosniac, an Angolan and a Somalian), who all spoke French well, received a brief training as dental health 1919supervisors", at the faculty of dental medicine, in 5 half-days. The training programme explained, in simple terms, the causes of oral disease and the main prevention axes. The last morning was devoted to the usage of the educational material. 'I

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Table 19. Prevalence of dental decay according to the subjects’ age groups and origin, SMILE project, Geneva, Switzerland, 1994. Age (no of subjects)

Subjects without dental decay PA)

Subjects with active dental decay (YO) milk teeth

DMF Index

DMF Index

Only milk

Final

teeth

teeth

mean (sd)

mean (sd)

final teeth

Population 1.6 (2.0) 22.2 50.0 22.2 5.5 (4.6) 5-9 years old (72) 11.1 --57. I _6.0 (5.5) 15- 19 old (63) 3 5 4 years old (55) 14.5 -61.8 -10.0 (8.2) Persons from ex-Yugoslavia (no=l28) 5-9 years old (55) 2.0 (1.9) 5.5 61.8 29. I 6.9 (4.3) --54.3 -9.2 (5.1) 5.7 15-19 old (35) 35-44 years old (38) 0.0 --68.4 14.1 (6.9) Persons from Africa (n0=62) 5-9 years old (1 7) 76.5 11.8 0.0 0.8 (2.1) 0.0 (0.0) 15- 19 years old (28) 17.9 --57.1 -3.2 (4.2) 3 5 4 years old ( I 7) 47.1 --47. I 2.8 (5.0) This table is read in the following way:for example, 61.8% of the childrenfrom ex-Yugoslavia aged between 5 and 9 years old have at least one actively decayed milk tooth, as opposed to 11.8% among the African children. The children from ex-Yugoslavia have on average 6.9 decayed, missing or filled milk teeth /DMF index), as opposed to 0.8 DMF milk teeth among the African children. I

A first series of 5 sessions took place in the AGECAS housing centres. during the autumn holidays, in November 1995. The children and their mothers were notified, a week before the date of the session, by the nurses of the Migrants-Health Centre who regularly visit the housing centres. About a hundred children between 4 and 12 were thus contacted. Most of the time the three supervisors intervened simultaneously, depending on the nationality of the children present at the sessions. The sessions always followed the same schemes, starting with an informal discussion: “have you never had toothache?” Then the supervisors, using the posters and a document, explained in images the causes of dental decay and the means of prevention. Following there was a games session: snakes and ladders for the smallest children. computerised test-game for the older children, with the printing of a 1919diploma” attesting having passed the test. A good for the teeth snack, followed by a collective toothbrushing session closed the session, which in all lasted about an hour and a half. Each participant (children and adults) received a toothbrush and a tube of toothpaste. The children also received a black and white copy of the snakes and ladders game, colouring pencils, and the document. An 8’3”’ videocassette provides a glimpse of the content of a session. A second series of 3 sessions took place during the 1996 February holidays. There were about fifty participants, including 15 children who had already benefited from the first session (after the first year asylum seekers leave the AGECAS for another institution). All the children following the programme for the second time said that they brushed their teeth twice a day. They could spontaneously name 3 tooth decay provoking foods and 3 foods that do not provoke decay.,

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Discussion The impression (inevitably subjective) of the persons in charge of the programme is that globally, the programme's objective has been attained: the children have been made aware of dental problems, the mothers who participated in the sessions were able to grasp the importance of dental care. Obviously it is difficult to know whether the knowledge acquired will be put into practice, in the long term. A formal evaluation of the programme's efficiency in terms of impact on the incidence of tooth decay among the children, cannot be undertaken with simple means, in the context of mobility and precarious conditions which characterise asylum seekers. At present, those persons who participated in the programme are no longer housed by the AGECAS but have either returned to their country of origin, or are dispersed in apartments throughout the canton. The discussions which we were able to have with persons in charge of dental programmes in other countries, when we presented this project at various colloquiums, confirmed that this type of prevention works and has an impact on children, at least for some time. To launch a costly evaluation to be sure is not among our objectives. Also, for the children who will continue to live in Switzerland, we count on the reminder " effect of the dental prevention programmes in schools, which take place each year. Directed towards children who are already aware, and speaking better French, they will have a positive effect. During the conception and realisation of this programme, the problem of how to carry out prevention among populations in precarious situations, who are physically, psychologically and economically deprived, was raised in a general manner. Most of the mothers and the children who participated in these sessions had, apart from exile, recently lived through war situations, with all this implies - death, violence and exodus. Also, on arrival in Geneva, the problems of daily life are other than health: "What has become of my family which stayed behind, how can we live in such a different context, learn the language of this country, manage on such a small budget...". As this was oral disease, for which mortality is virtually nil, we feared that it would be difficult to stimulate the asylum seekers' interest at information sessions. However, we were surprised by their enthusiasm for the project. The dental sessions sometimes went over the allocated time and were the occasion to talk about nutrition, health in general, and sometimes also of the child-parent relation in this new context of exile. It is also probable that our visit to the hostels broke the daily monotony. If we now plan to routinely maintain this programme, it will be necessary to train new dental health supervisors (in particular for Albanian speakers), a part-time nurse will also be needed to ensure the global co-ordination of the programme, under the supervision of a dentist or a doctor. The role of these supervisors is primordial, the person who led the sessions in Bosniac had nursery school training and her sessions were very well followed. 'I

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Influence of the social characteristics of patients on the behaviour of physicians as regards prevention within a hospital outpatients consultation Michele LCvy-Soussan Introduction

In France, the level of achievement of preventive care is globally weak among the general population, and prevention sessions greatly depend on socio-economic level. The data concerning social disparities in terms of access to care, excess mortality and avoidable morbidity challenge the different participants of the care system, in particular hospital professionals. As poverty increases, so does the number of people who. no longer having access to general practitioners' surgeries (usually the fiont line of prevention). go to hospital emergency services or outpatients clinics. Do hospitals fulfil their prevention mission, in particular as regards those for whom the hospital is the only contact with the health structures? Can hospitals contribute to the "correction" of certain health inequalities? The study proposed is a case-control study of the influence of the patients' social characteristics on the behaviour of physicians as regards prevention, within university hospital consultations. Our hypothesis is that there may exist a social differentiation of medical practices and that the practices to detect morbid situations (that are. themselves, socially stratified) are not equitably applied. The US Preventive Services Task Force advances the need for clinicians to seize all opportunities to practice preventive medicine among people whose access to care is limited. It seems to us that, in order to optimise our health care system. hospitals should not contribute to social inequalities in health, and should even seize the opportunities to ({correct))certain inequalities. Material and methods

The study is a case-control study of the behaviour of physicians as regards prevention during university hospital consultations. Two populations consulting at the Same medical polyclinic were compared: one without social coverage, which does not pay for care (cases), and the other with health insurance (controls). In some hospitals, such as the one where this study was performed, care is free for all persons attending the outpatient consultation and who are, for whatever reason, without effective social coverage, or unable to advance the costs or pay their share of the costs. An outside person administered the questionnaire, before the physician or the social worker received the patients. Various types of data were collected: - socio-demographic: sex, age, place of birth, job, socio-professional categop. neighbourhood and possible changes, housing conditions; - frequency, places, circumstances and reasons of need for care; - preventive medical practices at the time of previous hospital consultations. Regarding these practices, the themes were chosen both from the French High Committee of Public Health (HCSP) data concerning avoidable mortality and morbidiv. and from the Canadian study group (Goldbloom 1996) data and its American counterpart (USPST 1996). These data concern the elements of periodical medical examinations that have shown their worth in the improvement or the protection of the population's health.

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We thus retained the medical attitudes of prevention towards tobacco, alcohol, arterial hypertension, depressive syndromes, drug abuse, condom usage, and at-risk behaviour as regards HIV. The preventive attitude, during hospital consultations, towards cancers of the cervix and the breast was also assessed among women.

Results and discussion In total, 126 cases and 113 controls agreed to answer the questionnaire (66 refusals), which was well accepted. We systematically specified to the patients that the questionnaire was strictly anonymous and confidential, and that they could, of course, refuse to answer. Results show a significantly different distribution of the socio-demographic data and of consumption of care in the two populations. In comparison with the controls, the cases are younger; most of them (89%) were born outside France and 90% are unemployed but do not receive unemployment benefits; 22% are without profession. Also compared with the controls, a lower proportion of patients has stable housing (75% versus 94%); but only 3% is homeless, as opposed to 1% of the controls. These data are common in free consultations in hospitals: a mostly young male population, a high and increasing proportion of foreign patients (because careful social follow-up enables the recovery of social insurance and entry into the Social security system whenever possible), and major housing and employment difficulties. However, these consultations, mostly located at the very core of a hospital service, probably receive fewer excluded (such as, for example, homeless people) than other reception structures such as emergency services or care centres which are closer to the street. Among the cases, the frequency of resort to care is lower, notably in ambulatory medicine, and these patients essentially consult only when they cannot do otherwise. 43% of the cases heard about this consultation from NGOs or charitable associations. Among the cases the motives of resort to care are most frequently infectious and stomatological problems and, in hospitalisation, gynaecological problems. The high rate of stomatological motives can be explained by the existence in our hospital of a free stomatological consultation. It is interesting to note that, among the cases, more than 11% of the patients now come to the hospital to consult the social worker. The breadth and complexity of the social problems encountered by these patients deserves that, more than twenty years after the law separating health care from social care, this new but insufficiently recognised role that has fallen to the hospitals should be thought about. There is a marked difference between cases and controls as regards the preventive attitude of the hospital and the consulting physicians. The ((precarious))patients (cases) are significantly less questioned as to their consumption of tobacco (53% versus go%), of alcohol (45% versus 64%), the existence of depressive syndromes (29% versus 58%); blood pressure is less frequently measured (69% versus 84%), and reminders to have a cervical smear or a mammography performed when necessary, are less frequent. However, the generalised lack, without distinction between the two populations, of advice given to patients with detected consumption of tobacco or alcohol is striking, as is the absence of proposals of help to try to reduce this consumption. The only preventive advice that seems to be given - and this more frequently to ((precarious))patients - concerns the use of condoms. If one considers the high proportion of patients of Afiican origin among the cases (83%), and the lack of other preventive advice, one can wonder about the meaning of such messages.

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Conclusion

This study shows, as have others, that some "socially determined" morbid situations (addictive behaviours, severe disturbance of the thymus....) as well as certain risks and diseases (arterial hypertension, cancer of the cervix, cancer of the breast) too often escape routine medical care. Thus, despite a high prevalence of anxio-depressive syndromes among the excluded, the physician will most often not detect this problem whereas he will Frequentl) seek it in a socially inserted patient. Although the reasons influencing or aggravating the health problems of vulnerable populations mainly involve determinants other than access to care, the health precariousness correlation is, nevertheless, symptomatic of a certain dysfunction of our health system and its maladjustment to the living conditions of the underprivileged. But the deficiencies in prevention also concern patients with health insurance and reveal the lack of caring culture in this domain (counselling, health promotion, co-ordination between hospital and ambulatory, prevention guidelines, tobacco and alcohol consultations, nursing consultations, etc.). The university hospital, in the absence of a regulation system - such as "referent" co-ordinator - is solicited as a primary care structure but it neither performs this screening mission, nor refers to other types of structures. In this context, the WHO has established a programme named "Hospitals Promoters of Health". Health promotion sets the health systems three major challenges: prevention, greater equality in access to care and better care of chronic disease. In the United States, disease management strategies centred on sick persons or those with at-risk behaviours have been retained among priority research axes as regards prevention. Such strategies seem able to reduce social inequalities in the resort to both the curative and the preventive care system. Prevention cannot be conceived and practised without taking into account psychosocio-cultural differentiation factors. Indeed, individual behavioural changes are dependant on prior history, experience, trajectory, and desires. Questioning the knowledge on which prevention is based can reveal the possible slip-ups from scientific norms to moral and social norms. Thus, biomedical science alone can neither be a substitute to ethical references nor to political decisions regarding prevention (systematic HIV screening being an example in point). Bibliography Aiach D. Cebe D. Symptomatologie et conduites de maladie. Paris, Rapport au M i n i s t h de la Sante, 1982. Baudier F, A&nes J. Barom2tre santP adultes 95-96. Vanves, CFES, 1997. Department of Health and Human Services. Put prevention info practice and action kit. Washington DC, O f i c e GP, 1994. Farrel M. Drug misusers: whose business is it? B U I 1997; 3 15: 559-560. Gornick M, Eggers P, Reily T, and al. E&ts of race and income on mortality and use of service among Medicare beneficiaries. N Engl J Med 1996; 335: 797-798. Guignon N. L e s consommations d'alcool, de tabac et de psychotropes en France I991 - 1992. Solidarrte Same 1994; 1: 171-185. Guillemin F, Paul-Dauphin A, Virion J, Briancon C. Profil de santd de Duke. Sanre Publique 1997: 9: 35-44 Huas D, Dame B, Rueff B, Lombrail P, Leblanc B. Maladies alcooliques et consultations de medecine gCnerale : prdvalence et detection. Rev Prar 1990; 8 1 . 45-49. Kristenson H, Ohlin H, Huten-Nosslin M, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months and long-term study with randomized controls .4icooI Clrn Experim Research 1983: 7. 203-206

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Lebas J, Chauvin P, eds. Prbcaritk et santb. Paris, Flammarion, 1998. Physicians ACO. Inner-city health care. Ann Intern Med 1997; 127: 485-490. Samet J, Rollnick S, Barnes H. Beyond CAGE, a brief clinical approach after detection of substance abuse. Arch Intern Med 1996; 156: 2287-2293. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1998; 297: 663-665.

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Establishing health promotion programmes among migrant Rom populations living in precarious conditions in Europe:identification of the health determinants to elaboration of a transnational network Farid Lamara, Anabelle Gilg, Michele MCzard and Catherine Richard Objectives

The morbidity of the Rom - a migrant ethnic minority - living in precarious conditions in the European Union is similar to that of vulnerable groups in major difficulty. The ROMEUROPE network has collected quantitative and qualitative data in 3 member countries (Spain, France and Greece) in order to attain 3 objectives: - Identifjl the main determinants of the Romas' state of health (from data analysis) with Rom associations and six countries to which Roma migrate: France. Germany, Greece, Italy, Portugal and Spain. - Elaborate health promotion programmes (on the basis of the main determinants identified) responding to the public health needs of the populations involved and appropriate to the health systems of the member countries. - Promote public awareness among all the member countries of the European Union - and the migrants' countries of origin - of the need for health promotion programmes for the Roma. Context

Since April 1992 Mdecins du Monde - Mission Banlieue - (Suburbs Mission) implanted in the far suburbs north of Paris, has performed an evaluation of the state of health of the Rom population from Romania in the Departments of Hauts de Seine, Yvelines. and SeineSaint-Denis). The suburbs mission made 173 visits to "unauthorised" camps, during which 2 350 consultations took place. The data collected during these consultations have been the object of several reports relative to the sanitary condition of the camps, the pathologies encountered, and the actions undertaken to improve the state of health (primary prevention. orientation towards care structures, medical follow-up by the suburbs mission's team in partnership with the health establishments). A first programme, elaborated by the suburbs mission of Medecins du Monde, to improve the state of health of the Rom population was presented to the European Commission's DGV, and received financing in 199311994. The reports submitted were: "Medical interventions for access to care of the Rom population from Romania in the Hauts de Seine Department (France)", September 1994; and "Exploratory study of the life and identity strategies of the Roma of Romania, Reflections on the encounter between the Roma of Romania and Medecins du Monde", October 1995. Systematic collection from January to May 1997 of data of the Roma's state of health has made it possible to assemble trustworthy knowledge of their health problems. The conclusions were reported in October 1997 in a medical doctoral thesis: "The nosology of poverty: the case of the Romanian Roma in the Ile de France" Dr.H.Picard. A European network: the Romeurope network was established in September 1997 to link, in the last trimester of 1998, 6 member countries of the European Union: France. Greece, Spain (initiating countries), Germany, Italy, Portugal (countries which joined the network at a later date). It brings together associations of members of the Rom community. or working with Rom populations. Rom mediators and national missions of Medecins du

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Monde. A Steering Committee, composed of health professionals, was created in order to ensure the activity’s conception, establishment and survival.

Know-how The first of these activities was to collect a bibliography of the scientific works existing in the area of human, social and health sciences, in particular concerning the problems (ethnic, migratory and precarious conditions) of the Rom population. The Romeurope network has thus collected the international legal texts, the recommendations of the Council of Europe, activity reports of national and international associations, press articles, and the publications relating the actions initiated by the Roma in the member countries. The Romeurope network collaborates with several academic institutions (INSERM, CNRS, CRT, CERMES) recognised in the above mentioned scientific domains. Members of these institutions, and an expert, himself from the Rom population (Union Romani International), constitute the Scientific Committee, referring and guaranteeing the methodological activity of the Romeurope network and its ethics. The experience of the Romeurope network and the first results explain why Medecins du Monde, regarding the migrant European Rom population, deplores the absence or insufficiency of: - synthetic and analytic data of the determinants of their state of health, - conception and application of public health promotion actions, - transnational co-ordination - community health promotion, information and education policies among this population. Tools

Tools have been elaborated in order to collect, in the three initiating countries, the health, socio-demographic and ethno-sociologic data, which will be analysed. - questionnaires (between 600 and 900) will be administered to the target populations in order to collect health and socio-demographic data - a research protocol was written for a qualitative ethno-sociologic study, based on interviews held among the different target communities. Description of the project

I . Identflcation of the main health determinants A biostatistician is in charge of the treatment and the descriptive analysis of the health and socio-demographic data collected from the questionnaires. Ethno-sociologic study: a social sciences researcher will analyse the interviews performed. He will identifl and hierarchically order the expectations and the needs expressed by the populations, as well as the obstacles to access to health. Following this, the analysis will be turned into a synthesis report in French and translated into 6 languages (German, Spanish, Greek, Italian, Portuguese and Romani). - A Seminar will be organised at the end of this phase in order to deliver the first results of this research and compare them with those of the associations not belonging to the Romeurope network, and particularly the associations of the Eastern countries, members of the International Romani Union. - Steps will be taken towards the realisation of a Colloquium involving the 15 member States: place, speakers, organisations, institutions, political and scientific authorities concerned by the public health of the migrant Rom populations in Europe.

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2. Elaboration of programmes Workshops will bring together the Steering Committee, the Scientific Committee, and the various partners fiom the 6 countries. They will identie the real perspectives to setup fiture health promotion actions, in accord with the data previously collected and analysed. 3. Presentation of the health promotion programmes and the colloquium A report will be written in French and translated into 6 languages, presenting concrete propositions, health promotion programmes, and establishing a descriptive synopsis of appropriate actions in order to improve the state of health of the target population. The colloquium will present all the work and enable the suggested programmes to be known in order to incite awareness of the health question of the Roma within the European Union. The particular objective of this colloquium will be to launch the programmes in the other member countries of the European Union. 4. Feasibility study of the programmes A public health professional will undertake a feasibility study and develop the methodological tools necessary to evaluate the progress of health promotion action programmes, taking into account the health systems of the member countries of the European Union. The tools thus conceived during work sessions with the other public health professionals (institutions, associations, Rom communities), will be submitted to the Scientific Committee for methodological validation. The same will be true of a report on the feasibility and the possible pitfalls. This phase will make it possible to establish health promotion action programmes in each of the 6 member countries of the Romeurope network. 5. Commitment to observance of the programme Programmes destined to improve the state of health of the target population will be established. An evaluation will aim to validate the establishment of the programmes by the structures and the participants already mentioned, according to the method chosen and the tools elaborated during the feasibility study. The evaluation will be validated by the Steering Committee, the Scientific Committee, and the International Romani Union experts. 6. Publication of the results in the 15 EU member countries The final report in French will be translated into 7 languages (the 6 mentioned above and English). The health promotion action progrrunmes which can be duplicated by the European Union member States will thus be presented with the results of their evaluation among the populations. All the European countries being concerned by the Rom question, the results obtained by the Romeurope project on the scale of the 6 member countries will then be given to the other 9 member states of the European Union. The research performed beforehand, and the development with the evaluation of the health promotion programmes in 6 countries will be the guarantee that this is replicable on a global European scale.

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A workshop for HIV+ African women living in Paris Joelle Sauniere and Mikael Guezelot Introduction

These educational workshops took place from 1995 to 1998 at the H6pital Saint Antoine Polyclinic, on the initiative of the social worker and the head nurse, The reflection that enabled the elaboration of this project was due to a confrontation of different practices and different jobs. Paramedical and social personnel put together, which was not usual, their knowledge of, and their approaches to, a problematic situation that was not easy to handle. Indeed, the encounter of several sets of circumstances within one place, i.e. the establishment of consultations specialised in the care of HIV+ persons providing easier access for the most destitute, favoured the encounter of certain categories of the population who up till then were excluded from the health system, and the prevention system, if this exists. We were thus able to identify a certain number of African women who had been referred to us by various associations for medical follow-up. Their paths had been simple, that is: the first phase is the revelation of sero-positivity. Either, the family knows and very radical decisions can then be taken, such as the exclusion of the person from the family clan and even the news being spread within the family in Afiica. Or, the family does not know and from then on the young woman shuts herself into a solitude which does not allow for an understanding of the disease and thus the way is open for the maddest beliefs. We therefore thought about how to find a way for these women to, little by little, come out of their isolation. Objectives

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Knowledge of the HIV virus, the disease, prevention, nutritional hygiene, life hygiene, "living with" when one is destitute and without resources. Create a homogeneous group with this diffuse, de-structured population, give them back the desire to fight for life. Reconstruction of a relational network in a common place: the hospital.

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Educational: discovery of the body, the anatomy, the virus, the disease. Alternated with legal knowledge, rights etc. Nutrition: daily nutritional needs, how to feed oneself on a small budget. During the first meetings, lively discussions took place between the women and the two organisers. In their culture any disease can be cured, in their logic "God can cure everyhng if he wants to" which explains the resort to traditional medicine. They also discussed their arrival in France. Why did they come? Some of them came to improve their financial situation, to help their family. More frequently they came to follow their husband, their companion. But they all declare that when it was discovered that they were HIV+, they were thrown out. However, one says that "in love, one cannot give death". Guilt feelings, "God does not punish through meanness, but to make me understand...", but why me? Why now? One

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feels that they have no mastery over sexual relations. and even less over prevention because the questions flow: "Why must an HIV+ woman be careful? Careful about what, how?" We realise that these women receive the correct care for their illness, even at the gynaecology consultations, but the latter are too technical. They have not understood what was said. They feel that for men, they are still desirable objects that cannot bring death. But who cares about the esteem which women have for themselves? Nobody. Educational workshops We work a lot around the anatomy, the body Tongues loosen among us. We talk of the age at the first sexual relations. of "forbidden contraception", of prevention and finally we get to condoms. We explain to them that for us also, before 1981, the condom was "prehistoric", something rarely used. that had a vulgar connotation and for tendentious behaviours. For us also, in Europe, taboos had to be overcome for this "plastic-love-killer" (as one of them calls it) to be accepted. Discussion of the virus, the disease. Outside speakers: doctors, midwife.biologist The participants express their views regarding at-risk groups (IVDA, sex-workers. homosexuals, tourists). By means of educational tools, we bring them to understand that it is necessary to talk and think about at-risk behaviours rather than groups. Discussions, debates around selected films The basic representations of the red and white corpuscles interest them more than we imagined and the understanding of this something, invisible to the naked eye, starts to be more concrete. Some outside speakers helped us: thanks to a biologist with a microscope the women were able to see some parasites on slides; a doctor came to speak about the treatments; and finally a midwife helped us to clarify the possibility or not of pregnancy. Many questions about the baby. survival and the hope of these women so longing to give life.

The legal information workshops

The objective of these workshops was to provide information about the steps that they could take and to discuss each one's experience. The subjects discussed were: - Social cover with and without papers. - The possibility of regularising their administrative situation: the precautions to take when trying to do this. - The various benefits to which they would be entitled with these new administrative documents. - Understanding the measures taken for them in other structures. - The re-appropriation of their future. The nutrition workshops

In these workshops theoretical and practical sessions were alternated. The theoretical sessions were based on a keen analysis of each person's budget. An attempt at nutritional equilibrium was made according to three criteria: Thefinancial component The women present were women living in extremely precarious conditions. Sometimes they did not know where they were going to sleep, or what they were going to eat. It was absolutely necessary to find inexpensive products that did not need to be cooked or processed.

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The preservation of'the product aspect One of the objectives, therefore, was to make them discover, as they were not used to them, products that were easy to store and fraction for one person. Well-being,nutrition The products had to be not only practical and inexpensive, but they also had to contribute to the necessary daily intake for a correct functioning of the organism. Learning to read labels and basic notions of hygiene were also important elements of these workshops. Regarding the practical sessions, they led to typical dishes from traditional African cuisine being prepared while respecting the notions of hygiene in the preparation of these dishes. These sessions enabled the group to meet around a shared meal. Conclusion The workshop enabled us to realise that in fact this group of Africans which, at least in the collective imagination, belongs to a tightly knit ethnic group of great solidarity, is rejected, paradoxically, as soon as the symptoms of the disease appear. These women then become extremely fragile because they are alone and totally isolated. In fact, when they seek help from the H N patient aid and support associations the rejection there is invariably justified because of the ethnic group. We are sent back to the idea of African solidarity that must absolutely function in Paris as it would function in Bamako or Ouagadougou. These generally accepted ideas are without foundation and lack a real analysis of the problem. A11 they do is isolate these increasingly disarrayed women a little more. The group worked, as we have seen, essentially by affinity, on feelings. What we perceived as a difficulty in mobilisation (if this one does not come, 2 or 3 others will not turn up either) is in fact a great success, because they have, little by little, known how to reconstruct a universe of solidarity and mutual help. That was the primary objective and the African continent taught us "not to want to impose our European-style lessons, but to accept seeing spontaneous generosities and teaching from the group to the groups flourish". However, the women know that we are always there, and from time to time they ask a few questions about the evolution of their illness. They also tell us how they live their joy in having a job, housing, and their joy in having dared to give life to a child (for 3 among them). They have in a way made the hospital their own, a place of anchorage where they come to renew themselves. Future developments We know that the idea of this educational workshop has been adopted by the associative milieu, for example in Seine Saint Denis. We think that this initiative is very positive. We hope that these women will now be better equipped, and that they will be able to incorporate themselves within any group organised more or less along these lines, or even direct speech sessions, some of them are now absolutely capable for this.

N.B. Our thanks to Laurent Di Donato, Cook, "Les Petits du Canard" nursery.

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Trends in European health care systems: implications for destitute populations Rui Gentil Portugal and Pierre Chauvin

Trends in Health Care Reforms in Europe European health care systems are currently subjected to reforms. In fact, over the last two decades, health policy in Europe has become increasingly concerned with the growing cost of health care. The ageing of the population, higher levels of chronic disease and disability, the increased availability of new treatments and technologies, and rising public expectations have all exerted upward pressure on overall health-related expenditure. This clash between, on the one hand, the moral imperative of maintaining solidarity and the social good character of health care and, on the other, the fiscal imperative of cost control was the driving force behind much of the health debate across Europe in the 1990s. Must cost containment inherently and necessarily damage solidarity, defined in terms of health status and equity of access, as some public health professionals believe? Alternately. are increased efficiency, and effectiveness in the use of scar& resources, essential to preserving solidarity, as others believe? Health care reform debates ofien focus largely on questions associated with the supply of services, seeking ways to organise, finance and deliver health care in the most cost-effective way. Less attention has been paid to key aspects of the demand side, in particular how improving the wider determinants of the population's health might reduce the need for health care. The health promotion model adopted in some countries is based on an inter-sectorial approach, bringing together professionals from a range of disciplines, including epidemiology, social policy, psychology, marketing, anthropology and economics. In a few countries, however, activities are still based on an outdated consumerist medical model that consists of poorly co-ordinated programmes for preventive medicine and health education. Health promotion activities have not been given a central place within the reformed health care sector. One of the features of these reforms or proposals for reform is the establishment of an institutional division in the functions of providing and purchasing (or commissioning) health services. This division is supported due to the potential to increase the efficiency, responsiveness and quality aspects. A critical component of the separation is the existence of contracts mediating the interaction between the two parties, with purchasers acting as "agents" on behalf of patients. Asymmetry of information in the process of health care provision makes patient's choice a difficult task. The utilisation of health care services involves the transfer of responsibilities from the patient to the provider (agency relationship). When this relationship involves a group of people or the whole society, the transfer of responsibilities requires, in order to be effective, the intervention of a third party creating the necessary links. This complex relationship is the central element of the agency function, where providers of a third party perform the role of the agent in the name and interest of users or society. The agency function is the interface between the citizen and the provision of care It presupposes a clear distinction between the functions of financinglpaying health care and its provision. The agency function aims at representing and defending the interests of the citizens and of the whole society concerning the use of the resources available to all. The main objectives of the function can be described as:

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Anticipating health care needs (nature and volume) which will require adequate response. - Producing and disseminating knowledge about health services and promoting the utilisation of such knowledge by the administration as well as the citizens. - Monitoring the performance of institutions and other health care providers involved in satisfjling the needs of the population. - Evaluating gains in health and improvements in well-being achieved through the use of available financial resources. The introduction of contracting should not be seen as a development that is occurring only in health care. In practice, it is part of a wider process currently taking place in many sectors of public policy and society. The Dutch sociologist De Swaan has described this process in terms of transition fiom a command society towards a negotiating society, in which contractual relations replace traditional hierarchical relations. This evolution is not independent fiom the emergence and increasing availability of new information technologies whose social impact is underlined by other authors. Rapid technological changes and the growing need for more efficiency and innovation require a more efficient type of co-ordination than the rigid command-and-control model. In De Swaan's view, the contract model has a greater potential for responding to individual or small group needs than the command-and-control model.

The Contracting System In the context described previously, several countries have been using, or planning to use, contracts. Experience has shown that the same tool can be used in very diverse contexts. For instance, contracts are being used in countries where provider competition is very strong but they have also been used in circumstances where provider competition is weak. From the point of view of the broader organisational and financial fiamework of health systems, contracts have also been used in both insurance-based and in tax-based health systems. There is a need to clarifjl what contracts are and what people want to achieve with them. There are several goals for contracting. Different goals can compete with each other. As an example, focusing on equity can go against efficiency. Recent developments in contracting are numerous, reflecting not only better ways of dealing with old questions, but also reacting to obstacles that did not exist in the past. Often new approaches used internationally can be transferred to other settings, with immediate benefits. As an example, an overview of some recent developments that could have a considerable impact on health care provision can include: - In Bulgaria: Municipalities are the legal bodies with the powers to contract. But, municipal administrations do not have the competence to manage health facilities. The reform is under way. - In Finland: Municipalities have a special department for commissioning health services with their local primary health care institutions and with the referral hospitals. Here financing decision is very decentralised. - In France: The 1995 reform planned for the constitution, as an experiment, of "care networks" within which contractualisation mechanisms between fund and care providers could be instituted. These experiments opened a breach in the social security's monopoly in the financing of care, and the application of the reform is still suspended. - In Germany: Recent changes include the introduction of lump sum payments in the hospitals. These are related to DRGs and need to be bargained in the contracting negotiations between sickness h d s and hospitals.

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In the Netherlands: A new law specifically defines a contract between patients and providers. Thus, some patients' rights, such as the right to be informed. are now defined. - In Portugal: Regional health administration bodies organised their own agencies for contracting hospitals and health centres, as well as the private sector when working for the public one. In one region of Portugal. global and per service contracts commenced in 1997. - In Spain: Agencies were being created in Catalunia to purchase global health services with hospitals (mainly private) as well as with health centres. Public funds are in the hands of a regional government that contracts private institutions to fulfil the requirements of constitutional law. - In Sweden: Some counties have initiated structural reforms that include separating purchasers and providers, and promoting competition among providers. Nevertheless, an essential challenge for Sweden remains the traditional freedom of choice. - In the United Kingdom: Commissioning is being performed by District Health Authorities. GPs are fund-holders for a vast range of health services for local populations. This can cause concern in terms of the impact on the organisation of the health services, on the relationships between purchasers and providers. and ultimately on the health services that the individual receives. A key issue in the contracting process is the question of currency. Currency means the quantities in which different kinds of health services can be described and evaluated. What exactly is the "product" of a health service provider that a commissioner is buying? This is usually measured as a contact between a health professional and a person. However there is a strong will to move towards contracting health gains and outcomes - that is. to stop paying for what providers do and to start paying for what they achieve, or the real health benefit for the patient. Progress in this direction is inhibited partly by a paucity of research and reliable data on the outcomes of health care interventions, in particular when focusing on health promotion, and partly by the limitations of existing information systems. For health professionals, the outcome is the result of an intervention designed to improve the health of the individual and the population. For the citizen, the outcome is the ongoing condition in which they find themselves after a series of contacts, investigations and treatments. There is unanimous agreement about the absolute necessity for tools to evaluate the health oufcome and the limits of the existing tools. How can the quality of health be measured? For certain authors specialised in the approaches of managed care. these measurement tools (and the equally necessary health information systems) do not yet exist... Most of the indicators remain measures of usage (of access to care, use of the ambulatory and hospital services), measures of patient satisfaction, at best indirect measurements of the quality of the care (emergency hospitalisation rates, readmission rates. rates of ambulatory care use). It is often remarked that these indicators are too crude to really demonstrate, today, the efficiency (both financial and medical) of this contractualisation approach. The future development of new indicators and truly effective information systems will to a large degree condition its development in Europe. Contracts should guarantee the quality of the service provided, namely the appropriateness, equity, accessibility, acceptability and efficiency required. These attempts at contractualisation have shown their limits in the countries where this practice is already old, such as in the USA where for more than 15 years the HMOs (health maintenance organisations) have integrated this practice in the core of their managed care mechanisms. First of all. this contractualisation is not able to "create" resources. It can shift resources and induce more efficiency. but the process does not create any extra resources.

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On the other hand, a great deal of care is delivered informally and this will never be captured and valued in contracts. Secondly, the financial effectiveness of this approach remains controversial. In the USA, some authors note that during the past ten years there has been a significant decrease in these health expenditures. However, others remind us that they have nevertheless quadrupled in 15 years and that, even though the health insurance premiums of affiliated American employees have stabilised, these expenses should double by the year 2004. They would then attain 18% of the American GDP (in the different countries of the European Union they attain between 5.8 and 10.4% of the GDP). After managing to reduce the contribution rates for the young, active and globally in good health, while making substantial profit margins (between 20 and 30%), the American managed care organisations must now prove their productivity, confronted with an egalitarian imperative, i.e. the care of inactive, aged, poor, insolvent populations. At present this proof is lacking. Finally, it is not certain that, beyond a reduction of these expenses over time, this type of approach would be truly efficient in mastering health expenses in the long term.

Commissioning health promotion for destitute populations Contracts can be the formal link between the identification of the health care needs and the purchasing of services to satis@ those needs. In principle, needs assessment is applied to facilitate the choice of priority areas, which can then be tackled through purchasing plans and the specifications of services in the contracts. Purchasers should be able to assess the health needs of those for whom they are responsible, in order to act as prudent "agents" for patients. On the evidence available, it appears that there is a need for greater efforts in developing needs assessment for purchasing. In many cases, no data are available and the "needs of the population" are in fact a supply-induced demand. The most frequently used techniques for needs assessment include: using available public health statistics in combination with local provider activity data; information from national disease-specific or ad hoc surveys; participation techniques with community "key informers", such as rapid appraisal; and the use of practice information. In another way, acting on a different level, when third party payers guarantee universal access to basic health services, they are performing what has been called ''access function". This is particularly relevant when talking about destitute populations. It is recognised that there are still "blank" areas, which need further research and development. These areas mainly concern health promotion and the need for the population to participate in commissioning. In a system where purchasers act as agents for the patientlcitizen, there should be mechanisms which allow for accountability and participation. In principle, because contracts specify what is expected from the agreements, interested parties can closely monitor the progress towards such targets. However, some major challenges remain: - How to develop and maintain monitoring systems and institutions that guarantee a reasonable level of accountability to the population? This is a particularly difficult task when public money is being transferred to a wide range of semiautonomous or quasi-governmental institutions. - How to balance individual choice with public choice when purchasing? - How to avoid public accountability ending up by being understood only as economic accountability? * to such a degree that these managed care organisations now face the growing competition of PSOs (provider-sponsored organisations), which are groups of hospitals and doctors who contract directly with their employers (on the same capitation principle) by short-circuiting the managed care organisations...

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How to deal with the media’s power, which can induce public support or public aversion to purchasers’ decisions? When emphasising the commissioning system working for health promotion among destitute populations some questions arise. First, the contracting system is being developed mainly for disease-related services. The experience of contracting by insurance provided much knowledge of this aspect. However, even these contracts are mainly made with secondary organised care services hospitals, and the experience with primary health care is very limited. Second, citizen participation has been seen as having a very important role in the contracting process and monitoring. Purchasers developed different ways of incorporating citizen perspectives into the contracts: such as collaborations with for instance consumer associations. Primarily, we are talking about citizenship, i.e. the people who fulfil all the requirements to have rights and duties in the society and in the country. Destitute populations do not always have the right to be a full citizen by law (e.g. illegal immigrants). Third, health needs are evaluated for those who are registered in the traditional health care institutions. Health observatories have not developed schemes to collect information from other health care or heath-related care organisations. Certainly here is a major problem of bias if one wishes to assess the health needs of destitute populations Fourth, the costs and benefits of health promotion activities are very difficult to measure and the analysis is not conclusive. Politicians, and even some health professionals. are not very aware of these questions. As well as this, health promotion activities for destitute populations are often more costly than those for the populations usually targeted by the health services. More generally, the mechanisms to defend the needs of destitute populations are very weak compared to others. Indeed lobbying of health industries as well as public opinion, or its democratic representation, places a lot of pressure on health priorities in decision making. They run the risk of leaving out of these priorities the health needs of marginalised, invisible or stigmatised populations (illegal immigrants, drug abusers. prisoners, sex workers, etc.), and of forgetting that the allocation of scarce resources for health must also be guided by ethical principles. Faced with these pressures. only a strong political will, sustained by indisputable public health know-how (such as that developed by the Public Health Services in the countries where these structures exist) can enable the needs of populations living in precarious conditions to be taken into account when contracting health services. Recommendationsf o r Health Care Reforms in Europe: keeping in mind health promotion for destitute populations 1. Commissioning health promotion could be a good opportunity to emphasise health gains

and the participation of health services in well-being; 2. Contracts could offer a much clearer evaluation of the impact of health services performing health promotion activities. 3. Financing health promotion projects using commissioning systems would be of great interest to provide some extra money for health promotion among destitute populations.

4. Public health knowledge is essential in organising health services placing some emphasis on the most vulnerable populations. 5. Depending on the cultural aspects of a country, the organisation of systematic forms of participation in the decision of health priorities as well as on the performance of health institutions should be encouraged.

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6. Using all local resources for health promotion activities would probably increase productivity and lower costs. Local health systems providing all kinds of health or related services could develop better strategies for using their resources more eficiently in health promotion for destitute populations.

Bibliography Abel-Smith B, Mossialos E. Cost containment and health care reform: a study of the European Union. Health Policy 1994; 28: 89-132.. AgCncia de Acompanhamento dos Serviqos de Saude da Regiilo de Saude de Lisboa e Vale do Tejo. Acompanhamento Externo dos Seviqos de Saude. Documento de Trabalho. 1998. Anell J. implementing planned markets in health services. The Swedish Case. In: Saltman RB, Otter CV, eds. Implementing Planned Markets in Health Care. Buckingham: Open University, 1995,206-209. Bailey JE, Womeodu RJ. Prevention in managed care: obstacles and opportunities. J Tenn Med Assoc 1996; 89: 122-125. Barnum H, Kutzin J & Saxenian H. Incentives and Provider Payment Methods. Int J Health Planning Management. 1995, 10( 1):23-45. Cairns J. Contracts: Problems and Prospects. Health Policy 1993,25(1-2): 127-40. De Wildt G, Bhopal R, Lavender M. Research into purchasing health care: time to face the challenge. J Epidemiol Community Health 1996; 50: 6 1 1-6 12. Dixon M, Murray T, Jenner D. The Locality Commissioning Handbook. From vision to reality. Radcliff Medical Press. Oxon. 1998. Evans N, Panter D. Contracting through district health authorities. Br J Hosp Med 1995; 54: 52-53. Experton B, Li 2, Branch LG, Ominkowski RJ, Mellon-Lacey DM. The impact of payer/provider type on health care use and expenditures among the frail elderly. Am J Public Health 1997; 87: 2 10-2 16. Experton B. Reforme des systkmes de santC et choix de societe : vers I'adoption d'un "nouveau modele americain" ? Med Sci 1997; 13: 208-212. Fairfield G, Hunter DJ, Mechanic D, Rosleff F. Implications of managed care for health systems, clinicians, and patients. BMJ 1997; 314: 1895-1898. Fairfield G, Hunter DJ, Mechanic D, Rosleff F. Managed care: origins, principles, and evolution. BMJ 1997; 314: 1823-1826. Figueras J, Roberts J, Sanderson C. Contracting, Planning, Competition and Efficiency. In: Malek M, Vacani P, Rasquinha J, Davey P, eds. Managerial Issues in the Reformed NHS. Johno Wiley & Sons. Ltd. London. 1993. Files A, Murray M. German risk structure compensation: enhancing equity and effectiveness. Inquiry 1995; 32: 302-309. Friedman MD, Bailit MH & Michel JO. Vendor Management: A Model for Collaboration and Quality Improvement. Journal on Quality Improvement. 1995,21( 1 1):635-45. Glandon GL, Shapiro RJ. Economics and quality of life outcomes: managed care perspectives. -Oncology 1995; 9: 1 1 1-1 19. Glennerster H, Le Grand J. The development of quasi-markets in welfare provision in the United Kingdom. Int JHealth Services 1995; 25:203-18. Goldstein D, ed. Building and managing effective physician organizations under capitation. Aspen Publishers Inc., 1996.

Ham C. Population centre and patients-focused purchasing: the UK experience. The Milbank Quarterly 1996; 74: 1 9 1 -2 14. Harrison S . Working the Markets: Purchaser/Provider Separation in English Health Care. Int J Health Services 1991; 21: 635.

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Hinrichs K. The impact of health insurance reforms on redistribution and the culture of solidarity. J Health Politics POliCy LUW 1995; 20: 654-687. Hodgson K & Hoile RW, eds. Managing Health Service Contracts. WB Saunders Company Ltd. London. 1996.

Jost TS, Hughes D, McHale J, Grifliths L. The British health care reforms, the American health care revolution, and purchaserlprovidercontracts. J Health Polit Poliq Law 1995; 20: 885-908. Levaggi R. NHS contracts: an agency approach. Health Economics 1996; 5:34 1-352. Maarssen AM, Janssen R. Reforming health care in the Netherlands. Health Services Management 1994: 90: 19-21.

Maynard A. Can competition enhance efficiency in health care? Lessons from the reform of the UK national health service. Soc Sci Med 1994; 39: 1438- 1445. Ovretveit J. Purchasing for Health Gains. The Problems and Prospects for Purchasing for Health Gains in the “ManagedMarkets” of the NHS and Other European Health Systems. Eurf Public Health 1993; 3: 77-84. Palumbo FB. Mullins CD. Quality of care data from managed care organizations. N e w Engl J Med 1997: 336: 443-444. Rovner J. Scrutiny of managed care continues in USA. Lancet 1997: 349: 4 12. Saltman RB and Figueras J. European health care reform. Analysis of current strategies. WHO Regional Publications, European Series, No 72. WHO Copenhagen. 1997. Saltman Rl3. Figueras J. Analyzing the evidence on European health care reforms. Health tlflairs 1998: 17: 85108.

Schut FT. Health care in the Netherlands: balancing corporatism, etatism. and market mechanisms. J Healrh Polit Policy Law 1995; 20: 6 15-652.

Schwartz FW, Busse R. Fixed budgets in the ambulatory care sector: the German experience. In: FW Schwartz, H Glennerster, R Saltman, eds. Fixing health budgets: experience from Europe and North ’4merica. Chichester: Wiley, 1996. Signorelli TF, Allen J. The future of physician directed networks. Medical Source (website), Medical Alliances Inc., 1996.

Smith R.The future of healthcare systems. BMf 1997; 3 14: 1495- 1496. Tod D. GP fundholding: fact or fiction. Br J Med Hosp Med 1995; 54: 47 1472. WHO. Contracting Health Care Services. Expert Consultation. Copenhagen 29-30 November 1995. Report.

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Prevention and health promotion for the excluded and the destitute in Europe: recommendationsfor the health professionals and health institutions The EUROPROMED Working Group

Human rights raise the question of the societal conditions essential to well-being in terms of what the governments or States should ensure for all, such as basic education, social security, and access to medical care, adequate housing and food. Jonathan Mann We must first remember: That the principle of equitable access for all to care (in the widest sense, including all the health actions from which communities and individuals can benefit: health promotion, health education, prevention) cannot be disassociated from the ethics of human rights, and those guaranteed in the constitutional texts. Equitable access to care is an indispensable condition for the respect of the fundamental human rights, the main one being the right to dignity. In some cases, exclusion from health care is related to abuses of fhdamental human rights. That prevention and health promotion are areas of research and action which are only understandable if the other priority needs of the individuals and the communities are satisfied and if all the essential rights of people are ensured. That the battle against the health inequalities remarked in the different countries of the European Union necessarily implies taking into account areas of intervention not solely physical health - of the social policies in the widest sense (social protection, education, urbanism, justice, etc.) That the excluded and destitute can belong to identified groups or communities such as those "without" papers, or homes, or rights; those "outside the law" such as drug abusers, sex workers, prisoners, or clandestine immigrants; those "outside categories" such as migrants (Roma), refkgees. They can also be individuals who are at risk due to precarious trajectories and multifactorial processes, the result of financial, socio-cultural or family exclusions. It can be difficult for the social protection devices to identify them, or to obtain their participation in prevention or health promotion programmes. These persons also, for many reasons, have difficulty in obtaining access to these programmes, or are reluctant to attend the specific health care devices for the excluded. The EUROPROMED work group has formulated the following recommendations: 1. Prevention, health promotion and care of the socially excluded population groups should be a recognised and highlighted priority of the national health policies. This priority does not necessarily imply the mobilisation of new resources, but rather an improved redistribution of the existing ones constantly bearing equity in mind. This priority cannot be disassociated from the reflections and reforms, currently underway in all the countries of the European Union, to constrain health expenditure and improve the quality of the care the populations receive. Neither of these objectives can be achieved if an increasing proportion of the populations living in these States remains excluded from prevention and care.

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It is the responsibility of the politicians to define a minimum package of services which must be accessible to all, and this duty must be taken into account in the reforms mentioned above. Major inequalities in access to care from one member State to another are incompatible with European integration. 2.

Specific health promotion actions and improving the access to health care (both curative and preventive) of the excluded and/or precarious populations require the commitment of the local policy makers.

Health policies defined and led locally, as close as possible to the persons excluded or in precarious situations, are better able to respond to the health needs of these people and to remove the obstacles which lead, in practice, to their exclusion from care and prevention programmes. Equity in the access to these programmes and to health care is a primordial responsibility of the local political decision-makers, in particular in urban environments where situations of vulnerability and marginalisation are more fiequent and harsher. The policy makers and the elected must ensure that the national health policy reduces the gaps observed, in all countries, from one region to another. due to the diversity of the available resources... or the local commitment mentioned above. In the area of health promotion and of access to care of the excluded, there must be a continuity between the principles common to the different European welfare-states, the national policies guarantors of equity and social cohesion, and the action programmes decided by local authorities at the service of their populations. To attain these objectives it may be necessary to define priority health zones and apply positive discrimination principles to the local health policies. 3. All tbe professionals and the populations concerned must be involved in the definition of the health needs of the excluded and/or marginalised populations.

The commitment of the local and national health policy decision-makers requires. on the one hand, that they can be challenged regarding these questions by those likely to be confronted with these inequalities (health professionals, non-governmental organisations) and by the populations concerned. It also requires that these same persons be partners in the definition of health priorities and the policies necessary to respond to the health needs thus diagnosed. At the European level, the reports established by the institutions, organisations. professionals, and communities fighting health inequalities and exclusion from care of people in precarious situations should be united, compared and distributed in a European perspective. 4.

In their organisation and in their practice, care structures and health professionals must focus on the equity of access to care, and of tbe care itself, whatever the people's social situations and living conditions.

As regards care structures, this preoccupation - first affirmed and then evaluated could be part of the conditions of accreditation by the authorities andor the funding organisations in the countries where such accreditation procedures have been established. In this case, indicators to routinely assess the equity of access and care need to be defined. This preoccupation of accessibility and equity must result in the establishment of specific structures built-in to the public care structures such as, for example. the availability of cultural mediators andor interpreters in the structures receiving foreigners, the availability of therapeutic relays for drug abusers in substitution programmes. etc.

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For the health professionals, this preoccupation is an integral part of their professional code and their ethical rules. Whether we refer to the professional duty of employing all the means available, respecting people's dignity, and fighting discrimination, these rules require knowing, respecting and taking into account the patient's particular social situation to provide care. The availability of care structures providing a "safe" environment, respectful of the professional ethical codes, non discriminative (including towards people who can be in a "bad" administrative or legal situation), non-stigmatising (including structures which specifically tend to serve a particular population group), requires ensuring the empowerment of users by informing them of all their rights as patients. 5.

The authorities must develop and sustain multidisciplinary networks and intersectorial partnerships.

These networks must associate local organisations of health care providers (physicians and paramedical stan), other health professionals (health educators, health promotion participants), social care providers (social workers), and all the other organisations possibly involved (education, the police, etc.). Only such networks can simultaneously make the different professionals aware that their undertakings for the most vulnerable group are complementary, improve the efficiency of the approaches used, and reduce the number of missed opportunities in term of health promotion, medical or social care. Such networks cannot just be left to local (often voluntary) initiatives of nongovernmental organisations, or charitable institutions. The contracting approaches that are being developed in the different States of the European Union provide the opportunity to sustain, to formalise and to evaluate such networks. 6. Curative and preventive care must be integrated into the provision of primary care. Integrating preventive care into curative care - both primary and specialised - is an approach beneficial to the entire population but, for the excluded, this objective is particularly crucial in primary care. The rare, and often belated, access to care of people in situations of social exclusion and/or living in precarious conditions, must systematically be the opportunity to provide preventive care and information. This integration presupposes evaluating - in one way or another - the prevention practices of family doctors and general practitioners. In general, all primary care services - general practices, public or associative clinics, hospital emergency services and outpatients clinics - must include health promotion, prevention and screening actions for the under-served population groups that consult them. Operational detection and follow-up guidelines for the pathologies prevalent among these populations must be developed and used in primary health, concerning in particular all types of addictions (alcohol, tobacco, psychotropes, illegal drugs), communicable diseases (tuberculosis, HIV, Hepatitis C), and mental health (anxious-depressive syndromes). Disease management approaches that aim at a greater integration of the various care and health service offers (and which are more cost-effective) around a specific pathology, can contribute to this objective on condition, there again, that they take into account the living conditions of the excluded.

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Outreach health programmes must be established to reach the individuals and the communities that do not spontaneously come to d e existing care structures.

Those persons most vulnerable as regards health problems are often those most reticent to consult in the existing structures: e.g. drug abusers, immigrants in irregular administrative situations, the homeless, sex workers. etc. For all these people. only outreach programmes, which come to them, on their terrain, are likely to reach them. These outreach programmes must be an integral part of the care offer proposed to the popuIation and be co-ordinated with (if not managed by) the existing public care structures (outpatient clinics, emergency departments, etc.). 8.

The existing care structures (including general practices) must provide social care, either integrated or co-ordinated, with their medical care.

Health professionals note that (other than the cases of serious illness, or delay in consulting resulting in an aggravation of the clinical situations observed), a social request is often hidden behind the common somatic complaint, behind the request for medical care formulated by people in precarious situations. This social request must be taken into account at the m p e time or, at least, in the direct continuity of the health care either by integrating social workers in the health care structures, or by efficiently co-ordinating their activities with the nearest social services. In family medicine, these networks can break the isolation of general practitioners. who have difficulty handling social requests and are therefore reticent to provide care for certain marginalised patients. They also increase the excluded populations' usage of the family medicine system and avoid the observed transfer effects of an unsuitable and poorly justified usage of the hospital emergency services. 9. Specific prevention and health promotion actions must be undertaken for people in precarious situations and for the different marginalised and excluded population groups.

Prevention and health promotion actions and programmes deserve to be reinforced. everywhere and for all. Due to their living conditions, their social situation, their level of education or their culture, population groups can only be reached by specific health promotion and prevention actions. However, the true impact of actions undertaken among the general population should also be systematically evaluated among these groups of marginalised and excluded populations. 10. People in precarious situations, excluded population groups, and marginalised communities must be involved in the establishment and the assessment of health promotion actions destined to them.

The active participation of these populations is an essential pre-requisite for the success of such programmes. From the moment when the need for specific health promotion programmes appears. the objectives and the tools of such programmes cannot be defined and developed only "from the outside" by health professionals. however expert they may be. What health needs are felt and what health (individual and collective) priorities ensue? How do these priorities relate to others? (often concerning. for people in precarious situations. domains no less essential to life: housing. food. minimum financial resources.

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education of children, etc.). From this base, what messages are receivable, and in what conditions, are the questions to which the people themselves must provide their answers.

11. These topics underline the need to diversify medical knowledge as it is taught to health professionals, in particular the initial academic training and the continuing education of physicians and paramedical staff. Other subjects than the biomedical ones should be part of the curriculum of medical faculties and the paramedical training schools. Training health professionals to the health needs of vulnerable and marginalised people, and more generally to the social inequalities of health, requires that both initial training and continuing education award a central place to other health disciplines such as sociology, economics, ethnology, history, ethics, etc. Training periods - particularly in these disciplines - common to the various health and social professionals (physicians, paramedical staff, social workers, and health promotion professionals) should be promoted.

12. The development of these health approaches towards excluded people and populations requires, concomitantly, the development of health research on these situations and these populations. From the situations observed and the objectives cited above, three research priorities emerge: The need to develop research tools to study the living conditions, and states of health, both of individuals and of groups. The study of individual social and health trajectories should make it possible to detect the vulnerable individuals, and the at-risk social trajectories, beyond the old mainly inoperative social categorisations, thus improving the efficiency of the responses proposed. The need for studies of groups and communities, when and where these communities exist. The health status and the access to care of ethnic minorities and migrant populations constitute an emblematic example wherein questions of specific accessibility must be addressed as such, without them appearing contradictory to the principles of nondiscrimination. The need to develop research concerning the evaluation of health promotion programmes for these people and these populations. Their situation of marginalisation and exclusion is a barrier to their assessment that must be taken into account from the start of these programmes and requires the development of innovative approaches. These research objectives require a European approach. The various member states of the European Union share ethical principles and common objectives, and they are confronted with similar situations of exclusion. They have, however, developed different social policies and health policies, implemented health promotion and access to care programmes, and from these acquired much experience. All of this deserves to be valued: these States probably constitute a unique "laboratory of ideas".

13. The social inequalities of health must be one of the surveillance objectives of the various national health information systems. At the European level, standardised and comparable information must be routinely available. In all countries, including social data as well as health data in the existing health information systems (surveillance of causes of death, occupational diseases surveillance, mandatory surveillance of communicable diseases, hospital information systems, etc.) should allow the distribution and the tendencies of the social inequalities of health to be

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described. This would also enable the social and health impact of the prevention and health promotion programmes and actions established to be evaluated. At the European level, a synthesis of information should be made regularly. for example in the form of an annual report, perhaps under the responsibility of a European observatory of health inequalities. Specific comparative studies of the most vulnerable population groups, should be supported: for example of teenagers, isolated elderly people. migrants, foreigners in regular or irregular administrative situations. drug abusers. prisoners, the long-term unemployed. etc.

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Appendix: presentation of the institutions participating in the EUROPROMED project Institut de I 'Humanitaire (IDH), Paris, France

The IDH, a non-governmental non-profit organisation, is a centre for research, training, and the exchange of practices and knowledge. Its area of competence is the vulnerability and precarious conditions of certain population groups, the crises arising in consequence, and the medical, social, humanitarian and political solutions provided. Objectives To develop approaches to overcome precarious conditions in France and in Europe, taking into account the global dimension of the phenomenon, the human dimension of the problems, and the ethical dimension of the practices. To facilitate dialogue between the participants in the field: the institutions, the NGOs, the decision makers, and the university and research organisms; also to enable a convergence of the social policies, the public health policies, the humanitarian policies pursued by the various authorities concerned with the social and health problems of the underprivileged populations. To promote the co-ordination of intervention and prevention strategies, both public and private, and that of research and reflection networks; and to promote the dissemination of contributors' opinions to the governmental and intergovernmental authorities and public opinion. Activities The IDH performs transdisciplinary studies of the problems arising from field action in order to define intervention strategies on a European scale. - PRECARstudy The IDH is leading a multidisciplinary research project on the inter-relations between precarious social conditions, states of health, and access to care in the Paris region. This project, supported by the INSERM (French National Institute of Health and Medical Research) and the RNSP (French Public Health Network), associates public health and social sciences researchers with socio-medical professionals, both public and associative, intervening among destitute publics. - SUIVIH study Precarious social conditions lead to certain populations being vulnerable to emerging or re-emerging epidemics and require therapeutic responses adapted to the social contexts. The IDH is at present undertaking a sociological study of the circumstances of resort to care and the determinants of therapeutic observance among HIV+ immigrants in Paris. - PASSstudy The IDH has performed epidemiological studies of the social determinants of access to care of populations in precarious conditions in Paris. The IDH organises multidisciplinary training courses on precarious conditions and vulnerability, within the framework of adult education and in association with European Universities. - Health, precarious conditions, and access to care training This 3 day training in Health - Precarious conditions is aimed at health professionals, social workers, and local community and health insurance managers. - University diploma: Health and Humanitarian Action - Paris VI University The Humanitarian Institute also participated in establishing a permanent programme at Pierre and Marie Curie University, Saint-Antoine Medical School, Department of Health

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and Humanitarian Action. This cycle has a common root and two modules from which to choose, and is rewarded with a university diploma. - European Master of Humanitarian Action - University of Alicante This modular training is open to European doctors, wishing to become volunteers in humanitarian NGOs, and to grant-holders fiom underprivileged countries who wish to undertake humanitarian action. Its goal is to examine and transmit new intervention concepts, elaborated from field practices used by various NGOs. This training is multidisciplinary and includes interventions of specialists in domains as diverse as: public health. development, anthropology and sociology, urbanism, communication, economy and law. The IDH stimulates the analysis of practices and know-how in its area of competence. The IDH organises conferences and workshops, publishes reports. establishes expertise and collaboration networks on an international scale. Publications The Humanitarian Institute has published a reference work on the state of health of populations in precarious conditions in France (Paris, Flammarion, April 1998). A second book on the public health stakes raised by this problematic situation is being written in English, while one is planned at the European level. Conferences The IDH organises the bi-annual conference "Health, destitution and vulnerability in Europe". The first one took place in Paris, at the UNESCO headquarters, on November 1 5~ and 1 6 1996. ~ The second also took place in Paris, in December 1998. It was organised in collaboration with 1'Assistance Publique - H8pitaux de Paris (Public Hospitals of Paris) and the European Union'. Workshops The IDH organises the following workshops and workgroups: - Mediation in Public Health: this workshop will include a seminar, a training programme and events on related topics. - Money and the Humanitarian Action: this workshop will provide the opportunity for the treasurers of associations, fund-raising specialists, bankers and donors to reflect on this often hidden dimension of humanitarian aid. - The transfer of humanitarian know-how to the Southern countries: two pilot projects of workgroups around this theme will bring together NGO organisers. donors and businessmen. Expertise and co-operation network The IDH has been designated as an expert institute on the scientific committees of several international conferences on humanitarian action, and therefore co-operates with various organisations, such as the Henry Dunant Institute, Geneva; the International Committee of the Red Cross (CICR). Geneva; the ECHO-Voice Forum: the FranGoisXavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, and the French National Institute of Health and Medical Research (INSERM). Me'decins Sans Fronticres (MSF), Brussels, Belgium

Since October 1991, MSF - in partnership with Pharmaciens sans Frontieres - has run a medico-social unit where medico-social consultations are available for all those excluded from health care (the homeless, political refitgee status candidates, irregular immigrants...) or unable (on their own) to obtain access to the different welfare systems. The EUROPROMEDproject was presented in the closing session of this conference. and its recommandations distributed to the 1 000 participants (coming from 20 different countries).

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Objectives - To facilitate access to care; - To provide basic care and take the steps required by a patient's condition (hospitalisation, additional examinations...); - To facilitate access to the welfare system, according to each person's situation and potential rights; - To guide patients (at their request) to the associations which look after the different types of aid (housing, asylum procedures, employment, education....); - To lobby the authorities and institutions competent in the areas of health and welfare. Procedure The mobile unit (the bus) is parked near Brussels central station on 2 evenings per week and in rue des Tanneurs (in the Marolles neighbourhood of Brussels) on 2 afternoons per week. Medical activities A team of volunteer doctors who are in charge of a consultation every two weeks supplies front-line medical consultations. Care and medicines are provided free. Pharmaciens sans Frontieres (PSF) obtains and manages the stock of medicines, which are given to the patients after consultation. Medicines are provided free by PSF, except for some patent medicines which we buy. A certain number of specialised consultations are provided free of charge thanks to a network of specialised doctors and specialised centres which co-operate with the project. Thanks to an agreement with certain laboratories, clinical biological tests are also performed free of charge. Dental care is provided free by Dentistes sans Frontikres. Our team works in close co-operation with public health prevention institutions such as FARES (Foundation for Respiratory Ailments and Health Education) and ONE (the Office of Birth and Childhood). Their consultations are of course free of charge and available to all whatever their status. Unfortunately our network does not cover all branches of specialisation nor all the technical possibilities (X-rays, ultrasound scans.. .). We therefore have to send our patients to the public hospitals for these tests and consultations, which we pay for. Weyare activities 2 paid social workers, who receive the patients for the consultations and help them with their administrative procedures, look after the welfare branch. These social workers have several roles: - They receive the patient, define the patient's needs, and establish a file which includes the social information. - Being in a position of trust, they play an important role as the intermediary between the patient and the doctor. - They explain the doctor's prescription to the patient, the different medical facilities to which the patient is referred, and also provide reassurance that the patient will be well received. This role is particularly important as regards the illegal immigrants, who are unfamiliar with Belgian institutions, and need to be reassured that they will be sent to "safe" places, where they will not run the risk of administrative controls. Apart fiom urgent medical care, there are few welfare rights that the social workers can obtain for this population group. According to the patient's possibilities, the social workers help with the administrative procedures (health insurance registration, request for welfare, collection of certificates, request for allowances for the handicapped...). They may therefore need to find

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a patient's appropriate CPAS (Public Social Aid Centre) and ascertain why this Centre is not taking charge of the medical care, whether there is a possibility of obtaining health insurance, at what stage of the proceedings a candidate for political refugee status is at present... The social workers know the laws, the welfare rights and the patient's possibilities; their knowledge complements that of the doctor, thereby bringing together the medical and social aspects. The social workers also run the medical secretariat, making appointments with specialists, requesting medical reports from the hospitals, controlling the stock of medicines and ordering them from PSF. They organise each patient's access to care by co-ordinating specialised hospital consultations and contacts with various hospital departments. In Brussels the social workers also act as a link between the consultations of the mobile unit and those of the "second line". They ensure that the files and the medico-social information are transmitted from one place to another and also continuity between these two types of consultations. The social workers are often in contact with the other medico-social services. They can thus direct a patient towards those structures better adapted to his situation or able to help him in other areas than those of social help (for example asylum procedures). Relations with the other partners Various contacts are made with the medical and social organisations in order for our projects to be known and to enable us to help the patients: in particular, the associations specialised in the care of asylum seekers, the centres specialised in the care of drug abusers. mental health centres, shelters, night hostels.. . Results Since 1992, the number of patients attending the medico-social unit has constantly risen. The number of files opened per year increased from 274 in 1992 to 860 in 1996. Socio-demographic characteristics Most of our patients are male, but the number of females has increased constantly since 1992. In 1996, 70% of our patients were male. The average age is 3 1 ; 44% of the patients are under 30 and 74% are under 40 years old. During the last few months we have noticed that the average age is decreasing. During 1996 we treated patients of 69 different nationalities (Table 20). As regards social coverage, 75% of those consulting have none. Among the Belgians, 41% have social security and another 36% are entitled to it. Our objective is to help the patients to re-enter the welfare system, and to receive even a small income (unemployment benefits, handicapped benefits, pensions, minimum integration income). 15.7% of those consulting are homeless (either living on the street, or in a squat. or in a shelter). Of the non-Belgian patients 14.1% have a legal status, (EEC. student. visa). 3.3% are refugees, 17.8% are asylum seekers, 25.6% have been refused rehgee status and 33% are illegal immigrants. Table 20. Distribution of nationalities, Maecins Sans Frontihs, Brussels, Begium, 1996. Nationality Belgian Non Belgian European Eastern European African North-Afiican Asian South-American

Distribution ( O h ) 16 5.8

34.8 26.7 6.7 4.5 3.8

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Medical data In view of the increase in pathologies requiring heavy treatment, referral consultations were set up in 1995 in our offices. A doctor and a social worker hold two consultations a week. During 1996, 1800 consultations were held at the mobile unit and 800 in our offices. A separate consultation exists for drug abusers. Two social workers and a group of volunteer doctors take turns holding the consultations of the drug abuse programme. More than 50% of the consultations concern the respiratory system, and dermatological or gastroenterological problems. Neuropsychiatric problems are less frequent than previously. The other reasons for consultation are the following: dental problems (7.1%), neurospsychiatry (5.3%), gynaecology (4.0%), uro-genital (3.9%), cardiology (2.1%), ophthalmology (1.9%), endocrinology (1 .O%), various (5.7%). Conclusions Substantial work has been carried out with the Belgian patients in order to ensure their access to care: registration and up-dating of health insurance, contacts with the CPAS (Public Social Aid Centre). Even though health insurance and the CPAS pay particular attention to this vulnerable population group, the administrative procedures remain complicated and lengthy. Frequently, access to care cannot be envisaged without other welfare steps being taken (looking for housing, employment...) which require individual and intensive support. The new legislative measures concerning access to care (De Galan law) open new perspectives. Nevertheless, the cost of health care for those with low incomes must not be forgotten. For asylum seekers, the main difficulty lies in obtaining the designation of a CPAS competent as regards the Office des Etrangers (Foreigners Bureau) and then having their rights to medico-pharmaceutical care enforced. Whether for the Belgian or the foreign population, each CPAS has its own modalities and criteria for providing medical care. Foreigners often meet with refusals, which obliges them to undertake legal procedures. As far as the "illegal" population is concerned, few welfare measures are possible. A new Royal Decree regarding urgent medical aid will most certainly improve access to care but will not cover all medical needs. Once again the CPAS will decide the modalities of application which will vary from one CPAS to another in the absence of common guidelines. The Department of Public Health, Bremen, Germany The Bremen Public Health Department, with its aproximatly 180 employees, is at the core of a public health reform process in the smallest Federal State (see the European Health Care Systems, section on Germany). As with other institutions in the public services, the Bremen Pubiic Health Department has been forced to cope with severe budgetary cuts for more than a decade now. Nevertheless, efforts to change its structures and strategies according to modern concepts of public health appecer to be proceeding successfirlly. From a typical bureaucratic unit reacting more or less statically to impulses from outside, it has grown into a proactive health service centre utilising up-to-date public health approaches. Changes in local and regional need structures, as a consequence of social and economic change, had to be confronted. With four service departments : an Adult Socio-medical Service, a Health and Environment Department, a Socio-paediatric Service, and a Socio-psychiatric Service, the Public Health Department co-ordinates, interacts with other health care institutions, and provides its own health services. It has thus acquired a profile embracing all facets of the

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socio-medical complex at the community level. This multiplicity of tasks can only be understood if one is aware of the historical background of public health in Germany, and of its role within the structure of a community, especially as a municipally administered activity. In Bremen, the Public Health Department initiated a thorough restructuring process in the mid and late 1980s. Children and youth health services were reshaped into a sociopaediatric department with a new mission profile, integrating, among other innovations. a project of family midwives, pregnancy support and educational activities for expectant mothers. The traditional system of medical checks for sex workers emancipated itself to a modern advisory service on sexually transmitted diseases, especially for groups exposed to above average hazards (to avoid the cliche "risk groups"). The experts' opinion department. the so-called Health Officer and Company Doctor Service (Amts- und Vertrauensarztlicher Dienst) exposed itself to a critical revision, and developed a modified understanding, of its mission. A concept of counselling cancer patients from the community was formulated and tried out, although recently the service had to be closed due to budgetary problems. Other services were streamlined in response to new epidemiological insights and corresponding needs, resulting, for instance, in a reduction of the tuberculosis section and the x-ray facility. At present, a Federal law on "protection from infectious diseases" is being discussed in Germany which, if it comes about, might lead to a renewed revision of such facilities. The forensic medical service, the human genetics counselling service, and the section dealing with questions of environmental medicine, were extended in accordance with a growing demand for those services. As new facilities, the socio-psychiatric service. an advisory office for child and youth psychiatry, an outpatients service for drug abusers. and a multidisciplinary AIDS team were established. In 1993, the restructuring process was completed with the introduction of a section responsible for medical advice and care for migrants, especially asylum seekers and refugees. Since then, organisational improvements and the stabilisation of individual operational sections. against the background of a deteriorating situation in public spending, have remained ongoing concerns. More recentlj . public services in Germany in general have responded to material resources becoming ever more constrained by "budgeting" (Budgetierung) and the Itnew control model" (.%'cues Steuerungsmodell), an effort to simultaneously increase efficiency. The Bremen Public Health Department also attends to these processes and challenges. In the following, a few examples may serve to highlight the Public Health Department's endeavours to contribute to the growing practical interest in. and development of, public health concepts not only as a modem social science but also as a practical approach to the community's health problems in a changing society. Handicapped children Since the late 198Os, the Public Health Department has paid attention to improving the integrative advancement of handicapped children. The term integrative advancement implies both an aim and a method leading towards that aim. This has consequences for decisions on handicapped children at their various ages and stages of development. For babies and toddlers, it means integration into the family. For small children and pre-school age children, it means integration with non-handicapped children in the kindergarten. For school age children, it means schooling in integration classes or co-operation projects between schools. A holistic, multi-professional approach presupposes socio-paediatric groundwork as an indispensable component of the programme. The work performed by the Public Health Department:s paediatricians is directed towards both the individual child. and his or her family, as well as the care system as a whole. Thus, taking 1993 as a typical year, 100 detaiIed experts' reports were compiled on the type and extent of necessary measures of advancement, not as merely clerical work but on the basis of home \sisits. differentiated

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diagnosis of child development, giving advice to the parents, and communication with the institutions offering assistance, advancement, and therapy. The Public Health Department is also involved in the field of youth welfare. The Children's and Youth Health Service regularly participates in the social welfare procedures, at the city district level, regarding "children in specific problem situations" and is represented on the city's youth welfare committee. Intensive contacts with volunteer organisations in this field, such as the Evangelical Church's day care association or the Red Cross, are of equal importance. Psychiutric care Since the beginning of the 1970s, a broad psychiatric reform has taken place in Germany. In 1975 a comprehensive national report (Psychiatrie-Enquete),on behalf of the Federal Parliament, was delivered showing inhuman and anachronistic care and living conditions for patients in hospitals and a need for outpatients services, especially for severely and chronically diseased citizens. It became obvious that private psychiatrists failed to reach the core population. Consequently, acting on the principle of "subsidiarity", the public health service had to take over responsibility. In Bremen, the hospital for chronically handicapped patients outside the city was closed and a social psychiatric service, day clinics and group homes were introduced. In the socio-psychiatric department (Sozialpsychiutrischer Dienst) more than 60 professionals (psychiatrists, psychologists, social workers, nurses, and administrators) work in decentralised sections located in five boroughs of the city. Their main duties are: crisis interv.ention (accessible 24 hours a day) outpatients care for long-term and handicapped psychotic patients - special service for drug qbusers and senior citizens - expert opinions - development of a comprehensive community psychiatry infrastructure The next steps of the regional reform will be to reduce the number of psychiatry beds in the one hospital still existing for acute patients, and to implement so called psychiatric centres in the boroughs, which will put ambulant treatment to the front of the care chain, integrate hospital and outpatients services and guarantee personal and institutional continuity, especially for severely ill patients. Drug abusers Since 1991, an outpatients surgery for drug abusers has been in operation. Alongside a day care facility and the "open" counselling service, it forms part of a basic care concept for this group of clients. Again, taking 1993 as an example, 330 male and female patients received treatment at the outpatients surgery. Two physicians, a nurse, and a social worker have been active in the facility. In addition to the 330 patients who consulted, the social worker co-ordinated psychosocial support for clients on methadone substitution. Diagnosis and treatment of general illnesses, health advice, and smaller surgical interventions in cases of abscesses, ulcers, injuries etc. were also provided. In addition there are crisis interventions or emergency measures in case of heavy overdoses with dangerous sequels. Medical care is also administered to patients in a number of emergency hostels for drug abusers. In this way 55 additional patients with severe dependence were reached by the facility in 1993. Patients on methadone substitution make up about one third of the outpatients surgery's clientele. How complex this problem area is, is underlined by the fact that many of the substituted patients are still using cocaine, pharmaceutical drugs, or alcohol, and continue to belong to the drug-using street community. The conceptual, organisational, and resource deficits accompanying this situation are obvious. Nevertheless, since methadone substitution was recommended as a

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viable alternative in 1990,2 000 drug patients have been substituted in Bremen, and about 1 300 clients are currently taking part in substitution therapy. Homeless Estimates state that about 400 to 600 homeless live in Bremen, the majority of them single men. As in other cities, medical care by the regular health care system is not safeguarded due to the typical social situation of homeless people. In co-operation with an NGO (Vereinf i r Innere Mission), the Public Health Office initiated a way to provide health care for this group. In 1996, a pilot project was carried out, to provide emergency health care for single homeless in Bremen. The use of the term "emergency" does not, in this case. hint at a temporary escalation of the patient's situation as is usually the case in emergencies. Rather, it hints at the fact that the regular condition of these clients can only be described by referring to a state of affairs normally regarded as exceptional: medicall! and psychosocially speaking, they live in a kind of constant emergency. Of a total of 107 clients throughout the one-year pilot phase, 61% consulted the care centre established in the NGO's building once. 14% came twice, and 25% used the programme three or more times. A large part of the patients were treated sufficiently on their first consultation, displaying health problems such as skin diseases, minor infections, parasitosis and minor injuries, or needed simple wound treatment or advice in cases of drug dependence. Neurological illnesses, eye diseases, and some disturbances of the respiratory system were referred to physicians in the regular health care system for fbrther diagnosis'and treatment. A smaller group of patients approached the project with illnesses requiring a more detailed and repeated medical treatment which, however, was refused or at least ignored by them. These problems were mainly superinfections, mental or behaviour problems, and unclear symptoms. Most of the patients, although encouraged to come to the consultation a second time to check on the healing process, did not comply as soon as improvement manifested itself. The experience as a whole showed that there is a need for a special health service for the homeless. With homeless patients, a particular problem is seen in the building up of a relationship of trust, as they are less stationary than the patients of a regular physician's practice. However, if such a basis of mutual confidence can be established, the emergency care doctor becomes something like the "family doctor" for the homeless person. Immigrants and asylum seekers Contrary to the misconception, up to the 1970s, that immigrants to Germany would in due course return to their countries of origin, most of the roughly seven million "foreign" migrants in Germany today are here to stay, many of them already born in their host country and speaking German as if it was their mother tongue. Health care standards for migrants in Germany, however, are dependent on their legal status. This bears especially grave consequences for asylum seekers and war refugees. The Asylum Applicants Social Benefits Act reduces "required medical and dental treatment" to "acute diseases and painful conditions", a formula which leaves many questions unanswered, in particular that of health care in cases of chronic illness, mental health problems, and specific diseases such as AIDS. Complex problems of migrants' access to social and health services. to a great degree culturally determined, are not addressed. In Bremen, however, a medical programme, established by the Public Health Department in 1993, was designed to bridge some of the care deficits, using the legal basis of the Asylum Procedures Act. This law continues the tradition of German preoccupation with protecting the indigenous population from infectious diseases, but allows for the superior health agency of each federal state to define the scope of the examination. The main components of the "Bremen Model" are: - in the case of asylum seekers, using the "first contact" medical examination required by law to diagnose the general health status and obsewe an\ indications of specific diseases and disorders:

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for both asylum seekers and war refugees, follow-up checks and doctor’s advice on health problems as well as on health relevant factors such as accommodation, nutrition, hygiene etc. - if diseases or disorders are diagnosed, immediate treatment in minor cases, while in the case of more serious symptoms, patients are helped to access the appropriate treatment or further diagnostic measures by referring them to general practitioners, specialists or Public Health Department facilities; - the scientific evaluation of the examination procedures and results. Since June 1993, approximately 7 000 examinations have taken place, involving more than 3 000 patients. The majority of these people are housed in refugee hostels run by a number of organisations, spread throughout the town, and including a variety of building types: hotels, boarding-houses, blocks of flats, barracks, and, until recently, a ship. In other federal states, asylum seekers and refugees are also accommodated in former military or police facilities, container systems, schools or gyms, and other disused building complexes. The organisations running the facilities are the major NGOs active in the social sector such as the German Red Cross, the Arbeiterwohlfahrt (Workers’ Welfare), the Arheiter-Samariter-Bund (Workers’ Samaritan Federation), and others. Food supplies can be organised in various ways. In the so-called primary phase hostels, meals are usually delivered ready-made as people do not stay there long enough to settle down to a selfcatering situation. In Bremen, almost all subsequent phase hostels - where the migrants are accommodated after the primary reception phase of roughly six weeks - are equipped with cooking facilities. Food is supplied in storage packs, or money is issued to allow the person or family concerned to buy their own food and prepare their meals. In this respect, Bremen is not representative of conditions in other federal states where asylum seekers and refugees have less scope to organise their daily lives. On the hostel ship, where single men were accommodated, a central kitchen did the cooking, and meals were consumed in a large canteen. In six of the Bremen hostels, the Public Health Department is running its health programme for asylum seekers and refugees. Its physicians see to it that the legal requirement of detecting signs of a possible communicable disease is fulfilled, and at the same time all asylum seekers and refugees participating in the programme are given basic medical care. In this way, substantial health problems can be recorded. As there is no limit to the number of consultations a patient attends, an atmosphere of confidence can develop between the programme’s doctors and refugees. In turn, the continuity of physicians’ presence in the hostel leads to a more intensive familiarisation with the inmates’ problems. It also results in a good working relationship with the hostel staff. This may be of importance if the doctors observe other problems relevant to the refugees’ health, for instance in the areas of hygiene, nutrition, the state of repair of the building, or others. A stock of basic medicines for immediate treatment is kept in the simple rooms in the hostels where the programme’s doctors can be visited. If the diagnostic or therapeutic requirements exceed that basic level, physicians refer patients to near-by private practices of general practitioners or speci a1i sts. The programme includes the scientific documentation and analysis of medical data, enabling the Public Health Office to get a good view of the real health situation of asylum seekers and refugees. These insights serve quality control and cost effectiveness within the programme, but they also strengthen the Bremen Public Health Office’s contribution to the public and professional debate on the issue of medical care for migrants in the Federal Republic of Germany. Since 1993, on the basis of epidemiological experience gathered, Bremen public health services have gradually extended their work with asylum seekers and (mainly Bosnian) war refugees in the city state. With special ventures such as a programme of -

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preventive Tbc checks or an AIDS information project, the Bremen Public Health Ofice is striving for a positive gate keeper's role, the eventual aim being an "intercultural opening" of regular health services towards all groups of migrants in Germany. A decisive factor, in the context in which all these activities can be placed, is the identification of both administrative and professional workers in the Public Health Department with the demand for a dynamic, rather than a static, understanding of the role of public health in contemporary society. Most of them have in fact internalised that being secondary (in the sense of "subsidiarity") to an established, and already widely privatised. health system provides the challenge of having to confiont "difficult" social problem areas untouched by regular health care. In fields where complex tasks can only be shouldered by multidisciplinary approaches and the qualification and social awareness of the responsible municipal medical officer, the public health service is secondary to none. Its "product range" (in the terminology of the "new control model" presently discussed) is defined by the intersection between health professionalism, legal responsibilities, and political judgement, a definition with its very own dynamics. But this liability to social or, more precisely, political change does not make quality control, efficiency evaluation. standardisation of services, and adherence to cost effectiveness superfluous, on the contrary. The public health system will remain a complex of services mainly financed by the municipal budget and, therefore, by the taxpayer. At the same time it will continue to provide services mainly to clients with special socio-medical risks and, therefore. to minority groups. Undoubtedly the necessary reform process, whose national framework has been established by recent federal legislation commonly known as the "health reform'' (Gesundheitsreform), must be continued at the regional and local levels, in other words, in the community. Realistic and politically honest health reporting will form the best basis to openly discuss the health needs and supply deficits for specific target groups. the inefficient or dysfunctional structures of co-operation and performance, or the inadequate distribution of resources. Such a discussion is especially important with the background of continuing integration within the European Union, with all its demands for harmonisation and a "fair deal" for all citizens. The Bremen Public Health Department will continue to try and contribute towards the development of a public health system capable of coping with the need for specific professional approaches, multi-professionalism, cross-sectional analysis of all levels of health care and their performance, a potential for outgoing counselling and care. and intelligent use of scarce resources. Me'decins du Monde (MDW, Athens, Greece

The Athens University Medical Faculty has been involved in several projects to assess the phenomena of social exclusion in Greece. In the context of its undergraduate curriculum, initiatives have been encouraged to conduct research and clinical practice among excluded population groups. A first attempt to address such issues was made during the Congress entitled "Health Problems of Vulnerable Populations. Humanitarian medicine", held at Athens University Medical Faculty from April 1 9h to 2 1 S t , 1997. Additionally, medical student exchanges in the context of the IFMSA and ERASMUS/SOCRATES programmes have been encouraged and elective courses on Community and International Medicine are organised yearly. This particular project is implemented by the Athens University Medical Faculty, First Surgical Department, in co-operation with Medecins du Monde-Greece. MDM-G is a national delegation of the international organisation Medecins du Monde. It has been active for more than seven years. completing se\wal medical projects

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targeting vulnerable populations in Greece as well as in underdeveloped countries. It is dedicated to helping to solve the joint political and economic problems that are on our doorstep: unemployment, social exclusion, poverty, racism, xenophobia, refugee crises, etc. It is therefore planning co-ordinated medical interventions and widespread public education programmes. Greece’s rapidly changing economic climate, plus waves of refugees and illegal immigrants, have led to drastic upheavals in the national health system. Many have lost their access to primary health care. In addition, many are afraid of seeking assistance from state institutions (drug abusers, the homeless, runaway children, immigrants, Roma, iIIegal workers). There are at present over 800 000 such persons in Athens. The Open Polyclinic is located in the centre of Athens, in one of the most disadvantaged neighbourhoods in Attica. Approximately fifty volunteers give their time and expertise to the socially excluded, disadvantaged population groups in Athens. These volunteers are specialised doctors, nurses, dentists, psychologists, social workers, and medical students. They provide basic medical care and treatment, social and psychological support, and legal advice. Free basic medical care is administered, both at the Polyclinic and by means of mobile clinics, servicing the disadvantaged neighbourhoods in and around Athens, building bridges of social integration to excluded and minority population groups. During its first year, the Polyclinic provided health services ftee of charge to 6 000 people, resulting in over 10 000 consultations with the various physicians, due to the fact that many of the people had multiple medical problems. Relations of close co-operation between the MDM-G dispensary and public sector hospitals are developed. This is particularly true regarding vaccination programmes. For example, all vaccines are offered or donated by the public health service. In many instances, the doctors at the Polyclinic found it necessary to refer patients to private clinics, hospitals, or medical laboratories. All of these cases were transferred with the assistance of the Polyclinic social service personnel. The dental care offered at the Polyclinic goes beyond standard basic care. The dental department at the Polyclinic is open twelve hours per day, as approximately half of the patients who registered at the Polyclinic this year were in need of dental care. The largest groups of people who visited the Open Polyclinic were refugees and illegal immigrants. Groups such as Roma, the homeless, and drug abusers were somewhat smaller in number, due to the fact that they hold a general fear of, and therefore avoid visiting, organised institutions (even non-governmental organisations). For this reason, MDM-G purchased and dispatched a mobile clinic to conduct regular visits at the Rom encampments. Along with emergency basic medical care, a specialised team of nurses, physicians and paediatricians administered vaccinations. These vaccinations were given to young Rom children, who had either never been vaccinated, or had not been vaccinated properly. This team also provided health education for the Roma. Children were instructed in basic dental care and women were given advice regarding persona1 hygiene. Food and clothes donated by Greek citizens were distributed to this deprived population. Also. whenever necessary, medicines were given free of charge. Another specialised medical team from the Polyclinic, using the mobile clinic, paid routine visits to various neighbourhoods in the old and abandoned section of Athens, inhabited by Muslim minorities originally from the mountainous region of Thraki, northern Greece. During this past year, the medical teams followed the same medical programme as for the Roma, providing emergency basic medical care, vaccinations, health education, the distribution of food and clothing, and medicines free of charge, to this fringe population.

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Other services provided by the Polyclinic consisted in dispatching two other mobile medical teams. The first medical team provided vaccinations for the Rom children who work in the streets washing the windshields of cars waiting at traffic lights, and the second medical team provided vaccinations for Kurdish refugee children fiom Iraq, who were under the care of the Mother Teresa Religious Foundation of Greece. Several of the children who had serious health problems were taken by MDM-G to the Open Polyclinic for treatment. Programmes such as these were also carried out by the MDM-G. Thessaloniki branch in Lakes Prespes, located near the borders of Greece. Albania, and Fyrom in northern Greece. Another pilot programme for Greece, the "Needle Exchange" program, is currently underway. It has been proven effective in other parts of Europe, both as a way to slow down the spread of AIDS and as a way to reach out to drug abusers and begin a process of social rehabilitation with them. MDM-G has also been aiding the Kurdish refugees fkom Iraq for over a year and a half. The first gathering of 600 Kurdish refugees appeared in August 1996 at Othiou Square, at the very centre of Athens. They lived in appalling conditions inside cardboard boxes, begging from the passers-by. Many non-governmental organisations including MDM-G tried to provide these people with basic food and medical aid. After approximately a month, the City Council of Athen, in co-operation with the Ministry of Education. decided to transport the 600 refugees to a summer camp in Agios Andreas, near Athens, for an initial period of 40 days. MDM-G immediately intervened in order to help the refugees. In spite of the fact that it was during the peak of the election period in Greece, in a matter of two days, they managed to equip and organise a dispensary as well as to distribute hundreds of blankets and bars of soap to the people. The camp in Agios Andreas functioned for eight months. During this period, more than 12 000 Kurdish refugees were accommodated there. The refugees lived in tents and used the camp facilities. During the winter, living conditions were extremely difficult and it is only due to the mobiiisation of many NGOs and other relief agencies that these people managed to endure the harsh conditions. MDM-G treated more than 7 500 people free of charge in their dispensary. Moreover, they organised the hospitalisation of the most severe or emergency cases in public hospitals, the vaccination campaign in co-operation with Public Health authorities. and participated in organising of the distribution of various hygiene items and food. During this same period, two other camps were created: one in Sounion with 250 refugees and one in Perahora-Loutraki with 150 asylum seekers. In both of these MDM-G ran medical dispensaries. MDM-G also offered food, medication and medical aid to approximately 400 Kurdish refugees who sought shelter in abandoned train cars in Patra, on their way to Italy. At the beginning of January 1997 it was made clear that there would be no extension to the refugees' stay in the Agios Andreas camp and many solutions were proposed for them to be taken elsewhere. As Greek authorities were slow to meet the refugees' basic needs, MDM-G was obliged to find solutions to help the weakest individuals of this group. Ten months ago. the refugees were expelled from the PerahoraLoutraki camp and sought shelter elsewhere. The police refused to allow them to return to the Agios Andreas camp, and MDM-G decided to shoulder the responsibility for the future of these people, After hosting them for one night in a hotel, MDM-G managed to obtain approval to accommodate these refugees in an abandoned summer camp in Pendeli-Athens. which has the capacity to accommodate approximately 200 people. Unfortunately. the camp was in terrible condition, as it had not been used for seven years. There were three ruined buildings: the kitchen which was totally destroyed and full of rubbish, the dining room with a completely destroyed roof, no windows, and a ruined floor. and a warehouse which \\as damaged by a fallen tree. The showers were not in working order nor \"as the sekbage

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system. There was no electricity or running water system. The entire area was littered with rubbish and waste materials. MDM-G immediately undertook the rehabilitation of the camp's infrastructure: the kitchen, bathrooms, and warehouse were repaired, as were the oven and refrigerators. Two water heaters were installed, as were twelve new taps and two water fountains. Thirty-one tents, donated by a public relief organisation (PRONIA), were installed, as was an electrical system to provide light in each tent. A school was established and equipped. General cleaning, painting and maintenance of the camp was carried out. All of this emergency rehabilitation work was implemented in a one-week period by MDM-G volunteers and financed by their own finds. Since the very first day, MDM-G has co-operated with the elected representatives of the Kurdish people in order to ensure the maintenance of the camp. There is an organised warehouse, along with teams for cooking, cleaning, and security. Food, donated by private and public donors responding to the MDM-G appeals, is distributed and cooked daily. A mobile home was donated and transformed into a medical dispensary. Surgeons, internists, and paediatricians from MDMG volunteer their time on a daily basis. A vaccination programme was established to test and vaccinate all the residents of the camp for tuberculosis. Health education and dental care are among some of the services offered to the refugees. The more serious cases are either referred to the MDM-G Open Polyclinic, or in extreme cases, to state hospitals. Medicines are distributed free of charge. The Social Service Department of the Open Polyclinic solves many of the social problems of the refugees. The Psychology Department of the Open Polyclinic helps the Kurdish refugees to cope with their individual problems. It also tries to help all of the socially excluded population groups in Greece to overcome their many overwhelming psychological difficulties that are a direct result of being excluded from Greek society. In conclusion, Medecins du Monde Greece is faithful to the principles of humanitarian medical action, both in distant countries and here in Greece, bringing aid, bearing witness, and standing up for human rights. The Department of Hygiene and Public Health, University of Cagliari, Italy

The Department of Hygiene and Public Health of the University of Cagliari is divided into five laboratories: epidemiology and health promotion, environmental hygiene, food hygiene, serology and virology. Since 1993 it is part of the university hospital. The staff consists of six professors of public health (three medical doctors and three biological sciences doctors), seven lecturers, twenty full-time postgraduate students in public health, twenty technical and administrative co-workers. The department is responsible for the didactic activities of the University of Cagliari in the fields of epidemiology, health organisation and health promotion both for postgraduate (mainly public health, but also for other specialisation schools) and undergraduate (medicine, nursing, social work, psychology, education science) students. The main research areas concern water pollution, hepatitis, health promotion (particularly within schools), social epidemiology and social analysis of territorial areas. The epidemiology and health promotion laboratory The health promotion programmes are the main research and routine activity of the Laboratory of Epidemiology and Health Promotion. These programmes were introduced in the Department of Hygiene and Public Health of the University of Cagliari in 1993 by a team of researchers in touch with other European cities involved in the "Healthy Cities" network. At present, schools represent the most important setting for health promotion in Cagliari. During the last years a number of promotion activities have been carried out both in elementary schools (age 6-1 1) and in junior high schools (age 1 1-14). The schools were

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identified as key institutions in the development of inter-sectorial co-operation and community participation. During the meetings between teachers and researchers seven objectives were identified. Community diagnosis represented a pilot experience within the general fiamework of the global health promotion programme. This required the full involvement of the researchers in practical activities in order to correct mistakes and misunderstandings. Our aim is to create a global information system including periodical surveys and continuous monitoring. Community diagnoses were carried out at the city level for the city of Cagliari and some small centres and neighbourhoods. The main aim is to make inequalities clear and to highlight districts that need health promotion action, hoping that this will generate a debate among technicians, politicians, and the community. We defined and validated a set of indicators consistent with health promotion criteria, covering the demographic, social and health care sectors fairly well. European projects The department is participating in two European projects. The first one is the "Super project" in which eight European Healthy Cities collaborate in the promotion of healthy nutrition. The cities involved are Liverpool (UK), Valencia (Spain). Horsens (Denmark). Rennes (France), Eindhoven (the Netherlands), Amadora (Portugal), Charleroi (Belgium), and Cagliari (Italy). This project is based on the health promotion principles developed by the World Health Organisation (WHO), and aims to produce practical ways of improving the nutritional status in different European country settings. in order to prevent nutrition related diseases such as cardiovascular diseases and cancer. The second one is the European Training Consortium of Public Health. formed b) seven public health schools and institutions from seven European countries. The summer course is conducted at post-graduate level and constitutes 120 hours of formal study. The approach is based on participant self-leaming. oriented towards issue analysis and strategy development. The Super project The "Super" project began in 1991. This research also comes under the sub-heading of the Human Capital and Mobility programme, in which 4 cities take part in a "Young Researchers Exchange Programme". These cities are Wageningen (the Netherlands). Valencia (Spain), Cagliari (Italy) and Liverpool (UK). "Super1' was born of the principles laid down in the Ottawa charter for health promotion (WHO 1986). Like many other projects which emerged from the new public health movement, it aims at putting some of the new characteristics of this charter (highlighted later) into practice. The project started as a nutrition-based promotion programme. necessary due to the alarming rise in nutrition related diseases over the last decade. Most notably this rise has occurred in diseases of the cardiovascular system and a number of different cancers. including cancer of the stomach, pancreas, colon, bladder. cervix and ovary. "Super" is different to the old style, traditional health education programmes in a number of distinct ways. The project adopts a new methodological approach. in which action and research are strongly linked. It also adopts the public health approach. in so much as it focuses on populations, communities and groups instead of taking an individualistic approach. It takes into consideration the physical and social environment and believes these have an important role to play in shaping health status. "Super" could therefore be called a programme that is concerned with human factors. The basic assumption in "Super" is that the health promotion approach is necessary to favourably change nutritional behaviour. shaped by social. religious. economic. cultural and political factors and processes.

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The overall aim of the project is to find practical ways of improving the nutritional status in different European settings. Two of the main objectives are: - To produce a positive change in environmental factors influencing public nutrition. - To produce a positive change in knowledge and attitudes regarding healthy diet, thus improving public nutrition and contributing to the long term reduction of nutrition related diseases. Different professional sectors participate in the project, ensuring it has widespread representation. These sectors vary from university departments to municipal health services to, at a more local level, schools, supermarkets and community groups. It is hoped that in the future the project will serve as an example of how to put together the elements necessary to successfully develop and sustain health promotion programmes, and, of course, of how we can learn from those factors that according to our experience can lead to failure. The "Super'( project could therefore be used as an example of sustained multisectoral action, implemented in different European settings, aimed at improving health status through the mobilisation of different sectors and communities to act upon, define and improve their own health. At present it can confidently be said that the project has achieved notable success. Each city, through biannual meetings, has reported many success factors in their own individual programmes and a quantity of literature has been produced as a result of the project, for others to learn and gain experience from. The degree to which the project's overall goals and objectives have been achieved is yet to be discovered. What is known is that each city participating in "Super" has gained a tremendous amount from this participation and has had the opportunity to learn from the positive and negative experiences of others. What's more "Super" has grown into more than just a project. It has become a group of cities, and people who co-operate effectively for the benefit of the communities in which they work, sharing the same objectives and working towards the same principles. European Training Consortium in Public Health Seven public health schools and institutions from seven European countries form the European Training Consortium in Public Health. The summer course is conducted at post-graduate level and constitutes 120 hours of formal study. The approach is based on participant self-teaching, oriented towards issue analysis and strategy development. Methods include orientation sessions from the course team, self-study, group work and other forms of peer-based learning. In addition, participants develop their own project with tutorial support. Expert briefings and field visits are included. The consortium was born in 1990 after a meeting, organised in Goteborg by the WHO Regional Office for Europe and the Association of Schools of Public Health in the European Region (ASPHER), to investigate the possibilities of developing a European Public Health Training Programme. Eight years of co-operation have shown that there is a good basis for a worthwhile and successful collaboration among the ETC-PH members. The ETC-PH is the only working group that continued to work without interruptions on the ASPHER and the WHO/€ initiatives to start public health courses at the European level. In the past, the strategy for organising the courses (aims, methods, and evaluation) was usually prepared jointly. The ETC-PH's summer training courses pursue the following aims: - To improve public health practice, knowledge and skills, and to share experiences between countries within Europe. - To enable the participants to understand and put into practice the philosophy and ethics of the European Health for All strategy in a pan-European context, with a special emphasis on developing strategies for health.

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Its specific objectives are: To stimulate the students, from different European countries, to enter a learning process with HFA as the strategic framework and international co-operation as a tactical method. - To develop new skills as teachers in a European teaching team (this differs from just participating as a teacher in an international course). - To support both participants and teachers in their own work in order to attain the personal objectives established during the courses, for this reason the Network was initiated and contacts are maintained. At the end of the course, all the participants will have enhanced their competence in addressing strategy development to support HFA strategy. They will have had the opportunity to develop basic skills necessary for programme development and implementation. In addition, participants will have had the opportunity to present, to their peers and to course team members, a current issue facing them in their work and to develop an appropriate response. For those who wish to, it will be possible to continue to co-operate after the course, from a distance, following up on the strategy they started to develop during the course. This course is being conducted at the post-graduate level, i.e. as a Master of Public Health (MPH) course and its equivalent in degree courses in related areas such as health and social policy or public health sector management. The course constitutes 120 hours of formal study. The team running the courses (tutors, representatives from the ETC-PH members) has complementary strength in experience, skills and professional expertise. The team members are skilled facilitators with extensive experience in international and European cooperation and have a strong commitment to student centred problem-based learning.

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The Institute of Preventive Medicine. University of Lisbon, Portugal The University of Lisbon Following an outstanding scientific and cultural tradition, the University of Lisbon (UL), whose origins date back to the establishment of the Portuguese University by King D. Dinis in 1288, is a public institution, a centre intended to produce, transmit and transfer knowledge, culture and science at a higher level. At present the UL has approximately 20 000 students (including 700 foreigners who attend regular courses, approximately 600 students who attend the Portuguese Language and Culture Courses of the FLUL - Lisbon University Arts Faculty) and a highly qualified teaching staff (equivalent to about 1 600 full-time teachers), many of whom are eminent cultural and scientific Portuguese personalities. Research is carried out in laboratories, institutes and in research centres in connection with the public and private sectors. A continuous interchange is also conducted with universities and other national and international entities. As regards research projects. quality services promoting schemes, the construction of infrastructures and. broadly speaking, the overall modernisation and improvement of the university, the UL is represented and participates in community programmes, bilateral international programmes and in inter-institutional European projects. It also participates in, and is a member of. countless prestigious international organisations which cover the interests. concerns and goals that the UL pursues.' The Faculty of Medicine The Faculty of Medicine developed from the Royal School of Surgery founded at the Hospital of Saint Joseph in 1825. In 1836 it changed its name to school of Medicine and

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Surgery of Lisbon and finally in 1911, after the university reform, adopted its present designation. In 1954, it was transferred to the present building, the School Hospital of Saint Mary. The Faculty of Medicine of Lisbon belongs to the University of Lisbon and is the Institution responsible for the research and teaching of the sciences of medicine (for health promotion, prevention, treatment and rehabilitation of human diseases) and for the,training of future physicians. The presidents of the Directive, Scientific and Pedagogical Councils of the Faculties are elected. The students participate in the management of their faculty through their representatives at the Directive and Pedagogic Council and the Assembly of Representatives. In each faculty, there is an association to represent the students; the associations are members of the Academic Association of Lisbon. The Institute of Preventive Medicine The Institute of Preventive Medicine is a structural unit of the Faculty of Medicine of Lisbon. Its mission is to support teaching, research and community services in preventive medicine and public health. The main areas of development are: - Health promotion - Environmental health - School health - Epidemiology - Preventive measures - Health care management and organisation. The staff of the Institute consists of a director (Prof. Doutor Pereira Migeul), 4 professors and 9 assistant teachers, plus one research fellow, 2 secretaries and one technical assistant. Graduate Level Teaching - Preventive medicine I (medical ecology) - 1st year medical and dental students (59 hours of classes, 217 students). - Preventive medicine I1 (hygiene and epidemiology) - 3rd year medical and dental students (38 hours of classes, 187 students). - Community project - 2nd year medical and dental students (40 hours of classes, 169 students). - General practice and community medicine - 6th year medical students (83 hours of classes, 101 students). Post-Graduate Level Teaching: Two masters degrees: - School health (modules: healthy school and risks, pathologies and interventions). - Health care management (modules: management and health services research). Current Research Projects Cholesterol awareness among the Portuguese Health determinants in accidents among children and teenagers Antihypertension drugs .and adverse effects "Fluvastatine" in patients with hipercholesterol and cardiovascular risk Cost effectiveness assessment using "Nicorandil" for treating angor Health status of university students Cost effectiveness of "Fenofibrate" for treating hypercholesterolemia Satisfaction with health care and blood pressure control

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R&D priorities in relation to the interface between primary and secondary care. Other Activities

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Managing the university health centre

- Exchange programme in implementing a c o m e of health care management in -

Romania (three Romanian Medical Faculties) European module - Implementing a module of "health care" with five schools of health in Europe.

Me'dicos del Mundo (MDW, Valencia,Spain

In the Valencian Community, MDM-CV works with 3 population groups: immigrants in irregular administrative situations; persons practising high-risk behaviour as regards Aids, and who do not have access to health care: and the Rom population living in camps. Socio-medical assistance centre for immigrants MDM-CV's socio-medical assistance centre for immigrants (CASSIM) provides socio-health care for immigrants in Valencia, by undertaking various activities: - Recording the patients' clinical history; all the information is coded and computerised in data-bases. - Designing the necessary software. - Holding regular medical consultations, with prior appointments. - Requesting a series of additional test for each patient, among them hemograms. serologies, biochemistries, HBV, HCV, syphilis. - Obtaining pharmaceutical prescriptions for those in obvious financial need. - Managing the material and human resources necessary for the CASSIM to function correctly. - Evaluating and referring to other institutions those cases which are beyond the CASSIM's capabilities. - Providing material and psychological support when necessary. - Designing and developing health workshops. - Distributing information tracts of CASSIM activities. - Participating in public debates, scientific or not, to publicise our programmes. - Promoting and creating training courses for volunteers who work in our programmes. - Denouncing violations of the immigrants' human rights. - Co-operating with other NGOs in the framework of the "round table of solidarity with immigrants' entities". As well as its daily activity, the CASSIM. is also undertaking two sub-programmes: TBC screening of all patients attending the CASSIM. and a follow-up programme for pregnant women. ProJle of persons attending the CASSIM: In 1997 the CASSIM provided 3 558 medical consultations and received 779 persons (541 for the first time). 53% were men, 43% were between 16 and 31. and 38% between 31 and 45 years old. 44% were African, 39% South-American and 15% Asian. 45% emigrated for financial reasons, 13% for political, 13% for family, and the remainder for health reasons. Only 3% were illiterate, 50% had primary studies, 36% secondary studies, and 9% had higher education. 50% were unemployed, 19% worked in agriculture. 19% performed housework, 6% were street vendors and 3% were sex-workers. Half of the persons who attended the CASSIM had heard about it from other users.

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Aids prevention programme The objectives of this programme are risk prevention and damage limitation. The main instruments are syringe exchanges and the distribution of condoms. This programme is targeted at two groups of persons with high-risk behaviour: intravenous drug abusers and sex workers. These are groups, which because of their sociodemographic characteristics, social rejection, and police pressure, are extremely mobile, this led us to use a mobile unit that facilitates contact with them. The mobile unit moves 4 days a week, to 10 places in the city, in order to: - Inform as to, and provide, socio-medical (resources, allowances, etc.) sociofamily (schooling, childhood protection etc.) and legal assistance. - Provide health education by means of workshops focused on hygienic use of injection material, safe sex, and hygiene and health habits, whether personal, family or professional. - Protect health and prevent disease among the users of the programme by facilitating the destruction of potentially infectious material, providing condoms and information, exchanging syringes, and training the volunteers who participate in the programme. During 1997, our programme was used by 1 996 persons, of whom 58% were drug abusers (of these 5 1% were new users). We distributed about 146 000 condoms and 50 599 syringes in exchange for 42 802, i.e. 84.6%, and provided a total of 1 1 078 personal interviews. Profile ofpersons attending the mobile unit: Intravenous drug abusers: 88% were men, the average age was 29. 70% had 2-4 injections per day; 15% shared their injection equipment; 60% were sexually active, and of these only 41% used a condom during their last sexual contact. 21% had never had treatment for IVDA, 98% had been screened for Aids, 4 1 % were HIV positive. Sex workers: 67% were between 20 and 39 years old; 55% were single; 90% were Spanish; 50% had children. Half of them had attended primary school. 39% were drug abusers (of whom 30% were IVDA), mainly of heroin. 86% stated that they had always used a condom with their customers, and 15% stated that they had used one even with their partner. 78% had been screened for Aids, and 19%were HIV positive. Rom minorities See specific paper regarding our work with Roma minorities Other areas of activity of MDM-CM: Developing countries: - Geostrategic analysis - Bibliography - Situation studies - Elaboration and proposition of exploratory missions for the "Committee of MDM-E Missions" - Computer follow-up of the co-operation development programmes financed by institutions belonging to the "Comunidad Valenciana". Training - Determination and implementation of the "Annual training Plan" - Coordination of the bibliographical funds - Evaluation of the trainees - Favouring the participation of MDM-CV in scientific forums Volunteers - Promoting the participation of volunteers - Creating a data-base of volunteers

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- Informing all who are interested of our objectives and facilitating their

participation. Co-ordination and mobilisation of volunteers. Public awareness - Planning and co-ordinating the organisation's public awareness activities. - Designing and implementing campaigns to recruit volunteers and donors.

The mobile community care unit of the Department of Community Medicine, Universiot Hospital, Geneva, Switzerland Switzerland is a federal state comprising 26 cantons, each of which enjoys political autonomy as regards health policy. In practice, there are therefore 26 different health ministers, one per canton. At the federal level, the role of the Ministry of Health (OFSP: '* Federal public health ofice") is that of epidemiological surveillance (collection of data for the diseases which entail obligatory declaration), elaboration of treatment procedures and vaccination recommendations. There is however one exception: Aids prevention. which is a federal responsibility, with prevention campaigns organised at the national level. As regards care for underprivileged populations, there are no federal regulations. Each canton is in charge of developing the care system of its choice for these specific groups. In general, the charitable associations (Caritas, Entraide protestante, Armee du salut...) are quite active in the social area and try, if necessary. to bridge the gaps in the public system with financial and human resources. A11 these cantons do have, however, a common denominator, since health insurance became obligatory at the federal level (January 1st 1996, see chapter on the Swiss insurance system). Thus each canton must ensure the payment of the health insurance contributions of its residents whose income is below a certain scale. This measure only applies to Swiss citizens and to foreigners with a valid residence permit. How the unitJirnctions In the canton of Geneva (400 000 inhabitants), the Department of Community Medicine (DMC) of the University Hospitals of Geneva (HUG) created, in October 1996, a mechanism of ambulatory care for persons in precarious conditions (homeless, without income, without papers...). Baptised Mobile community care unit, it renews the mandate historically developed by the medical Policlinic (which ensures the outpatients consultations of the DMC) regarding care for the destitute, socially and/or financially excluded. There is also, in this same department, a migrations medicine unit. in charge of the medical care of asylum seekers and refugees. A clinic director ensures co-ordination of the mobile unit which consists of two fulltime nurses, and a half-time assistant doctor. The social service of the Department of Community Medicine also participates in this work. The unit functions in the following manner: Nursing work The nurses are the spearhead of the mobile unit. From Monday to Friday, from 9 a.m. to 6 p.m., they are on duty at the various reception centres that manage, in Geneva, the support associations for persons in precarious conditions (a dozen different locations are thus visited each week). A care centre has also been created outside the Hospital. which provides nursing consultations, with or without appointments. on Mondays and Wednesdays from 10 a.m. to 12 a.m. and from 2 p.m. to 4 p.m. During 1997, the nurses provided 1 800 consultations, corresponding to 394 patients, of whom 40% were Swiss. Besides health care, the patients also receive psycho-social care: a social worker is available to help with their social and administrative problems. with the specific aim of establishing their rights to health insurance. I'

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The nurses each have a cellular phone, which enables them to rapidly direct requests towards the most appropriate response (urgent nursing or medical consultation in a reception centre, or by sending the patient to one of the reception centres). This telephone also makes it possible to immediately contact the team's doctors for advice or orientation when faced with a patient whose problem is beyond nursing competencies. This particular aspect of the care is an element that helps to establish a relationship of trust with patients who have often had the feeling of being shunted from one service to another. Depending on the health problem in question the nurses can suggest a consultation with a general practitioner. The patients can also consult the doctor spontaneously (the nursing and medical timetables are well displayed at the reception centres). Medical approach At present, 3 afternoons of medical consultations are organised each week: Tuesdays at the hospital and Wednesdays and Fridays at the care centre. In 1997 and 1998, the majority of the patients seen by the doctors had been referred by the nurses. However, since the medical consultations without appointments were inaugurated at the care centre outside the hospital (November 1997), there has been, by word of mouth, an increase in the number of patients coming on their own initiative. In particular, the fact that the consulting doctor speaks Spanish "attracts" part of the Latin-American community that is "without papers". Among the various communities which make up the group of foreigners in irregular situations in Geneva (whose population is evaluated at close to 10 000 persons), the Latin-Americans are in second position, after the Portuguese. A nurse is systematically present at the care centre during the medical consultations. The nurse is in charge of receiving the patients and can also settle a certain number of the health problems. Also, once a week, a social worker comes from the hospital to the care centre, which enables certain administrative aspects to be solved while patients attend a consultation. In the care centre situated outside the hospital, during the twice-weekly medical sessions, 210 consultations, corresponding to 107 patients, took place in 4 months, with 6 hours of consultation per week. It is likely that this consultation, which in particular attracts people in irregular situations, who hesitate to come to the hospital except in extreme situations, will have to be expanded. It must, however, retain its original approach, of placing the nurses at the forefront. Financing The mobile unit's budget is shared between the various canton institutions: the Department of community medicine finances the doctors and the operational costs, the nurses are paid by the SASCOM (home care nursing service) budget, the City of Geneva provides the locations, and paid the installation costs of the care centre. Regarding the medical costs, nearly two-thirds of the patients are not entitled to health insurance benefits because they are foreigners in irregular situations. There is therefore a specific fund of 20 OOOFS, allocated by the Hospice GCneral Cantonal (Geneva Welfare Centre), to the Community Medicine Department, to pay the medical bills and treatments of those persons without financial resources. If necessary the Department makes its own funds available, or in certain cases receives private funding (for example from the Ligue contre le cancer). The patients who can do so, according to their means, participate in the costs; if necessary this can be by instalments. At the same time a co-operation has developed with an association of pharmacists in Geneva, the Pharmaciens du coeur, which provides the mobile unit with "recycled" medicines, for the patients who cannot buy them themselves. However, as the mobile unit is growing rapidly, the resources available at present will very soon be insufficient, both as regards personnel and the funding necessary to finance the care for the patients.

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Conclusions The mobile unit is in full expansion. According to those using it (direct users and the managers of the reception structures), it corresponds to a growing need of a segment of Geneva’s population that, more or less involuntarily, finds itself on the fi-inge of the classical health system. The originality of the mechanism is that the nursing staff, hired by the hospital, works “in the street”, where the patients are to be found, and moves about to evaluate the different situations. This functional flexibility makes it possible to provide care rapidly, by reducing the number of intermediaries. Also, the institutional label ensures a certain credibility to the mobile unit in the eyes of the other hospital services. The functional limits of this mechanism are those of an ambulatory medicine senice: hospitalisation, other than vital emergencies, of an uninsured and uninsurable patient (which is the case of foreigners in irregular situations), is still a question of case by case negotiation with the services involved. with major financial stakes in play.