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Brian Edwards CBE
Professor of Healthcare Development
University of Sheffield
Preparations for the extension of the European Community are now well advanced. Close negotiations are continuing with 10 of the candidate countries: Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia. All are expected to complete the negotiations in sufficient time to participate in the elections for the European Parliament scheduled for June 2004. (Bulgaria and Romania are expected to join in 2006 once their economies are more stable. The one major omission from this list, Turkey, was judged not to have met the political conditions for entry.) These are countries with very different histories, cultures and health systems. According to a recent opinion poll conducted by the Commission, 74% of those asked thought enlargement would be good for business and 77% thought it would increase the EU’s international influence. However, not everybody is enthusiastic – the Irish government had to have two national votes before they finally agreed. According to the same poll, the Dutch are very cool on the idea and Luxembourg, Denmark, Belgium and Finland have serious reservations. The most enthusiastic countries were Italy and Greece.
Health provision remains, of course, a matter for individual countries, but the enlargement will undoubtedly have some impact, if for no other reason than the freedom of movement for health professionals. Those countries that operate vigorous registration systems for health professionals are already expressing concern about the implications of allowing into practice large numbers of professionals from candidate countries who, in their view, are inadequately prepared for independent practice. On the other side of the coin is the fear that the richer countries will attract many young and mobile professionals from the candidate countries. Some turbulence in the supply of professional manpower looks to be inevitable in the short term.
The entry of these countries will undoubtedly play havoc with European averages. Some countries, such as the UK, have actually made policy decisions on the basis of such averages. A recent international study highlighted once again the wide variations among the richest members of the Community. Germany and France spend around 10% of their GDP on health, compared with the UK at 7% (but rising). Germany has almost twice as many doctors per head of population compared with the UK and, interestingly, more than the USA, which currently spends nearly 14% of its GDP on health.
The impact of enlargement on the pharmaceutical industry will be significant. The High Level Group on Innovation and Provision of Medicines, which reported in 2002, thought that on the whole it should be positive, provided a level playing field could be created, particularly with regard to parallel importing.
The process of full integration of 10 new countries will shift the problems of asylum-seekers now being experienced by many European countries, including the small ones like Malta. Concern is growing about the public health consequences of increased movement, particularly from regions of the world with high HIV infection rates. It is not at all clear how the Community will deal with patients from the candidate countries claiming the freedom to be treated elsewhere in the Community because waiting lists in their home country are unreasonably long. The European Court will have some testing cases to review. If there is to be a significant movement of patients across national borders, the impact on the receiving health systems will be significant.
Enlargement is going to be challenging politically, and all now await the results of the Commission set up to reform the Community’s structures so that it can cope with enlargement. In the health field, European organisations like HOPE (Standing Committee of the Hospitals of the EU) and the professional associations are extending a hand of welcome. The health family transcends national boundaries.