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Painful cuts and trade-offs in prospect







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Published: 01:05 - 30/09/09


The organisers of the annual European Health Forum in Gastein, Austria, could hardly have chosen a more gloomy but appropriate theme for their latest gathering of politicians, business executives, officials and academics that begins on Wednesday.

After the optimism of last year's "Creating a better future for health in Europe", the 2009 meeting has a more sober theme: "Financial crisis and health policy". Some 600 delegates will debate the recent past and its negative consequences - as well as potential bright spots ahead.

Melinda Medgyaszai, Hungary's state secretary for health policy and one of the speakers, highlights the dilemma for her country.

With lay-offs causing an estimated drop in contributions to the national health insurance fund of more than €150m ($219m), the government plans to cut reimbursement on medicines, easing the short-term deficit but threatening long-term damage to well-being in the process.

Companies are also feeling the pinch. Richard Clark, chairman and chief executive of Merck, one of the largest US pharmaceutical groups, says: "The financial crisis has caused families to reset priorities. We have seen a slowing of prescriptions." That includes a shift away from more potent innovative drugs to less effective but cheaper generic versions.



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In parts of the developing world, the impact is much greater. As Dr Shin Young-soo, the World Health Organisation's regional director for the western Pacific, warned last week: "Health is central because unemployment, job insecurity, the lack of income, and the reduction in benefits and social protection all have effects on health."

Médecins Sans Frontières, the medical charity, warned recently of growing funding gaps that were "potentially catastrophic", as its teams of doctors in countries including South Africa, Malawi and Uganda began to report stocks of life-saving anti-retroviral medicines for HIV running out.

In fact, in the first year since the financial crisis, the overall impact has been less than was initially feared.

Recent research commissioned by the WHO found no clear trend, and the latest financial results from pharmaceutical companies have shown no significant overall decline in medicine sales.

Indeed, Mr Clark says that demand in emerging markets such as China has continued to grow, helping offset stagnation in the US.

Given the relatively rare occurrence of large-scale economic crises, rigorous research on their effect on health is scant.

A study led by David Stuckler at Oxford University painted an ambiguous picture, showing that mortality rates even declined during the Great Depression in the US.

While there has been much speculation about the impact on mental health of rising stress, unemployment and debt, the evidence is also far from clear-cut. More leisure time, and falling interest rates for many borrowers ease some types of pain.

Those countries with strong health systems funded through governments or widespread insurance - including most of Europe - offer strong protection to their citizens.

Those who pay out of their own pocket, including most people in the developing world, are more threatened by the negative health effects of the crisis.

There are two mitigating factors. One is that health is usually among the last and least of discretionary spending items to be cut.

Another is that, as pointed out in a recent World Bank study, many of the poorer countries of Asia are in much stronger shape than they were during the previous financial crisis of 1998.

Funding cuts will take time to be felt, including their impact on weakened prevention, and lower ongoing investments in health and social services for an aging population.

The consequences of increased consumption of unhealthy but cheaper food, and a possible slowdown in lower smoking rates, will become clear only years hence.

The World Bank cautioned this year that at least 400,000 additional children could die each year as a result of the crisis.

That reflects the impact of reduced budgets for healthcare, including essential services for children and prevention programmes.

After enormous expansion in recent years under the Labour government, the UK's National Health Service is starting to feel the squeeze, with planned savings sought of £15bn-£20bn ($24bn-$32bn) in the coming year. This is unprecedented since its creation after the second world war.

In the US, President Barack Obama's efforts to create universal health insurance may help expand cover to some additional citizens in need, but the costs are likely to be significantly offset by efficiency measures, which are perceived by many to threaten their existing levels of care. That sentiment, in turn, is impeding the progress of reform.

While governments around the world pare domestic health budgets, foreign assistance has also come under pressure, whether from richer donor countries, companies or philanthropists, even including the Bill & Melinda Gates Foundation, the world's largest private contributor to global health projects.

The Global Fund to Fight Aids, Tuberculosis and Malaria is struggling to fund its latest rounds of grants, with long-standing donors such as Italy and even the US showing signs of cutting back or reallocating foreign aid flows.

A forthcoming report from the World Bank and Unaids, based on a survey of 63 developing countries, suggests 10 have already cut HIV budgets for 2010 and 20 are preparing for falling external aid contributions. Half anticipate cuts in HIV treatment and three-fifths in prevention programmes.

Mario Raviglione, director of Stop Tuberculosis at the WHO, warns that funding for health traditionally declines rapidly during a downturn, but recovers much more slowly, long after deep-rooted problems have taken hold. The growth of multi-drug-resistant TB has been one consequence of such stop-start approaches in the past.

In New York last week, western leaders unveiled their latest attempts to make good some of the shortfall, through a series of innovative financing initiatives for health, including voluntary contributions from airline passengers, VAT rebates and debt swaps.

Yet their proposals come at a time when many other worthy causes - not least climate change and family planning - are competing for ever scarcer funds.

After a period of rapid expansion since the start of the decade, donors and recipients alike will need to spend much more time co-operating and making painful trade-offs to ensure that more limited resources are better spent. That means greater accountability, tougher management and efforts more explicitly geared to improving health outcomes rather than measuring crude inputs.

A new era of austerity will create economic opportunities. It could also spark debate about the greater cost effectiveness of prevention over treatment, encouraging investment in earlier diagnosis, more aggressive health promotion and speedier adoption of electronic patient records, to lower costs and stimulate more research.

Some countries - from the US to China - have already included substantial new health-related investment as part of fiscal stimulus packages, spending to extend coverage or to boost research.

Others may yet introduce additional measures to counteract disease, which would be best targeted explicitly at the poor to generate the greatest impact.

As with the burden of greater debts to fund the recent global bail-out, the greatest health consequences of the crisis will be paid back over many years to come.




ΠΗΓΗ: FT.com
Copyright The Financial Times Ltd. All rights reserved.


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