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Journal: Health policy (Amsterdam, Netherlands)


The Republic of Cyprus is the only country in the European Union (EU) whose health system is comprised of public and private sectors of relatively similar sizes. The division within the health system, combined with a lack of efficient payment mechanisms and monitoring systems, contributes to inequalities in access to care, and inefficient allocation and utilization of resources. In part to address these issues, a new General Health Insurance Scheme (GHIS), was proposed by stakeholders from the Cypriot government along with a team of international consultants in 1992 and eventually approved by the Parliament in 2001. However implementation of the GHIS has been repeatedly delayed since that time due to cost concerns. In 2012, following recommendations by the European Commission, the Cypriot Cabinet decided to recommit to the reform. In light of this development, the recent Cyprus application for accession to the EU support mechanism due to the economic crisis, and the international spotlight associated with Cyprus' EU Presidency, this article discusses the anticipated Cypriot health system reform-which is now slated to go into effect in 2016-and examines lessons from other countries.

Concepts: European Union, Treaty of Lisbon, European Commission, European Council, Council of the European Union, Belgium, Cyprus, President of the European Commission


The aim of this article is to investigate the association between corruption and antibiotic use at sub-national level. We explore the correlation between, on the one hand, two measures of corruption (prevalence of corruption in the health sector and prevalence of bribes in the society) at regional level from the European Quality of Government Index; and, on the other, the consumption of antibiotics in those European regions from a 2009 Special Euro Barometer. In a multivariate regression model, we control for potential confounders: purchasing power of standardized regional gross domestic product, inhabitants per medical doctor and age-standardized all-cause mortality rates. We find that there is a strong positive association between both measures of corruption (i.e. in the health sector, and in the society at large) and antibiotics use; and that this association is robust to the introduction of the control variables. These results support previous findings in the literature linking corruption to higher antibiotic use at cross-national level. We show that corruption does seem to account for some of the remarkable between-region variation in antibiotic consumption in Europe.

Concepts: Regression analysis, Medicine, European Union, United Kingdom, Antibiotic, Eastern Europe, Western Europe


CONTEXT: From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). METHODS: We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. FINDINGS: After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. CONCLUSIONS: Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences.

Concepts: European Union, Europe, Germany, European countries, German language, NATO, Liberal democracies, Parliamentary system


To identify diverging HTA recommendations across five countries, understand the rationale for decision-making in specific therapeutic categories, and suggest ways forward to minimize these inter-country differences.

Concepts: Decision making


We assessed the actual implementation and achievements of regional HTA in Italy. We conducted a web-based analysis (updated until July 2012). Six key elements were identified: availability of official documents, existence of a specific workgroup, involvement of external organizations, formal funds for HTA, publication of HTA reports, and membership of HTA networks. Then, we searched all HTA reports retrieved by key words to analyze whether their contents included clinical efficacy, economic evaluation, legal issues, ethics and organization. Two researchers analyzed the information separately, as a double check. Sixteen regions have formally established a structured workgroup inside their organizations. Specific funding for HTA activities could be traced in six regions, web-available reports only in four. Around 91% of the total reports concerned drugs. Contents mostly focused on epidemiological and clinical issues, economic evaluation was often restricted to a brief analysis of costs. Only a few reports mentioned organizational implications; ethical, legal and social issues were lacking. This survey showed a very uneven picture of HTA in the Italian regions. As expected, not all the regions were able to perform HTA, probably on account of their wide differences in size, tradition and skills in the health care field.

Concepts: Health care, Clinical trial, Illness, Ethics, Organization, Italy, Region, Regions of Italy


This review study explores the “brain drain” currently evident amongst physicians in Greece, which is closely linked to the country’s severe financial woes. In particular, it shows that the Greek healthcare labour market offers few opportunities and thus physicians are forsaking their homeland to seek jobs abroad. The main causes generating or greatly inflating the brain drain of Greek physicians are unemployment, job insecurity, income reduction, over-taxation, together with limited budgets for research institutes. It is argued that, to stop the evolving mass exodus of skilled medical staff, policy-makers should implement fiscal and human-centred approaches, thoroughly safeguarding both the right of skilled Greek physicians to work in their homeland with motivation and dignity, but also of Greek citizens to continue receiving high-quality healthcare by skilled physicians at times when this is mostly needed.

Concepts: Medicine, Brain, Human migration, Employment, Policy, Implementation, Labour economics, Beveridge curve


Turkish health system showed major improvements in health outcomes since initiation of the Health Transition Programme (HTP) in 2003, however little is known regarding income-related inequalities in health care use. The aim of this study was to assess horizontal inequities in health care use in Turkey.

Concepts: Health care, Health economics, Medicine, Healthcare, Massachusetts


A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of “disruptive innovations” to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners' potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners' place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.


This paper assesses whether the concession card, which offers discounted out-of-pocket costs for prescription medicines in Australia, affects discontinuation and adherence to statin therapy. The analysis uses data from the Australian Hypertension and Absolute Risk Study (AusHEART), which involves patients aged 55 years and over who visited a GP between April and June 2008. Socioeconomic and clinical information was collected and linked to administrative data on pharmaceutical use. Patients without a concession card were 63% more likely (hazard ratio (HR) 95% confidence interval (CI): 1.14-2.33) to discontinue and 60% (odds ratio (OR) CI: 1.04-2.44) more likely to fail to adhere to therapy compared to concessional patients. Smokers were 2.12 (HR CI: 1.39-3.22) times more likely to discontinue use and 2.23 (OR CI: 1.35-3.71) times more likely to fail to adhere compared to non-smokers. Patients who had recently initiated statin medication were also 2.28 (HR CI: 1.22-4.28) times more likely to discontinue use. In conclusion, higher copayments act as a disincentive for persistent and adherent use of statin medication.

Concepts: Pharmacology, Prescription drug, Medicine, Medical statistics, Statin, Relative risk, Pharmaceutical drug, Food and Drug Administration


Reports on the implementation of the Directive on the application of Patients' Rights in Cross-border Healthcare indicate that it had little impact on the numbers of patients seeking care abroad. We set out to explore the effects of this directive on health systems in seven EU Member States. Key informants in Belgium, Estonia, Finland, Germany, Malta, Poland and The Netherlands filled out a structured questionnaire. Findings indicate that the impact of the directive varied between countries and was smaller in countries where a large degree of adaptation had already taken place in response to the European Court of Justice Rulings. The main reforms reported include a heightened emphasis on patient rights and the adoption of explicit benefits packages and tariffs. Countries may be facing increased pressure to treat patients within a medically justifiable time limit. The implementation of professional liability insurance, in countries where this did not previously exist, may also bring benefits for patients. Lowering of reimbursement tariffs to dissuade patients from seeking treatment abroad has been reported in Poland. The issue of discrimination against non-contracted domestic private providers in Estonia, Finland, Malta and The Netherlands remains largely unresolved. We conclude that evidence showing that patients using domestic health systems have actually benefitted from the directive remains scarce and further monitoring over a longer period of time is recommended.

Concepts: Health care, Medicine, European Union, Member State of the European Union, Europe, Treaty of Lisbon, Poland, European Union member states