Reviews Books

Health Care Systems in Transition: Cyprus/Germany/Slovakia/Estonia

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:241
  1. Jane Salvage
  1. international health consultant

    The European Union is here to stay, whatever the outcome of referendums, budget battles, or the Eurovision song contest. It has and will have a profound impact on health issues, even in the United Kingdom, where “Europe” is often talked about as though it were somewhere else. Health, and increasingly health care, is no respecter of frontiers; its determinants range from imported diseases to health tourism, from drug trafficking to the migration of doctors.

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    Christina Golna, Panos Pashardes, Sara Allin, Mamas Theodorou, Sherry Merkur, Elias Mossialos, Ed Sara A llin, Elias Mossialos

    European Observatory on Health Systems and Policies, pp 117 Vol 6, No 5, 2004 ISSN 1020 9077

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    The study of health and health care in neighbouring countries is therefore increasingly important. We may consult, employ, or work alongside their professionals; treat their patients or send them ours; and encounter illnesses contracted there. Willingly or not, we may participate in experiments launched after fact finding missions to foreign capitals—most notoriously the former health secretary Alan Milburn's Madrid visit that inspired foundation hospitals. The search for different solutions drives us to compare and contrast, and scrutiny of other health systems prompts critical appraisal of our own.

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    Reinhard Busse, Annette Riesberg

    European Observatory on Health Systems and Policies, pp 232 Vol 6, No 9, 2004 ISSN 1020 9077

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    The European Observatory on Health Systems and Policies, a partnership between the World Health Organization, six European governments, and other leading institutions, is an invaluable resource. From modest beginnings in the early 1990s, as the WHO European office struggled to understand and influence the aftermath of the collapse of communism, the observatory is playing an expanding role in gathering, analysing, and disseminating information and ideas. Its most visible and handy product is a series of country profiles, Health Care Systems in Transition (HiTs for short).

    For all this plethora of information we don't really know what works

    Each profile uses the same template to combine facts, figures, and analysis and is occasionally updated by a team combining native and foreign expertise. The latest batch comprises the third updates on Estonia and Slovakia, the second on Germany, and a first edition on Cyprus—so almost every European country is now covered, as well as Australia, Canada, and New Zealand. The authors are the first to admit that much of the information is patchy and of variable quality, reflecting the often parlous state of official data. There may be big discrepancies (for example, the World Bank puts infant mortality in 2002 in Estonia at 10 per 1000 live births while the government puts it at 5.7).

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    Svätopluk Hlavaèka, Róbert Wágner, Annette Riesberg

    European Observatory on Health Systems and Policies, pp 116 Vol 6, No 10, 2004 ISSN 1020 9077

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    Designed primarily for analysts of financing and resource allocation, with most interpretation left to the reader, the profiles make dry reading; only those with a forensic interest in social insurance and reimbursement will read them from cover to cover. Nevertheless, assisted by a conclusion that ventures to make a judgment, they give a good flavour of the current state.

    The latest profiles of three new EU members (combined population 7.5 million) and mighty Germany (82.5 million) provide ample opportunity to compare, contrast, and assess EU trends. Slovakia has made the least headway in outgrowing the negative aspects of its communist legacy; health sector reforms have failed to contain costs or improve effectiveness, and it faces severe organisational and financial difficulties. Former Soviet colony Estonia is slowly improving, with better health and health system indicators than other former Soviet republics and financial sustainability in the healthcare sector, despite spending less than the EU average share of gross domestic product (GDP) on health (5.5%). Cyprus, once a British colony, does well on some indicators, but many of its citizens are overweight and smoke too much, while over half its health spend goes on private medicine.

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    Maris Jesse, Jarno Habicht, Ain Aaviksoo, Agris Koppel, Alar Irs, Sarah ThomsonEd Sarah Thomson

    European Observatory on Health Systems and Policies, pp 140 Vol 6, No 11, 2004 ISSN 1020 9077

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    According to what is inevitably the most hefty profile, at 230 pages, Germany's health system works well in terms of free choice, ready access, high staffing levels, and technology, with waiting lists and rationing virtually unknown—popular with the public. It has helped reduce health inequalities between the former East and West and contributed to a remarkable rise in life expectancy of the “Ossies.” But before we rush to emulate its 300-odd statutory health insurance schemes, complex funding mix, and high percentage of GDP spend on health (double Estonia's, at 10.9%), beware: in the 2000 WHO global league table, Germany ranked only 25th on health system performance, the efficiency of goal attainment to money spent.

    And there's the rub: for all this plethora of information we don't really know what works. “There is increasing doubt whether the high level of spending on health translates into good quality care and cost-efficient use of resources,” the Germany HiT concludes. The four reports leave an abiding impression that, unfortunately for patients and staff, healthcare reform is a huge laboratory where experts advocate their pet solutions on a shaky evidence base, bending the ears of politicians who use that evidence as a drunk uses a lamppost, for support rather than illumination. Next time you go to “Europe,” download the profile free from to stick in your bag along with your Lonely Planet guidebook, and you'll have plenty to think about on the plane.


    • Items reviewed are rated on a 4 star scale (4=excellent)

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