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Issue 3, 2002 |
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Participation and Shaping Adalbert Evers: Democracy and Participation as Reform Ideas for the Health System, FJNSB 3/02, pp. 8-12 The article describes the potential of volunteering, self organisation and participation in the area of health care including the self-help movement, hospice movement as well as poltical activism. The author draws on results from the Enquete Commission "Future of Civic Volunteering". The current system of an independent health service is dominated by powerful interest groups. Less restricted regulation for insured people and insurance companies could empower them to become a self organising sector in a true sense. This process should be accompanied by independent public institutions to guarantee basic rights for patients. Ulla Schmidt: Patients Must Be the Focus, FJNSB 3/02, pp. 13-17
The federal minister for health outlines the basics of social democratic health policy. The concept is orientated at the publicly regulated health insurances which are financed on a solidarity basis. Patients should no longer be regarded as objects of care but rather as active participants in their roles as patients and insured. This is the background for her presentation of activities in her department, which include the option for insured to change their insurance, improvements for chronically ill and improved transparency, consultancy and information. In the bill on quality of care and in the bill on flat-rates for hospital care information rights for patients have been guaranteed. Health insurances have to support independent patient consultancy. Schmidt calls for more preventive measures and further empowerment of patients. The head of the parliamentary Green party and its spokes person on health issues point out massive quality problems in the German health sector. The problems are the result of a concentration on service suppliers. A reform of the health service should therefore empower insured and patients by more choice options, a national structure of patient support and consultancy similar to consumer protection and improved participation rights. In the consultation procedure besides representatives of physicians and insurances the patients should form a third group. For a paradigm change in the health sector which aims at improved quality as well as cost efficiency further participation of patients and insured is a prerequesite. Frank Bsirske/Ulla Derwein: New Roles in Health Policy?, FJNSB 3/02, pp. 23-28 The German health insurances which are based on a solidarity principle are to some extent influenced by unions. The service sector union ver.di represents 400,000 employees in the health sector and plans furthermore a stronger representation of patients' interests. Frank Bsirske, the head of ver.di, and Ulla Derwein, responsible in the board for health policy, define ver.di as a large patients' organisation. The service union initiated a campaign on health issues which tries to integrate the diverse initiatives and self-help groups to a network for patients' interests. Based on Hirschman's concept of exit and voice the authors analyse the influence chances of insured and patients in the health service. They describe the relationship between insured and insurance on the one hand and between patients and service providers on the other hand. On this background they suggest an empowerment of the insured in face of insurances. The major structural problem in the health sector is the imbalance between supplier power and consumer protection. A recent study by the American 'Institute of Medicine' presents for the first time worldwide the quality of clinical care in the USA. The results are alarming: every year 44,000 people in the USA die due to false medical treatment. Bandura calls for public evaluation and quality assessment in hospitals as well as in comparative perspective. A public agency should control minimal standards of clinical service and patients; insured should be empowered. The authors assess the chances of extended patients' rights to improve quality standards. Referring to the 'Harvard Medical Practice Study' they can show that juridical action on medical mistreatment is rarely successful. Therefore further juridical rights do not seem to be the way to improve quality. Patients are by and large not able to judge the quality of medical treatment, so juridical rights do not seem to be helpful. These rights cannot replace external assessment but rather supplement it. The authors recommend neutral assessment agents and the improvement of guidelines which are easily to read and obvious to control for patients. Jan Böcken: Reform of the Health Care Reconsidered, FJNSB 3/02, pp. 52-55 The health sector is marked by complex coordination problems. According to the Bertelsmann foundation a well developed frame is needed. International comparison can show that this frame should consist of a combination of market mechanisms and state regulation. The current structure, which is oriented towards self regulation, is characterised by a systematic dilemma of self interest and public responsibility. Adding new actors to this system of self regulation is not helpful. Instead the competence of actors outside this system should be improved and used via public moderated Round Tables. The German health system is undergoing structural changes. Discussion often focuses on financial matters and the distribution of the 130 million Euro budget for the obligatory health insurance companies (excluding the private insurances which are only open to high income groups). The authors call for a broader reform process which takes into account current deficiencies, i.e. organisation and quality of information flow, care quality, and transparency. Further participation of patients and insured could help to reach the goals of better efficiency, quality and economic viability, while maintaining the principle of solidarity. The obligatory health insurance companies should not limit their political position on established corporatism but engage in reform and thereby gain legitimacy. 88 per cent of the German population are insured in the obligatory system. The insurance companies therefore should define themselves as speakers of citizen interests as well as intersts of patients, insured and consumers. Bernard Braun/Gerd Marstedt: Alternative Movements in Health Care, FJNSB 3/02, pp. 67-75 Traditional Medicine is based on the concept of pathogenesis which interprets illness as malfunction of the organism. Alternative concepts drawing on Antonowsky intepret illness as an organism's activity to heal itself. A growing number of patients is asking for advice beyond classical medicine. The authors describe this current trend, analyse its causes and discuss consequences for the health system. Corporatist structures are the primary reason for the average quality of the German health system. The author is head of the 'Organisation of Democratic Physicians' since its foundation in 1986. He describes the influence of the 'Kassenärztliche Vereinigung', the major organisation of physicians, and discusses the oppositional political activity of his own organisation. Though the opposition has had some remarkable successes the dominating power of the major phyisicians' organisation is unchallenged and radical reforms are necessary. If patients are to participate effectively in the reform of the health system this participation needs to be professional and based on legal regulation. Christoph Kranch, who is leading the department on health in the consumer organisation Hamburg, calls for an equal participation of patients instead of the current paternalistic structure. Patients need professional, well funded interest representation to compete with the established actors. Efficient patient participation could reduce costs in the system. Therefore its funding would man a net gain. A powerful patient movement needs further support as without such a movement no radical reforms will occur. Jürgen Matzat: Self-Help as the Fourth Pillar in the Health System, FJNSB 3/02, pp. 89-97 Jürgen Matzat describes the size of the self-help health sector in Germany and discusses its (potential) role as a correcting element in the health system. However, one should refrain from idealising accounts. If self-help initiatives are to have a function in the health system they need further acceptance by other actors, better funding, and better participation rights. The author calls for dialogue and joint activity to reform the health system. The German health system needs fundamental reforms. Anke Martiny, representative of Transparency International, criticizes high costs, corruption and inefficiency. The main problem, however, is the lack of transparency in the system. The author analyses the behaviour of patients, insurances, physicians, hospitals, pharma industry, and interest groups, which result in the current situation. A reform should be oriented at the following guide lines: clear responsibility, increased transparency and professional administration. Since 1994 the World Health Organization (WHO) demands the adoption of guidelines for human health care. In the juridical sense these guidelines are widely shared in Europe but in practice the authors find considerable shortcomings. Especially deficiant are the information on treatment options, rights and information for inpatients, care after hospital, and dying in dignity. Based on social movement research the authors analyse trends, goals, and organisational structure of the Dutch patients' movement. Of foremost importance for this new and influencial movement is the emergence of a collective identity. The authors describe the tension and interference of instrumental and identity action. Disabled and chronically ill try to establish a positive identity against the dominating idea of illness and dependence. On the instrumental side they are trying to work on circumstances which allow a positive identity. Heidi Nadolski: Patients in America, FJNSB 3/02, pp. 123-131 In the USA large parts of the population do not have a health insurance at all. Heidi Nadolski explains the American system of health insurances including the Medicare, Medicaid, Children's Health Insurance Program (CHIP) and the privately managed care-organisations. Still more than 40 million people lack any health insurance, mostly from the working poor. Nearly a quarter of them are children. The Clinton government was not able to reform the health sector and the new Bush government concentrates on reductions in taxes, which are of no use to the working poor as they are mostly not liable to taxes anyway. The author does not see a chance for fundamental reform in the American health system. Klaus-Peter Stender: Healthy Cities, FJNSB 3/02, pp. 132-137 In 1986 the World Health Organisation (WHO) recommended an intersectoral understanding of health. This includes healthy circumstances, a coordinated approach, and support for health competence. The German expert commission on the health system has adopted this perspective, therefore focussing on local governments and cities as agents for healthy circumstances. The author describes the 'Healthy Cities'-network, which unites 50 local governments and more than 16 million people. Problematic are the lack of integration of social, environmental, and health activities as well as the sectoral administration which finds it diffcult to deal with cross sectoral tasks. An overall acceptance of these activities in politics and administration is still missing. In early 1990 health committees were founded in North Rhine-Westphalia to gather all major actors of the health sector. These commission allow more democratic and participative decision procedures, innovative concepts, and the involvement of local administration. The author explains the organisational structure and working method of these committees, which have been formally established recently. The involvement of self-help groups and representatives from patient protection organisations and preventive health care is planned. The committees are currently under scientific evaluation by a research group from the university of Düsseldorf. Petra Kolip/Ingeborg Jahn: Women, Women's Movement and the Health System, FJNSB 3/02, pp. 143-148 The authors present the history and current state of the women's health movement. They explain central concepts as gender justice, gender appropriateness, and gender specifity. The idea of gender mainstreaming shows that a gender sensitive health care is a concern for men and women. In a next step gender competence needs to disperse among actors in the health system. Gabi Rohmann: Health Is Not Sellable. The Major Attac-Campaign in 2002, FJNSB 3/02, pp. 149-151 This year's campaign of the globalisation critical network Attac is focused on health. It criticizes the globally increasing privatization of public services which means a replacement of the solidarity principle by market competition. Gabi Rohmann explains the conception and actions of the campaign. |