neka pitanja u vezi sa finansiranjem zdravstvene...

Ibrahim Toti * 1

NEKA PITANJA U VEZI SA FINANSIRANJEM ZDRAVSTVENE ZAŠTITE U ZEMLJAMA- LANICAMA EVROPSKE UNIJE

Sažetak: Pred vama je rad iji je osnovni cilj da pokaže kako su ure eni zdravstveni sistemi doprineli, a i dalje doprinose, da se zdravstveno sta-nje gra ana zemalja- lanica Evropske unije zna ajnije poboljša. To je razlog zašto su starije zemlje- lanice Evropske unije (Austrija, Belgija, Francuska, Nema ka, Holandija), spremne da utroše ve i deo svog bruto društvenog proizvoda (BDP) na zdravstvenu zaštitu svojih gra ana. Na drugoj strani, zemlje- lanice sa periferije Evropske unije (Portugalija, Italija, Irska, Gr ka i Španija), poznatije kao grupa (PIIGS-prasi i), zbog zapadanja u dužni ku krizu nisu spremne na takav korak zbog ega se njihovi gra ani suo avaju sa velikim problemima prilikom koriš enja zdravstvene zaštite. Rad se bavi problemima nejednakog pristupa zdravstvenim uslugama i nedovoljnom zdravstvenom pokrivenoš u koje jednako egzistiraju kod pojedinaca i kod odre enih društvenih grupa u mnogim zemljama- lanicama Evropske unije. Analiza nejednakog pri-stupa zdravstvenim uslugama izvršena je na osnovu procenjenog stepena njegove zavisnosti od socioekonomskog statusa korisnika-nekorisnika zdravstvene zaštite, pri emu nisu zaobi ena prava osiguranika i njihovo sticanje. Prava osiguranika, iji se koreni nalaze u agidumu Hipokratove zakletve: primum non nocere – „prvo da se ne naškodi“, variraju od vrlo uskih do vrlo širokih i raznolikih okvira.

U radu je konstatovano da vo enje javnih nansija u zemljama- lanicama Evropske unije nije bez problema, naro ito tamo gde su doprinosi za zdravstveno osiguranje dominantni mehanizmi nansiranja. Finansiranje zdravstvene zaštite u zemljama- lanicama Evropske unije zna ajnije od drugih funkcija uti e na kvalitet zdravlja gra ana, na raspoloženje za investiranjem u dostupnost zdravstvenim uslugama i na univerzalnu pokrivenost zdravstvenim osiguranjem. Politika nansiranja zdravstvene

* Državni univerzitet u Novom Pazaru, departman za pravo i departman za ekonomiju.

55NEKA PITANJA U VEZI SA FINANSIRANJEM ZDRAVSTVENE ZAŠTITE...

zaštite nije jedina karika od mnoštva njih u dugom lancu globalne politike. Me utim, ona je nezamenjiva kod merenja efekata donešenih odluka, pri-mene konkretnih mera usmerenih na sistemati no i analiti ko razmatranje raspoloživih zdravstvenih resursa i kod sagledavanja faktora politi kog, ekonomskog, društvenog i tehni kog karaktera na svim nivoima. Posebna pažnja posve ena je prikupljanju sredstava za pokrivanje troškova koji su posledica univerzalne pokrivenosti zdravstvenim osiguranjem.

Klju ne re i: Evropska unija, zdravstveni sistem, zdravstvena zaštita, univerzalna pokrivenost, prikupljanje sredstava, zdravstvene usluge

Uvod

Bez obzira da li neka zemlja pripada ili ne pripada odre enoj organizaciji, uniji, savezu, grupaciji i sl., u pogledu nansiranja zdravstvene zaštite, u njoj mora da do-minira stav makar minimalne regulative. To zna i da u svakoj zemlji, nezavisno od njenog društvenog ure enja, politi kog angažovanja i ekonomskog delovanja, politika nansiranja zdravstvene zaštite mora biti zacrtana u svim vladinim dokumentima i

valjano donešenim deklaracijama i/ili rezolucijama. Time se ne želi podvu i crta ispod limitiranih nansijskih sredstava potrebnih zdravstvenoj zaštiti ve se nudi konkretan odgovor na pitanje, ko i na koji na in pla a ili raspore uje sredstva izme u raznih so-cio-ekonomskih grupa, odnosno korisnika-nekorisnika zdravstvene zaštite. Dosledna zdravstvena politika, odnosno politika realnog alociranja zdravstvenih resursa mora da odražava sistematsko odre ivanje prioriteta koji se odnose ne samo na zdravstveni ve i na druge njemu komplementarne sektore. Finansijska politika u zdravstvenom sektoru je snažna poluga na koju se oslanjaju pojedinci, grupe, odnosno celo društvo koje se stara za one kojima se sre a u okviru sopstvene zajednice nije dovoljno osmehnula.

Zdravlje ljudi, dobro ili loše, nije posledica individualnog izbora, ali je zato vr-hunska vrednost ili neželjeno stanje, koje u najve oj meri zavisi od uticaja politi kih, društvenih i ekonomskih faktora, odnosno globalnih uslova u kojima ga ljudi poseduju. Pristup kvalitetnim zdravstvenim uslugama, na koje se može i mora ra unati, determiniše, prvo, pravo na obuhvatnu zdravstvenu zaštitu, i drugo, obavezu uvanja i unapre ivanja zdravlja, ime se dodatno ja a njegova socijalno-ekonomska dimenzija. Shodno tome, u završnom izveštaju Svetske zdravstvene organizacije (SZO) o determinantama zdravlja stoji (20) da je loše zdravlje, posebno siromašnih kategorija me u gra anima zemalja-lanica Evropske unije, posledica nejednake distribucije mo i, naglašene socijalne i

zdravstvene nejednakosti, neuravnoteženih prihoda i nedostatka kvalitetnih roba i usluga na nacionalnom i globalnom nivou. Osim toga, mnoge, golim okom vidljive, okolnosti i nepravi nosti neposredno uzrokuju nejednak pristup zdravstvenoj zaštiti, školskim i obrazovnim sadržajima, adekvatnoj radnoj sredini i uslovima za koriš enje slobodnog vremena. Ma kakvo mišljenje o zdravlju ljudi vladalo u Evropskoj uniji, izvesno je da

56 MEDICINSKI GLASNIK / str. 54-68

gra ani u nekim zemljama- lanicama nisu u prilici da na prosperitetan na in organizuju svoj i život svojih porodica i da adekvatno štite i unapre uju globalno zdravlje. Mnogi od njih nisu imali, a mnogi nikada ne e imati, izgledne šanse da žive u odgovaraju im okruženjima, pristojnim stambenim uslovima, u ure enim zajednicama ili istim grado-vima. Zato ne treba gubiti iz vida na koliki rizik gra ani u mnogim zemljama- lanicama Evropske unije moraju ra unati.

Politika nansiranja zdravstvene zaštite podrazumeva niz funkcija, procedura i mera fokusiranih na pribavljanje sredstava potrebnih za obuhvatno zdravstveno osi-guranje. Ono podrazumeva odgovaraju i obim zdravstvene nege, ravnopravan pristup zdravstvenim uslugama, tehnologiju prikupljanja nansijskih sredstava, korektnu dis-tribuciju i alokaciju i racionalnu upotrebu. Znameniti teoreti ari (McKee, Mossialos, Belcher) nisu imali dilemu kada su ispred svih funkcija u okviru zdravstvene delatnosti stavili funkciju prikupljanja nansijskih sredstava i njihovo udruživanje. Znali su da, uz izvesne rizike, ova funkcija tendira ka neometanom obezbe ivanju adekvatnih uslova za pružanje zdravstvene zaštite stanovništvu koga smatraju univerzalnim i najsigurnijim resursom (13, str. 263–286). Politika nansiranja u zemljama- lanica-ma Evropske unije doživljava se i kao najvitalniji deo zdravstvene politike zato što, isklju ivo u duhu zakonskih pravila i prava korisnika, usmerava potrebna sredstva za zadovoljavanje njihovih potreba iz domena zdravstvenog osiguranja.

Cilj rada

U svakoj zemlji- lanici Evropske unije nansiranje zdravstvene zaštite se spro-vodi u cilju unapre enja zdravlja njihovih gra ana i uglavnom uklju uje funkcije prikupljanja poreza, doprinosa, naplate od prodaje zdravstvenog osiguranja i prihode iz drugih izvora. Nacionalni organi svake zemlje- lanice Evropske unije udružuju prikupljena sredstva u za to namenjene zdravstvene fondove (14, str. 179–189). Udru-živanje sredstava skop ano je sa rizikom koji uvek odnekud vreba. On je permanentna smetnja poboljšanju efektivnosti i ublažavanju neizvesnosti koje se vezuju za obuhvat zdravstvenim osiguranjem i pravo na koriš enje zdravstvenih usluga pod istim uslo-vima (2, str. 101–106). Iz ekonomske perspektive gledano, u odnosu na pomenuta sredstva, važno je imati na umu da su zdravstveni troškovi konstantno u porastu i da izdvajanja za zdravstvenu zaštitu iz bruto društvenog proizvoda (BDP), iako razli ita od jedne do druge zemlje- lanice, stalno pomeraju lestvicu nagore.

Finansiranje zdravstvene zaštite u Evropskoj uniji

Funkcija nansiranja zdravstvene zaštite u zemljama- lanicama Evropske unije, kao nijedna druga poznata funkcija, determiniše ukupni zdravstveni kvalitet njihovih


gra ana. U prvom redu, zna ajnije uti e na stvaranje predvi enih pogodnosti za pra-vovremenu dostupnost zdravstvenim uslugama i na obezbe ivanje jednakih tretmana za osiguranike u svim vrstama zdravstvenih procedura. Finansiranje zdravstvene zaštite podrazumeva održivo i permanentno obezbe ivanje potrebnih sredstava iz raspoloživih resursa na svim nivoima, bez obzira na njihovu izloženost raznovrsnim uticajima politi kih, ekonomskih, društvenih i tehni kih faktora. Obezbe ivanje i odr-živost pomenutih resursa uvek je prvi cilj; me utim, promoteri zdravstvene ekonomije u svakoj zemlji- lanici Evropske unije potpuno su svesni da su samo kontinuirani i održivi nansijski resursi garancija za neometano nansiranje zdravstvenih programa i ciljeva. Budu i da zdravstvena politika ina e li i na lanac, njegove vezivne karike, u pravom smislu te re i, predstavljaju odre ene doga aje. Svaki od njih je prakti no vezan za izbor, utvr ivanje, jasnu formulaciju i metode realizacije zdravstvenih ciljeva i programa ili za propisivanje i preduzimanje konkretnih mera za njihovo kona no efektuiranje. S tim u vezi, a u smislu ozbiljnog shvatanja zna aja ovog pitanja, Svetska zdravstvena organizacija (SZO) (30) je još davne 1984. godine promovisala koncept Program-budžetiranje (Programme-Budgeting), koji se sprovodi u programiranju prema ciljevima zdravstvenog razvoja, a u budžetiranju prema usvojenim prioritetnim programima zdravstvenog razvoja. Zanimljivo je da su ovaj program prihvatile, osim zemalja- lanica Evropske unije, i druge zemlje u svetu i u Evropi (24, str. 37).

Neraspoloženje pojedinih grupa da kolektivno pla aju subvencionisanje troškova zdravstvene zaštite za druge, iz dana u dan, posebno u siromašnijim zemljama- lanica-ma Evropske unije, pove ava otpor prema redovnim uplatama poreza i/ili doprinosa. Tamo gde centralne vlasti za dodelu subvencija lokalnim samoupravama ili lokalnim zdravstvenim vlastima kao mehanizam koriste lokalne poreze i doprinose (Danska, Finska, Italija, Španija i Švedska), postoji velika odgovornost s obzirom na obavezu koja predstoji u prikupljanju sredstava kojima se nansiraju zdravstveni kapaciteti. Dodela subvencija je proces koji u najve oj meri predstavlja predmet politi kih de-bata posle kojih sledi donošenje odluka o dodeli sredstava siromašnijim regionima za obezbe ivanje jednakog pristupa zdravstvenoj zaštiti. Što se doprinosa za socijalno osiguranje ti e, njih prikupljaju institucije centralne vlasti (Belgija, Bugarska, Estonija, Francuska, Litvanija, Holandija, Poljska i Rumunija) i tako prikupljeni predstavljaju sopstvena sredstva koja se usmeravaju u zdravstvene fondove i drže radi nansiranja socijalne sigurnosti (16, str. 109–116). U pojedinim zemljama- lanicama Evropske unije (Austrija, eška, Nema ka, Gr ka, Slova ka) obezbe eni su mehanizmi pomo u kojih se pokušavaju izbe i problemi kod prikupljanja sredstava zbog nastajanja ra-zli itih oblika rizika. Pomenuti mehanizmi podupiru sposobnost sprovo enja naplate poreza i doprinosa za socijalno osiguranje i zna ajno uti u na pronalaženje mogu -nosti za generisanje sigurnih i dovoljnih sredstava kojima se pokrivaju zdravstveni troškovi. Na primer, Estonija ovaj problem rešava tako što odgovornost za naplatu prebacuje sa Fonda za zdravstveno osiguranje Estonije (Health Insurance Fund of Estonia–EHIF) na centralnu vladinu agenciju za naplatu poreza. Od 2009. godine u


Nema koj su doprinosi centralno postavljeni i objedinjeni u novi nacionalni Fond za zdravstveno osiguranje, tako da je on ve tokom 2011. godine postao odgovoran za blagovremenu naplatu doprinosa.

Me utim, i pored primene ovih i sli nih mehanizama, mnogo je primera gde se nansijska politika posebno u poslednjih nekoliko decenija, u novijim zemlja-ma- lanicama Evropske unije, prosto davi u navedenim problemima. Uvek kada se povede debata o nansiranju zdravstvene zaštite u zemljama- lanicama Evropske unije (i van nje), neizostavno se operiše sa terminom prioritet, te je poželjno objasniti njegovu suštinu, kao i razloge zbog kojih se tako esto potencira. Mnogi teoreti ari su skloni, kada je re o nansiranju zdravstvene delatnosti, da kao razlog zbog koga se prioritet kao termin, ali i kao akcija, esto pominje navedu siromaštvo sa kojim se ljudi suo avaju više u perifernim nego u razvijenim zemljama- lanicama Evropske unije. Rešavanje problema siromaštva svojstvenog perifernim zemljama- lanicama Evropske unije, posebno onih iz grupe PIIGS (Portugalija, Italija, Irska, Gr ka, Španija), zahteva pre odre enu moralnu hitnost i/ili ozbiljnost nego donošenje od-luka o prioritetu. Budu i da postoji dužnost pružanja adekvatne zdravstvene zaštite, donošenje odluke u skladu sa tim predstavlja podršku njenim korisnicima i prevagu hitnosti nad prioritetom. Prema tome, hitnost je i kao termin i kao prakti na injenica u supremaciji u odnosu na prioritet. Radi toga, kako isti e Douver, radije treba re i hitnost nego prioritet, jer ideja prioriteta sugeriše da se mora uspostavljati odre eni poredak u stepenima neželjenih stanja, pri emu se pristupa lan anom ublažavanju prvo jedne, zatim druge i tako redom do kona ne situacije (3, str. 393–407). Me utim, to nije uvek najsigurniji na in kojim se odre uje ili treba da se odredi koncepcija zdravstvene brige za saniranjem neželjenih stanja. Treba imati na umu da se tome suprotstavljaju razne otežavaju e okolnosti. Na primer, jedna od tih okolnosti vezana je za troškove delotvornosti, odnosno za troškove hitnog pružanja pravovremene zaštite ljudskom zdravlju u svim segmentima, a naro ito u nansijskom. Ali ni to nije jedini razlog zbog koga je, u odnosu na nansijsku funkciju, zahvalnije govoriti o hitnostima nego o prioritetima.

Politika nansiranja zdravstvene zaštite u ve ini zemalja- lanica Evropske unije zavisi od hitnosti i veštine nalaženja pravih rešenja koja obezbe uju sigurne resurse, stru ne davaoce usluga, jednak i neometan pristup zdravstvenoj zaštiti svim korisnici-ma i, na kraju, administrativnu e kasnost. U ve ini zemalja- lanica, javno prikupljena sredstva namenjena za nansiranje zdravstvene zaštite objedinjena su na nacionalnom nivou. Zna i da postoji jedan zdravstveni fond odgovoran za prikupljanje, uvanje i distribuciju sredstava od doprinosa za zdravstveno osiguranje. Fond je u obavezi da prilikom distribucije pribavljenih sredstava izvrši nadoknade siromašnijim regionima i da nadoknadi sredstva siromašnijim gra anima i/ili onima sa ve im rizikom od obo-levanja. Prema podacima Svetske zdravstvene organizacije (SZO) (31) u Nema koj je u toku 2004. godine 77% zdravstvene zaštite nansirala nema ka vlada a 23% je nansirano uplatom premija za privatno zdravstveno osiguranje. Ukupna zdravstvena


potrošnja iznosila je 10,8% od vrednosti nema kog bruto doma eg proizvoda (BDP). Sistem javne (državna) zdravstvene zaštite u Irskoj (6) regulisao je pitanje zdravlja njenih gra ana 2004. godine, kada je uspostavljeno novo telo (Health Service Execu-tive–HSE) odgovorno za pružanje zdravstvene zaštite i socijalnih usluga svima koji žive u Irskoj. Irska je tokom 2005. godine za zaštitu svojih gra ana utrošila 8,2% bruto društvenog proizvoda (BDP) ili 3.996 $ USA po glavi stanovnika. Od toga je oko 79% zdravstvenih rashoda pokrila irska vlada (11, str. 152).

Zdravstvena zaštita u Holandiji nansira se dualnim sistemom koji je stupio na snagu u januaru 2006. godine. Holandski zdravstveni sistem, upore en sa zdravstve-nim sistemima Sjedinjenih Ameri kih Država, Australije, Kanade, Velike Britanije, Nema ke i Novog Zelanda ubedljivo zauzima prvo mesto. Tome je doprinelo usvajanje Opšteg zakona o izuzetnim zdravstvenim troškovima (General Law on Exceptional Healthcare Costs–GLEHC) (25). Za sve redovne (kratkoro no) medicinske tretma-ne, postoji sistem obaveznog zdravstvenog osiguranja preko privatnih kompanija za zdravstveno osiguranje. Osiguravaju e kompanije su obavezne da obezbede paket de nisanih tretmana za osiguranike (9, str. 5–29). U 2009. godini ovo osiguranje po-krivalo je 27% svih troškova zdravstvene zaštite. Drugi izvori pla anja zdravstvene zaštite su porezi 14%, pla anja iz džepa gra ana (OOP–out of pocket) 9%, dodatni opcioni paketi za zdravstveno osiguranje 4% i drugi izvori 4%. Pristupa nost zdrav-stvenim uslugama u oba slu aja je apsolutno zagarantovana. Francuski zdravstveni sistem je univerzalni sistem u kome u velikoj meri zdravstvenu zaštitu nansira nacionalna vlada. U svojoj proceni svetskih zdravstvenih sistema iz 2000. godine, Svetska zdravstvena organizacija (SZO) tvrdi da Francuska pruža „najbolju ukupnu zdravstvenu zaštitu” na svetu (29). U toku 2005. godine, Francuska je potrošila na zdravstvenu zaštitu 11,2% svog bruto društvenog proizvoda (BDP) ili 3.926 $ USA po glavi stanovnika. Izdaci su mnogo ve i od proseka na nivou zemalja- lanica Evropske unije, ali su znatno manji od onih u Sjedinjenim Ameri kim Državama. Oko 77% zdravstvenih troškova pokriveni su od strane vladinih agencija koje nan-siraju zdravstvenu potrošnju. Troškovi zdravstvene zaštite u Španiji u 2006. godini iznosili su 8,4% bruto društvenog proizvoda (BDP). Oni su po glavi stanovnika za 2006. godinu iznosili 2,458 $ USA, što je manje od proseka na nivou OECD, koji je 2.824 $ USA (18).

Prikupljanje sredstava i zna aj privatnog zdravstvenog osiguranja

Sve zemlje- lanice Evropske unije za nansiranje zdravstvene zaštite opsežno koriste doprinos kao osnovni mehanizam, uklju uju i javno zdravstveno osiguranje (porezi i doprinosi za socijalno osiguranje), privatno zdravstveno osiguranje (medi-cinski štedni ra uni–medical savings accounts MSA) i pla anja iz sopstvenog džepa (out-of-pocket–OOP). Dakle, re je o direktnom pla anju zdravstvenih usluga koje


ne pokriva obavezno zdravstveno osiguranje, o podeli troškova (naplata od korisnika) za usluge koje pokriva paket korisnika obuhva enih obaveznim zdravstvenim osigu-ranjem i, na kraju, o neformalnim pla anjima. Velika promena u politici nansiranja zdravstvene zaštite u mnogim zemljama- lanicama Evropske unije usledila je po et-kom 1990-ih godina. Tada je prikupljanje sredstava prešlo sa terena poreza na teren doprinosa za socijalno osiguranje, koji je postao dominantan mehanizam ne samo u zemljama- lanicama Evropske unije ve i onim koje to nisu, a nalaze se na teritoriji centralne ili isto ne Evrope. Istraživanja pokazuju, da u mnogim zemljama- lanicama Evropske unije, zdravstvena potrošnja kao deo ukupne javne potrošnje opada od kraja XX i po etkom XXI veka, što izaziva u enje, ali ne menja stvar. Zašto? Prvo, što je porast bruto društvenog proizvoda (BDP) u mnogim zemljama- lanicama Evropske unije vrlo teško ostvariv, drugo, u mnogim od njih njegov pad je hroni na pojava, i tre e, iako je procentualno u eš e rashoda za zdravstvenu zaštitu zna ajno poraslo, ono ne atakuje ozbiljnije na integritet bruto društvenog proizvoda (BDP). Treba ista i, nisu retke zemlje u svetu, a samim tim i Evropskoj uniji, koje na ime zdravstvene zaštite izdvajaju jedva nešto preko 6% svog bruto društvenog proizvoda (BDP).

Rezultati pomenutih analiza, vezanih za privatnu zdravstvenu potrošnju, pokazuju da su direktna pla anja (out-of-pocket–OOP) u najve oj meri doprinela da od 1996. godine, pa dalje, ukupna zdravstvena potrošnja permanentno raste. Me utim, ažurne evidencije i izveštaji relevantnih organa ignorišu, odnosno negiraju pomenute navode, jer u ve ini zemalja- lanica Evropske unije rashodi po osnovu privatnog zdravstvenog osiguranja ne prelaze više od jedne tre ine ukupne zdravstvene potrošnje. Privatno zdravstveno osiguranje ima mali uticaj na porast zdravstvene potrošnje, tako da nije doprinelo a i ne može, makar ne u ve oj meri, doprineti njenom zna ajnijem porastu. Njegov pove ani uticaj na porast zdravstvenih rashoda mogu je izuzetno, u novijim zemljama- lanicama Evropske unije (Litvanija, Slova ka, Rumunija, Bugarska), ali vrlo retko u nekoj od starijih zemalja- lanica. Naprotiv, veliki broj teoreti ara, ekspe-rata za zdravstvenu ekonomiju smatra da privatno zdravstveno osiguranje garantuje osiguranicima neometan pristup zdravstvenoj zaštiti, odnosno pristup u istoj ravni sa onim koji imaju drugi osiguranici. Pod istim uslovima im stoje na raspolaganju svi zdravstveni resursi u skladu sa ste enim pravima iz domena privatnog osiguranja. Zato vlade pojedinih zemalja- lanica javno forsiraju privatno zdravstveno osiguranje, formiraju nacionalne fondove za njegovo nansiranje i sve snažnije podsti u oštru konkurenciju me u kupcima njegovih usluga. To izgleda kao dobar podsticaj za aktivniju kupovinu ponu enih usluga iz domena privatnog zdravstvenog osiguranja, me utim, postoji bojazan da, zbog rizika koji nastaje prilikom izbora i kupovine pra-va iz zdravstvenog osiguranja, troškovi prevagnu nad pravima korisnika obaveznog zdravstvenog osiguranja.

Primeri Nema ke, Belgije, Francuske i Slova ke (1, str. 4–5) pokazuju da do-nošenje odluke o izboru i kupovini privatnog zdravstvenog osiguranja nije nimalo lak posao, jer kupovina aranžmana predstavlja iskustvenu normu i uvek opominje na


opasnost od rizika. Rizik u svim oblicima neizbežno slabi podsticaj i interes prema ponu enim paketom usluga iz domena zdravstvenog osiguranja i, bez obzira na mo-gu nost primene namenjenih mehanizama za njegovo uklanjanje, ne može se uspešno eliminisati. Ponuda obima privatnog zdravstvenog osiguranja, i u okviru njega zdrav-stvenih usluga, operativna je funkcija provajdera i strateški korak prema odgovaraju im resursima. Zagovornici privatnog zdravstvenog osiguranja skre u pažnju na raskorak izme u onoga što se trenutno troši na zdravstvenu zaštitu i onog što e možda morati da se potroši u budu nosti. Oni to ine sa jasnom namerom da skrenu pažnju budu im klijentima, da je jedini na in da se ovaj problem premosti njihovo ja e oslanjanje na privatno nansiranje zdravstvenog osiguranja. Nasuprot njima, ima onih koji ovaj pristup dovode u pitanje suprotstavljaju i mu javno (državno) nansiranje zdrav-stvenog osiguranja. McKee tvrdi da je u nekim zemljama- lanicama Evropske unije neformalno pla anj umesto formalne podele troškova postalo izazov za sprovo enje zdravstvenih reformi (13, str. 263–286). U najgorem slu aju, smatraju Ensor i Moreno, ova pla anja mogu biti oblik korupcije, mogu podrivati zvani ni sistem pla anja, što dovodi do smanjenja ili otežanog pristupa zdravstvenim uslugama. Prema njihovom mišljenju, privatno nansiranje zdravstvene zaštite u odnosu na javno nansiranje, podriva vrednosti zdravstvenog sistema i predstavlja atak na siromašno stanovništvo. Centralizovani sistemi prikupljanja sredstava, smatraju oni, imaju bolje izglede da sprovedu prinudnu naplatu i bolje generišu prihode nego sistemi u kojima se doprinosi za potrebe zdravstvenih fondova pojedina no prikupljaju (4, str. 106–124).

Grosso modo – ovde su identi kovana dva široka trenda zdravstvenih reformi. Prvo, mnoge zemlje- lanice Evropske unije napravile su zna ajan iskorak u promociji jednakog pristupa korisnicima zdravstvene zaštite i u proširivanju palete zdravstvenih usluga. Proširenost se ogleda u ve oj obuhvatnosti osiguranika, ure enju pravnog statusa nosioca privatnog zdravstvenog osiguranja, poboljšanju tehnologije deljenja zdravstve-nih troškova i izradi strategije alociranja raspoloživih resursa. Drugo, ba ena je ve a svetlost na obezbe ivanje kvalitetne zdravstvene nege, naglašen je njen zna aj i prak-ti na vrednost u odnosu na nov anu. Pove ano koriš enje kvalitetne zdravstvene zaštite podsti e kupovinu zdravstvenog osiguranja i svakodnevno usavršava i pojednostavljuje modele pla anja zdravstvenih usluga (28). U skladu sa iznetim, cena zdravstvenih usluga, koja je motivacija ili demotivacija pri izboru osiguranja i na ina pla anja, ne sme biti zanemarena. U mnogim zemljama- lanicama Evropske unije, cena zdravstvenih usluga je podgrejala težnju da se, umesto formalnom podelom troškova, zdravstveni fondovi dopunjuju neformalnim pla anjima i dodatno pozvala na zdravstvene reforme.

Dostupnost zdravstvenim uslugama

Dostupnost zdravstvenim uslugama Svetska zdravstvena organizacija (SZO) (31) de niše kao „meru–procenat stanovništva koji za svoje potrebe neometano


obezbe uje odgovaraju e zdravstvene usluge”. Jednak pristup zdravstvenim uslugama podrazumeva adekvatno snabdevanje koje je blisko povezano sa njihovom cenom, prihvatljivim vrstama, zi kim prisustvom i neposrednim kontaktom izme u njihovih davalaca i korisnika. Neometen pristup zdravstvenoj zaštiti u zemljama- lanicama Evropske unije snažno odre uje socio-ekonomski status njihovih gra ana. Mnogi gra-ani (osigurani ili neosigurani), zbog nedostupnosti odgovaraju eg oblika zdravstvene

zaštite, mogu zapasti u nezavidan i neravnopravan položaj, što ih bezuslovno svrstava u neku od vulnerabilnih ili socijalno ugroženih kategorija. Evropska unija ima veliku raznovrsnost ranjivih grupa koje mogu da dožive nejednak pristup razli itim vrstama zdravstvenih usluga. Socijalno ugrožene grupe uskra ene su za bilo koji, a ne samo za ravnopravan pristup zdravstvenim uslugama, o emu govore loša iskustva i dalje prisutne ali nepremostive barijere (23, str. 43–55). Ranjive grupe uglavnom obuhva-taju pripadnike raznih etni kih zajednica, osobe sa zi kim invaliditetom, hroni ne bolesnike, nezaposlene, besku nike, imigrante, izbeglice, azilante, ljude bez validnih dokumenata, starije osobe i žene. Poražavaju e je što u tom nizu prepreka svaka od njih može da spre i, na primer, žene, iznemogle ili decu da uživaju svoja osnovna prava na zdravstvenu zaštitu i kvalitetne zdravstvene usluge. Neki teoreti ari, kao na primer Huber, smatraju da ove prepreke nastaju pod dejstvom mnogih faktora u okviru samog zdravstvenog sistema (8). Misli se, izme u ostaloga, na speci nosti i praznine u pokrivenosti zdravstvenog osiguranja, obim javne zdravstvene koristi, na podele pla anja, geografske faktore (udaljenost ili nedostatak infrastrukture), organizacione faktore (liste ekanja i radno vreme), ili na nedostatak-neadekvatnost informacija. Osim toga, proizvod su dejstva faktora koji se odnosi na karakteristike korisnika usluga, prihode, obrazovanje, starost, jezik, invaliditet, seksualni identitet, kulturno nasle e, civilni status i sl.

Pristup zdravstvenim uslugama može da se posmatra dvojako. Prvo, kao zna ajno ograni en jer lišava pripadnike odre enih društvenih grupa na potpunu zdravstvenu zaštitu, i drugo, kao neprikladan jer, iako je dostupna, zdravstvena zaštita vrlo esto nije adekvatna da bi zadovoljila potrebe gra ana. To upu uje na bitne razlike u zdrav-stvenom stanju populacije izme u zemalja- lanica Evropske unije, i na zaklju ak da su one posledica tesne korelacije izme u socijalnog i ekonomskog statusa. Kada se raspodela po zdravlje štetnih iskustava studiozno posmatra mora se ista i da znatan broj njih, bez obzira na to što iniciraju nejednakosti, ni u kojem smislu ne predstavljaju prirodan fenomen. One mogu biti, a i jesu, najpre rezultat loše vo ene zdravstvene i socijalne politike, što se ogleda kroz nerealno postavljanje, usvajanje i sprovo enje zdravstvenih ciljeva i programa, kroz sklapanje nepravednih ekonomskih aranžmana i pravljenje društveno-toksi nih kombinacija. S tim u vezi vlada mišljenje da socijalne determinante zdravlja i uslovi u kojima se odvija život predstavljaju veliku enigmu i u najve oj meri su odgovorne za prisutnu zdravstvenu nejednakost izme u gra ana unutar zemalja- lanica Evropske unije. Univerzalni pristup zdravstvenim uslugama, iako po mnogo emu karakteristi an za zdravstvene sisteme u pojedinim zemljama-


lanicama Evropske unije, predstavlja osnovni cilj i dugogodišnju težnju njihovih gra ana. Koliko je princip univerzalnog pristupa zdravstvenim uslugama bitan kao cilj pokazuje ne samo to što je eksplicitno naveden u ustavima mnogih zemalja- la-nica Evropske unije, ve i što je uklju en u Povelju o osnovnim pravima. U lanu 35. Povelje o osnovnim pravima stoji da svako ima pravo na pristup preventivnoj zdravstvenoj zaštiti i pravo da koristi medicinski tretman pod uslovima utvr enim nacionalnim zakonima i praksom (15, str. 184–186). Vlast, koja ima mandat, dužna je da zdravstvenu negu usmeri i stavi u kontekst sa ljudskim zdravljem i da omogu i promociju i poboljša pristup kvalitetnim zdravstvenim uslugama.

Svetska zdravstvena organizacija (SZO) (20) preporu uje da primarna zdrav-stvena zaštita bude srce svakog zdravstvenog sistema. Pored toga, uklju ivanje više specijalizovanih zdravstvenih usluga, kao što su seksualno, reproduktivno ili men-talno zdravlje, tako e treba da se najozbiljnije uzme u obzir. Pristup zdravstvenim uslugama odavno prevazilazi tradicionalne terapijske okvire i standarde. Dakle, potpuno je logi no što se snažno podsti e privatno zdravstveno osiguranje, koje u mnogim zemljama- lanicama Evropske unije nije bilo dovoljno razvijeno. U nekim zemljama- lanicama taj problem se objašnjava time što provajderi–agenti osiguranja nisu uvek imali mogu nosti da sa raspoloživim snagama i alatima podstaknu nivo svakako bitne, ak strateške kupovine. Smatra se da bi kupovina usluga, koje ono pokriva, u velikoj meri odredila ne samo njegovu ekonomsku i skalnu održivost, nego bi se to isto dogodilo i drugim vrstama osiguranja. Zdravstvene reforme esto nisu sprovo ene na odgovaraju i na in, što je stalno potenciralo potrebe da se mnogi detalji zna ajnije dorade. Trebalo je najpre, u kontekstu povezivanja performansi pla anja i kvaliteta zdravstvenih usluga, na i odgovaraju i mehanizam kojim bi se merili kona ni ishodi. Neke zemlje su uložile velike napore da prošire pokrivenost stanovništva zdravstvenim osiguranjem i postigle su izvrsne rezultate, skoro uni-verzalnu pokrivenost. Me utim, koliko je važna univerzalna pokrivenost toliko je važna njena dubina i njen obim, ako se zna da zna ajno potkopavaju nansijsku pokrivenost zdravstvenih sistema. U nekim zemljama- lanicama Evropske unije trend je postalo, smanjenje obima i dubine univerzalne zdravstvene pokrivenosti (12, str. 172).

Globalna nauka je mnoge standarde davno stavila ad acta, a orijentisanost na širi pristup zdravlju mogu a je samo kroz njegovu konkretnu promociju i preko široke palete kvalitetnih raznovrsnih zdravstvenih usluga. Promocija kvalitetnog zdravlja de niše sve vrste aktivnosti koje ljudima omogu avaju pove anu kontrolu nad sop-stvenim (i tu im) zdravljem. Pod tim se standardno podrazumeva obezbe ivanje resursa za nansiranje zdravstvenih usluga, smeštaj, bezbednost hrane, zapošljavanje, kvalitet životne sredine i uslova rada. Ovaj navod usmeren je na svakim danom po-trebniju realnu procenu raspoloživih nansijskih sredstava, bez kojih nema govora o željenoj pristupa nosti zdravstvenim uslugama. One su, u najve oj meri, permanentno zavisne od obima raspoloživih nansijskih sredstava. Ocena raspoloživih nansijskih


sredstava, koja se izdvajaju za nansiranje primarne zdravstvene zaštite, zna ajna je sa stanovišta sagledavanja stvarne mogu nosti njenog potpunog ostvarivanja kroz pravovremeno pružanje zdravstvenih usluga prema utvr enim standardima. Osim toga, nužno je sagledati deo sredstava koji se izdvaja za intermedijarni i centralni nivo zdravstvene zaštite, odnosno sredstva koja odlaze na skupe i teže dostupne zdravstvene usluge koje nedostaju velikom broju siromašnijih gra ana. Što se ti e univerzalne ili blizu univerzalne pokrivenosti stanovništva zdravstvenim osiguranjem, ona u ve ini zemalja- lanica Evropske unije dostiže fantasti nih 98–99% ukupne populacije. Nema ka po tom pitanju predstavlja izuzetak (5), jer je u njoj zakonska pokrivenost stanovništva oko 88%. Naj eš i osnov za sticanje prava na zdravstveno osiguranje i zdravstvenu zaštitu je boravak u pomenutim zemljama.

Univerzalna pokrivenost zdravstvenom zaštitom

Zdravstveni sistemi u okviru Evropske unije razlikuju se (21) od jedne do druge zemlje- lanice. Slede i pravnu doktrinu, zdravstveni nacionalni sistemi u Evropskoj uniji uglavnom se dele na dve kategorije. Prva je Nacionalni zdravstveni sistem (The National Health System–NHS), koji funkcioniše u mnogim zemljama-lanicama Evropske unije (Velika Britanija, Italija, Španija, Portugalija, Gr ka) (7,

str. 21). Zdravstvena zaštita za obuhva ene osiguranike nansira se iz pribavljenih poreza a procenat obuhvatnosti je poslovi no visok, i do 99%. Druga kategorija je Sistem socijalnog osiguranja (Social Security System–SSS), koji podrazumeva obavezno zdravstveno osiguranje za sve gra ane ili odre ene grupe gra ana. Nji-hovo povezivanje sa Fondom za zdravstveno osiguranje je obavezno. Na primer, u Holandiji, u kojoj Sistem socijalnog osiguranja besprekorno funkcioniše, svi sta-novnici su obavezni da zaklju e ugovore sa privatnim osiguravaju im društvima. Francuski sistem zdravstvene zaštite je paradigma, odnosno pravi primer kako u jednoj zemlji treba da funkcioniše Sistem socijalnog osiguranja. Njegovu prirodu de nisale su reforme, koje su 1998. godine zna ajno izmenile ukupan zdravstveni ambijent. Doprinosi za socijalno osiguranje su postali dominantan mehanizam za prikupljanje nansijskih sredstava namenjenih nansiranjem zdravstvenih troško-va francuskih gra ana. Vo en promenama Ekonomski savet je 2006. godine (19) usvojio Deklaraciju o zajedni kim principima i vrednostima sistema zdravstvene zaštite zemalja- lanica Evropske unije. U njoj je doslovno istaknuto da je univer-zalna pokrivenost zajedni ka vrednost. Ne bi, dakle, bilo poželjno da bilo koja od njih ostane izvan utvr enog okvira ili da, eventualno, na bilo koji na in osuje uje pristup zdravstvenoj zaštiti, odnosno da bilo kome uskrati pravo na zdravstveno osiguranje.

U svojoj Strategiji „Zajedno do zdravlja“ (Toughater for Health) (26, str. 5), usvojenoj 2007. godine, Evropska komisija je apostro rala zna aj univerzalne po-


krivenosti. U skladu sa tim, lan 35. Povelje o osnovnim pravima Evropske unije propisuje da svako ima pravo na pristup preventivnoj zdravstvenoj zaštiti i pravo da koristi medicinski tretman pod uslovima utvr enim nacionalnim zakonom i prak-som. Univerzalna zdravstvena pokrivenost predstavlja najve u vrednost u evrop-skom zakonodavstvu i de nisana je kao prostor u kome je gra anima omogu en nesmetan pristup svim oblicima zdravstvene zaštite. Zdravstvena pokrivenost se ipak razlikuje me u zemljama- lanicama Evropske unije, kao i koristi koje njihovi gra ani imaju od nje (27, str. 47). S obzirom na to da razlika mora biti, izvesno je da sve zemlje- lanice, kao jedna, smatraju da je neophodno da svi njihovi stanovnici poseduju pravo na minimalni nivo zdravstvene zaštite i koristi od pružene-primljene zdravstvene nege. Kao mo no sredstvo, kojim garantuju univerzalnu pokrivenost i nansijski podržavaju zdravstvenu zaštitu svojih gra ana, zemlje- lanice Evropske

unije koriste nansijske subvencije. Subvencije mogu biti pod znakom pitanja jedi-no ako se njihovim ustupanjem krši lan 87. Evropske komisije (10, str. 232–233). U suprotnom, sigurno je da su interesi zdravstvene zaštite regulisani primenom pozitivnih pravila koja važe kod pružanja državne evropske pomo i. Zajednice sudova i Evropska komisija se bave odredbama koje ure uju Sporazum o državnoj pomo i, iji je cilj univerzalna pokrivenost integrisana onako kako su je one pro-pisale. Realizacija ovog cilja svakako e doprineti ve em poštovanju zdravstvene zaštite i zdravstvene nege i prepusti e ve a ovlaš enja nacionalnim organima u zemljama- lanicama Evropske unije. U sporazumu stoji da nacionalnim organima ostaje dovoljno nadležnosti i manevarskog prostora da, kada zatreba, nansijski intervenišu, garantuju pristup zdravstvenim koristima njihovim gra anima i da podsti u univerzalnu pokrivenost.

Nadležnosti zemalja- lanica na planu zdravstvene zaštite Lisabonski sporazum predvi a kao obavezu, da nacionalne vlasti uklju uju i alociraju sve vrste resur-sa upotrebljivih za pružanje adekvatne zdravstvene zaštite u skladu sa stepenom univerzalne pokrivenosti. Kakvu ulogu u ovom slu aju može igrati univerzalna pokrivenosti pokazuje primer iz Španije. Zajednica sudova je odlu ila da španski nacionalni zdravstveni sistem nije preduze e, jer se nansira iz doprinosa za soci-jalno osiguranje i sredstvima iz drugih državnih fondova. Dakle, zdravstvene usluge su besplatne za sva lica koja su povezana sa fondom za zdravstveno osiguranje na osnovu opšte pokrivenosti. Primer pokazuje da su u zdravstvu principi solidarnosti i univerzalne pokrivenosti me usobno tesno povezani i da princip solidarnosti esto dovodi ne samo do preraspodele bogatstva, ve i do transfera nansijskih sredstava od zdravih prema nezdravim licima. Na kraju, de nicija univerzalne pokrivenosti je vrlo jednostavna jer je u pitanju pristup prema kome su sve vrste zdravstvene zaštite i sve vrste naknada koje iz nje proisti u apsolutno obezbe ene za sve kategorije gra ana. Prima facie, glavni argument za univerzalnu pokrivenost, služi princip solidarnosti što potvr uje injenicu da je ona od opšteg interesa, odnosno vrhovna vrednost i opšte javno dobro.


Zaklju ak

Namera da se posle svega izvede realan zaklju ak osuje ena je opravdanom dile-mom, postoji li u zemljama- lanicama Evropske unije optimalna metoda nansiranja i obezbe ivanja potpune zdravstvene zaštite? Na temelju dostupnih informacija može se tvrditi da postoji kada je re o nansiranju obaveznog zdravstvenog osiguranja koje je rasprostranjeno i u mnogo emu superiorno u odnosu na druge oblike osiguranja. Me utim, ne zna se do kada e ta supremacija trajati imaju i u vidu savremene tren-dove, sve siromašnije zdravstvene trezore, pad bruto društvenog proizvoda (BDP) i sve skuplje zdravstvene procedure. Javno nansiranje na elno doprinosi delotvornom i temeljitom pružanju zdravstvene zaštite nezavisno od rizika koji je posledica loše zdravstvene slike osiguranika. Ima naro ito veliki uticaj u obezbe ivanju i dodeli sredstava u skladu sa iskrslim potrebama, ali znatno manji uticaj na platežnu snagu osiguranika. Zdravstveni sistemi uglavnom obezbe uju visok procenat zdravstvenog obuhvata za korisnike obaveznog osiguranja, koje, u prvom redu, pokriva preventiv-ne javne zdravstvene usluge, primarnu zdravstvenu zaštitu, ambulantnu i bolni ku specijalisti ku zaštitu, lekove na recept, mentalnu zdravstvenu zaštitu, stomatološku zaštitu, rehabilitaciju i ku nu negu. U svim zemljama- lanicama postoje tolerantni prostori po kojima se od korisnika obuhva enih obaveznim zdravstvenim osigura-njem, zavisno od vrste i obima zdravstvene usluge, može zahtevati podela troškova. Osim toga, u nekim zemljama- lanicama Evropske unije neretko postoji jaz izme u onoga što obavezno zdravstveno osiguranje formalno i zvani no pokriva, i prisutnih zbivanja koja bi trebalo da budu nansirana u svakodnevnoj praksi.

Nasuprot javnom, obaveznom zdravstvenom osiguranju, privatno zdravstveno osiguranje je prepoznatljivo po tome što prilikom zaklju ivanja ugovora sa klijentom, budu im osiguranikom, isklju uje rizik njegove loše zdravstvene mape. Tako e, privat-no zdravstveno osiguranje je superiornije od javnog (obavezno) osiguranja u vo enju javnih nansija. Ono svoju supremaciju demonstrira kroz sigurnu naplatu premija zdravstvenog osiguranja i kroz direktnu naplatu prihoda od pruženih zdravstvenih usluga. Pored toga, obezbe uje sigurne prihode preko strateških nabavki i na osnovu smanjenja administrativnih troškova. Navedene reference ovog oblika zdravstvenog osiguranja na prvi pogled garantuju visok stepen ekonomske i skalne održivosti. Ali postoji i druga strana medalje. Opasnost kojoj je izloženo privatno zdravstveno osiguranje vezuje se za eventualno pogoršanje zdravlja gra ana-osiguranika i porasta zdravstvenih rashoda usled njegovog saniranja. Osim toga, sve je prisutniji strah zbog zapadanja zemalja- lanica Evropske unije u dužni ku krizu (Portugalija, Italija, Irska, Gr ka Španija–PIIGS) (2, str. 101–106), zbog laganog siromašenja gra ana i njihove iz dana u dan slabije kupovne mo i. Ona e zna ajno ugroziti fondove privatnog zdravstvenog osiguranja. Od toga nije pošte eno ni obavezno zdravstveno osiguranje, tako da se mora ozbiljno ra unati na reducirane mogu nosti koriš enja zdravstvenih usluga i manju zdravstvenu pokrivenost, što zna i da je univerzalna pokrivenost oz-


biljno dovedena u pitanje. Ravnopravan pristup zdravstvenim uslugama bi e otežan i sve dalji za gra ane kojima platežna sposobnost ne garantuje adekvatnu zdravstvenu zaštitu. U takvim okolnostima ni tehnika pribavljanja novca ne e biti svrsishodna, pa e i zdravstveni fondovi postajati prazni.

Mnogo je zemalja- lanica Evropske unije, naro ito onih sa periferije, u kojima porast zdravstvene potrošnje zabrinjava kako gra ane tako i relevantne organe. Dobar primer za to je Italija (17), u kojoj je zdravstvena potrošnja u 2006. godini u estvovala u bruto društvenom proizvodu (BDP) sa 9,0%, što je iznosilo oko 2.600 $ USA po glavi stanovnika. Od toga je oko 75% utrošeno na obavezno zdravstveno osiguranje koje obezbe uje italijanska vlada. Samo tri godine kasnije, ta nije 2009. godine, ukupni rashodi za zdravstvenu zaštitu dostigli su 9,5% bruto društvenog proizvoda (BDP) ili 3,027 $ USA po glavi stanovnika. Dakle, italijanska zdravstvena potrošnja je iznad pro-seka zemalja OECD koji iznosi 8,9% bruto društvenog proizvoda (BDP) (18). Prema kvalitetu, što je veoma bitno za komparativnu analizu, italijanski zdravstveni sistem na svetskoj lestvici zauzima vrlo visoko drugo mesto, odmah iza francuskog.

Literatura

1. A. P. van der Mei, 2003, Free Movement of Persons within the European Community. Cross-Border Access to Public Bene ts, Oxford.

2. De Oliveira G., 2005, Some improvements in the Portuguese medical law. In: Sanderfelt M, ed. Yearbook of European medical law. Lidingo, The Institute of Medical Law.

3. Douver N., 2004, Svetsko siromaštvo. (U: Piter Singer, Uvod u etiku, izdava ka knjižarnica Zorana Stojanovi a, Sremski Karlovci–Novi Sad.

4. Ensor T. and Duran-Moreno A., 2002, Corruption as a Challenge to Effective Regulation in the Health Sector. In: Regulating Entrepreneurial Behaviour in European Health Care Systems, ed. R. B. Saltman, R. Busse, and E. Mossialos.

5. Germany country pro le. Library of Congress Federal Research Division (December 2005).

6. “Health Act 2004”. Irish Statute Book. Of ce of the Attorney General.7. Hervei T.K. and Mekhejl J.V., 2004, „Zakon o zdravstvu Evropske unije”, Kembrdž.8. Huber H., Stanciole A., Wahlbeck K., Tamsma N.,Torres F., Jelfs E. and Bremner J., 2008,

Quality in and equality of access to healthcare services, Study Report for European Commission, Directorate-General for Employment, Social Policy and Equal Oppor-tunities. Available at: www.euro.centre.org/data/1237457784_41597.pdf. (Pose eno: Novembar 16, 2011)

9. Van de Gronden J. W., Financing Health Care in EU Law: Do the European State Aid Rules Write Outan Effective Prescription for Integrating Competition Law with Health Care?The competition law review Volume 6, Issue 1, December 2009.

10. Law for the Twenty-First Century. Volume 2: Internal Market and Free Movement Com-munity Policies, Oxford, 2004.


11. Legido-Quigley H., McKee M., Nolte E., Glinos I. A., 2008, Assuring the Quality of Health Care in the European union, A case for action, Observatory Studies Series No 12, Sixth Framework programme, World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policie.

12. Louri V., 2002, ‘“Undertaking” as a Jurisdictional Element for the Application of EC Competition Rules’, Legal Issues of Economic Integration 172.

13. McKee M., Mossialos E., Belcher P.,1996, The in uence of European law on national health policy, Journal of European Social Policy 6(4).

14. McKee M., Baeten R., eds, 2008, Patient mobility in the European Union: learning from experience. Copenhagen, WHO Regional Of ce for Europe.

15. Mossialos E., McKee M., Palm W., Kar B. L. and Marhold F., 2002, ‘EU law and the Social Character of Health Care’, Brussels.

16. Mossialos E., 1997, Citizens Views on Health Care Systems in the 15 Member States of the European Union, Health Economics 6(2).

17. ”OECD Health Data 2008 How Does Italy Compare”. OECD, 2008.18. ”OECD Health Data 2008: How Does Spain Compare”. OECD, 2008. 19. Savet Evropske unije 2007. 20. SZO, Komisija za socijalne determinante zdravlja 2008.21. The Council Conclusions on Common values and principles in European Union Health

Systems, OJ 2006, C156/1. 22. The World Health Report 2000: WHO.23. Toti I., 2011, Politike u zdravstvenom sistemu Evropske unije, Zdravstvena zaštita,

asopis za socijalnu medicinu, javno zdravstvo, zdravstveno osiguranje, ekonomiku i menadžment u zdravstvu, novembar, br. 5.

24. Vukmanovi L. ., 1994, Menadžent u zdravstvu, politika i strategija zdravstvenog ra-zvoja, Menadžent zdravstvenih programa i zdravstvenog sistema, Evropski centar za mir i razvoj–ECPD, Univerzitet za mir Ujedinjenih nacija, Savremena administracija, Beograd.

25 .”Zorgrekeningen; uitgaven (in lopende en constante prijzen) en nanciering” (in Dutch). Centraal Bureau voor de Statistik: StatLine. 20 May 2010. http://statline.cbs.nl/StatWeb/publication/? (Pose eno: oktobar 19, 2011)

26. ”White Paper“,Together for Health: A Strategic Approach for the EU 2008-2013’ COM (2007) 630 nal.

27. Wismar M., Palm W., Figueras J., Ernst K., E.van Ginneken, Cross-border health care in the European Union, Mapping and analysing practices and policies, World Health Organi-zation 2011, on behalf of the European Observatory on Health Systems and Policies.

28. WHO Statistical Information System.29. World Health Organization Assesses the World’s Health Systems. 30. World Health Organization Statistical Information System: Core Health Indicators.31. “World Health Organization – Italy”. WHO, 2010.

Ibrahim Toti * 2

SOME QUESTIONS REGARDING THE FINANCING OF HEALTH CARE IN MEMBER STATES OF THE EUROPEAN UNION

Summary: Before you deal with the primary aim to show that regulated health care systems have contributed and still contribute to the health of citizens of member states of the European Union signi cantly improved. That is why the older member states of the European Union (Austria, Belgium, France, Germany, Netherlands), prepared to spend most of their gross domestic product (GDP) on health care for its citizens. At the other member countries on the periphery of the European Union (Portugal, Italy, Ireland, Greece and Spain), better known as a group (PIIGS-svi-nje), due to falling into a debt crisis is not ready for such a step because of which their citizens are faced with big problems when using health care. The paper deals with problems of unequal access to health services and lack of health coverage that exist among individuals as well as in some social groups in many member countries of the European Union. Analysis of unequal access to health services was carried out based on the estimated level depending on its socio-economic status of user-non-users of health care, are not bypassed with the right of the insured and their acquisition. The rights of the insured whose roots are in agidumu Hippocratic Oath: “primum non nocere” – “ rst do no harm to” vary from very narrow to very broad and diverse framework.

The paper konstatatovano to the conduct of public nances in the Member States of the European Union is not without problems, espe-cially where contributions for health insurance funding mechanisms dominate. Health care nancing in member countries of the European Union, more important than other functions affecting the quality of health of citizens, the mood to invest in access to health services and universal health insurance coverage. Financing of health care policy is not the only link of many of them in a long chain of global politics.

* State University of Novi Pazar, Department of Law and Department of economy


However, it is indispensable to measure the effects of decisions made, the application of speci c measures aimed at systematic and analytical review of available health resources and in consideration of political factors, economic, social and technical character at all levels. Special attention is given to raise funds to cover expenses resulting from uni-versal health insurance coverage.

Key words: European Union, the healthcare system, health care, uni-versal coverage, fundraising, health care services

Introduction

Whether a country belongs or does not belong to an organization, union, union group and the like, in terms of nancing health care, there must dominante at least the minimum regulatory stance. This means that in every country regardless of its social system, political participation and economic activity, health care nancing po-licy must be enshrined in all government documents and proper issued declarations and / or resolutions. This is not to draw the line under the limited nancial resources needed for the health care, but also provides a concrete answer to the question, who and how the paids or distributed among the various socio-economic groups, or users of non-users-health care. Consistent health policy or policies of the real allocation of health resources must to re ect systematic prioritization that apply not only to health, but also on his other complementary sectors. Financial policies in the health sector is a powerful lever that individuals, groups or the whole society relies on, and to take care of those who are fortunate within our own community has not smiled enough.

Health, good or bad is not a consequence of individual choice, but it is a pre-mium value or unwanted state, which largely depends on the in uence of political, social and economic factors, and global conditions in which people own it. Access to quality health services that can and must be counted, determine rst, the right to comprehensive health care and second, the obligation to protect and promote health which further strengthens its social and economic dimensions. According to the nal report of the World Health Organization (WHO) on the determinants of health (20), says that the poor health of the poor in particular categories of citizens among mem-ber countries of the European Union, is the result of unequal distribution of power, expressed social and health inequalities, imbalances of income and lack of quality goods and services at the national and global levels. In addition, many, visible to the naked eye and inequity circumstances, directly cause unequal access to health care, school and educational facilities, an adequate working environment and conditions for use of leisure time. No matter how thinking about the health of the people prevailed in the European Union, it is clear that citizens in some member states are not able to organize on your way prosperous, and life for their families and to adequately protect

71SOME QUESTIONS REGARDING THE FINANCING OF HEALTH CARE IN MEMBER...

and improve global health. Many of them did not have, and many will never have, promising chance to live in appropriate environments, decent housing, the regulated communities and cities clean. So we should not lose sight of how much risk people in many member countries of the European Union, must be calculated.

Politics of health care nancing includes a range of functions, procedures and measures focused on the acquisition of resources necessary for comprehensive heal-th insurance. It includes adequate volume of the health care, equal access to health services, technology, fundraising, distribution and allocation of fair and rational use. Famous scholars (McKee, Mossialos, Belcher) had no dilemma when they put ahead of all functions within the health services the function of collecting funds and their association. They knew that with some risks, this function tends to smooth the pro-vision of adequate conditions for the provision of care to the population health who is considered the safest and universal resource (13, pp. 263-286). Financing policy in the Member States of the European Union is seen as the most vital part of health policy, because she only in the spirit of the legal rights of rules directs the necessary funds for their own satisfaction in the eld of health insurance.

Aim

In each country-member of the European Union funding of health care is im-plemented in order to improve the health of their citizens, and mainly involves the function of collecting taxes, contributions, proceeds from the sale of health insurance and income from other sources. National authorities of each Member States of the European Union, joined the collected funds for the intended health funds (14, pp. 179-189). Pooling resources is linked to the risk that is always lurking somewhere. He is a permanent obstacle to improving effectiveness and reducing the uncertainties that are related to health insurance coverage and the right to use health care services under the same conditions (2, pp. 101-106). From an economic perspective, in rela-tion to the above-mentioned means, it is important to bear in mind that health care costs are constantly increasing, and that spending on health protection from gross domestic product (GDP), although different from one country to another member, always moving the bar up.

Health care nancing in the European Union

The function of nancing health care in member countries of the European Union as no other known function, determines the overall quality of health of their citizens. At rst has a very signi cant in uence on the creation of anticipated bene ts for the timely availability of health services and to ensure equal treatment for the insured


in all kinds of medical procedures. Health care nancing and sustainable means permanently securing the necessary funds from the available resources at all levels, regardless of their exposure to various in uences of political, economic, social and technical factors. Ensuring the sustainability of these resources is always the rst goal, however, the promoters of health economics in each country-member European Union, are fully aware that only a continuous and sustainable nancial resources are guarantee for the smooth nancing of health programs and goals. Since health poli-cy otherwise resembles the chain, its connective link in the true sense of the word, represents a certain events. Every each one of them is virtually tied for the election, determination, a clear formulation and methods of implementation of health goals and programs, or to prescribe the speci c measures for their nal realisation. In this regard, in terms of a serious understanding of the importance of this issue, the World Health Organization (WHO) (30) was founded in the 1984th, to promote the concept of Program Budgeting (Budgeting-Programme), implemented in the programming of the goals of health development, and budgeting according to the adopted priority health development programs. Interestingly, this program was adopted in the mem-ber states of the European Union, but also in the other countries of the world and in Europe (24, pp. 37).

Resentment of certain groups to collectively pay for subsidizing health care costs for others, day after day, especially in the poorer member countries of the European Union, increasing the resistance to the regular payment of taxes and / or contributions. Where the central authority for awarding grants to local governments or local health authorities, as a mechanism are using the local taxes and contributions (Denmark, Finland, Italy, Spain and Sweden), there is a big responsibility with regard to the obligation that lies ahead in raising funds that nance health facilities. Allocation of subsidies is a process that is mostly a matter of political debate after which follow a decision on the allocation of funds to poorer regions to ensure equal access to health care. As social security contributions are concerned, they collected the central gover-nment institutions (Belgium, Bulgaria, Estonia, France, Latvia, Netherlands, Poland and Romania) and collected in that way represents their own resources directed to health funds and held for nancing social security (16, pp. 109-116). In some Member States of the European Union (Austria, Czech Republic, Germany, Greece, Slovakia) are provided mechanisms by which they try to avoid problems in raising funds for the emergence of various forms of risk. These mechanisms support the implemen-tation of the realisation of ability to collect taxes and social security contributions and signi cant impact on nding opportunities to generate safe and suf cient funds to cover health care expenses. For example, Estonia solves this problem by shifting the responsibility for payment of the Health Insurance Fund of Estonia (EHIF) to the central government’s tax collection agency. In 2009. in Germany contributes are centrally positioned and integrated into the new National Health Insurance Fund, so it already in 2011. became responsible for the timely payment of contributions.


However, despite the application of these and similar mechanisms, there are many examples where nancial policies, especially in the last few decades, the newer member countries of the European Union, just drowning in the aforementioned pro-blems. Whenever it’s brought the debate on nancing health care in member countries of the European Union (and beyond), inevitably it operates with the term priority, so it is advantageous to explain its essence and the reasons why so often is empha-sized. Many theorists are prone, when it comes to nancing health services, that as the reason for the priority of the term, as well as action often mentioned, to indicate poverty of the people more in peripheral than in developed countries-members of the European Union. Solving the problem of poverty inherent in peripheral countries-EU members, especially those from the group PIIGS (Portugal, Italy, Ireland, Greece, Spain), requires prior speci c moral urgency and / or severity than making decisions about priority. Since there is a duty to provide adequate health care, making decision in accordance with that, is a support for it’s bene ciaries, and prevail over the priority of urgency. Therefore, the urgency is, and as a term and as a practical fact, in supre-macy in relation to priority. Therefore, as pointed out Douver, rather than to say the urgency of priority, because the idea suggests that priority should be establishing of some order in degrees of adverse conditions, with the easy chain access to the rst one, then another one, and so on until the nal situation (3, pp. 393-407). However, this is not always the safest way to determine or to be determined by the concept of health care for the rehabilitation of adverse conditions. It should be on the mind that opposed of that is a variety of aggravating circumstances. For example, one of these conditions is related to cost effectiveness and the cost of emergency of providing timely protection to human health in all segments, especially in nance. But that’s not the only reason why is in relation with the nancial function, much grateful talk about the urgency of the priorities.

Health care nancing policies in most member countries of the European Union depends on the urgency of nding the right skills and solutions that provide secure resources, professional service providers, equal and unimpeded access to health care to all users at the end of administrative ef ciency. In most member states, publicly raised funds intended to nance health care, are consolidated at the national level. This means that there are a healthcare fund responsible for collecting, storing and distributing funds from contributions for health insurance. The Fund is required to obtained during the distribution of compensation money to the poorer regions and to reimburse the funds to poorer citizens and / or those with a higher risk of becoming ill. According to the World Health Organization (WHO) (31) in Germany during 2004. the 77% of health care is nanced by the German government and 23 % is funded by paying premiums for private health insurance. The total health expenditure was 10.8 % of the value of German gross domestic product (GDP). The system of public (state) health care in Ireland regulated the health question of its citizens in the 2004th when he established a new body (Health Service Executive-HSE) that is responsible


for providing health care and social services to everyone who lives in Ireland (6). The Ireland in 2005. for the protection of its citizens spent 8.2 % of gross domestic product (GDP) or U.S. $ 3,996 per capita. Of these, about 79 % of health expenditures was covered by the Irish government (11, pp. 152).

Health care in the Netherlands is nanced by a dual system which came into force in January 2006. year. Dutch health care system compared with the health systems of the United States, Australia, Canada, Great Britain, Germany and New Zealand ranks rst by far. Contribution to this was the adoption of the General Law on Exceptio-

nal Healthcare Costs (25). For all regular (short-term) medical treatment, there is a system of compulsory health insurance through private health insurance companies (9, pp. 5-29). Insurance companies are required to provide a de ned package of treatment for the insured. In 2009. in this insurance cover is 27 % of all health care costs. Other sources of health care are paying 14 % taxes, citizens pay out of pocket (OOP-out of pocket) 9 %, the additional optional insurance packages for 4 % and 4 % other sources. Accessibility to health services in both cases is absolutely guaranteed. French health system is a universal system in which health care is largely nanced by a national government. In its assessment of world health systems in 2000. year, the World Health Organization (WHO) said that France provides the “best overall health care” in the world (29). In 2005. year, France spent on health care, 11.2 % of its gross domestic product (GDP) or U.S. $ 3.926 per capita. Costs are much higher than average level of the Member States of the European Union, but are much smaller than those in the United States. Approximately 77 % of medical costs is covered by government health agencies that nance consumption. The expenses of health care in Spain in 2006. amounted to 8.4% of gross domestic product (GDP). They have per capita for 2006. year amounted to U.S. $ 2.458, which is less than the average OECD level, which is $ 2,824 U.S. (18).

Raising funds and importance of private health insurance

All member countries of the European Union for nancing health care are using contribution as a basic mechanism, including public health insurance (taxes and social security contributions), private health insurance (medical savings accounts-MSA) and payments from their own pockets (OOP-out-of-pocket). So it is a direct payment for health services not covered by compulsory health insurance, cost-sharing (user charges) for services covered by the package’s covered by compulsory health insurance and at the end of informal payments. Large changes in health care nancing policy in many Member States of the European Union followed in early 1990’s. Then gathering funds were transferred from the eld of taxes, contributions to the eld of social security which has become the dominant mechanism not only in member countries of the European Union but also in those who are not, and are located in Central or Eastern


Europe. Research shows that in many Member States of the European Union, health spending as a share of total public spending has been declining since the end of the twentieth and early twenty- rst century, causing amazement but does not change a thing. Why? First, an increase of gross domestic product (GDP) in many Member States of the European Union is very elusive, secondly, in many of them their fall is a chronic phenomenon and third, although the percentage of expenditures for health care has increased signi cantly, it is not attacking seriously the integrity of the gross domestic product (GDP). It should be noted that, there is a small number of countries in the world, and therefore in the European Union, that on behalf of health care stand just over 6% of its gross domestic product (GDP).

The results of these studies on private health spending showing, that the direct payments (OOP-out-of-pocket) largely contributed to since 1996. year onwards, the total health care spending is growing continuously. However, up to date records and reports relevant authorities ignore or deny the above allegations, as in most member countries of the European Union, the expense of private health insurance do not exceed more than one third of total health spending. Private health insurance has little impact on the growth of health spending, so it is not and can not be helped, at least not to a greater extent, a contribute to its signi cant increase. Increased its in uence in the health expenditure is very possible, in more recent member states of the European Union (Lithuania, Slovakia, Romania, Bulgaria), but very rarely in some of the older member states. On the contrary, a large number of scholars, experts in health econo-mics believes that private health insurance policy holders guarantee unimpeded access to health care or access to the same level with those who have other insured. Under the same conditions at their disposal are all the health resources in accordance with the acquired rights in the domain of private insurance. Therefore, the governments of member states are forcing public health insurance, establishing national funds for its nancing and encouraging the increasingly sharp competition among the buyers of its services. It looks like a good incentive for buying the services offered active in the eld of private health insurance, however, there is concern that because of the risk that arises in the selection and purchase of health insurance, the costs might outweigh the rights of bene ciaries of compulsory health insurance.

The examples of Germany, Belgium, France and Slovakia (1, pp. 4-5) show that the decision on the selection and purchase of private health insurance is not an easy task, because an experiential purchase arrangement is the norm of experience and always warned of the danger of risk. The risk in all forms, inevitably weakens the incentive and interest in the offered package of services in the eld of health in-surance and regardless of the applicability of mechanism intended for its removal, it can be successfully eliminated. Offer scope of private health insurance in the health care services is an operational function of provider and strategic step towards the appropriate resources. Advocates of private health insurance drew attention to the discrepancy between what is currently spent on health care and what may be needed


to be spend in the future. They do so with the clear intention to draw the attention of prospective clients, that the only way to overcome this problem, their greater reliance on private funding of health insurance. In contrast there are those who approach this question by opposing him in public (state) funding of health insurance. McKee said that in some Member States of the European Union informal payments instead of a formal cost sharing has become a challenge for the implementation of health reforms (13, pp. 263-286). In the worst case considered Ensor and Moreno, this payment can be a form of corruption that could undermine of cial payment system which leads to a decrease or lack of access to health services. According to them, private funding of health care in relation to public funding, undermining the value of the health system and represents an attack on the poor. Centralized systems of raising funds, they say, have a better chance to enforce collection and generate more revenue than the systems that contribute to the health needs of individual funds collected (4, pp. 106-124).

Grosso modo here we have identi ed two broad trends of health care reform. First, many member states of the European Union have made a signi cant step in promoting equal access to health care customers, and expand the range of health services. Prevalence is re ected in greater coverage of the insured, the arrangement of the legal status of private health insurance carrier, the improvement of technology sharing health care costs and a strategy of allocating available resources. Second, was thrown more light on the provision of quality health care, also is emphasized its importance and practical value in relation to unemployment. Increased use of quality health care encourages the purchase of health insurance and daily improving and simplifying models of payment of medical services (28). In accordance with the above, the price of health services that are either motivation or demotivation in the choice of insurance and payment must not be ignored. In many Member States of the European Union, the cost of health services has fomented desire, to instead a formal division of health funds, supplement the cost of informal payments and further called for health care reform.

The availability of health services

The availability of health services World Health Organization (WHO) (31) de nes as a “measure-the percentage of the population for their own purposes freely provides appropriate services.” Equal access to health services means that adequate supply is closely related to their cost, acceptable species, physical presence and di-rect contact between their providers and users. Unimpeded access to health care in member countries of the European Union is strongly determined by socio-economic status of their citizens. Many citizens (secured or unsecured) due to unavailability of appropriate forms of health care can run into a competitive disadvantage and, that necessarily make them to belong to one of the vulnerable or socially disadvantaged


cathegories. The European Union has a great variety of vulnerable groups who may experience unequal access to different type of medical services (23, pp. 43-55). Vulnerable groups are deprived of any, not only for equal access to health services on what they are talking bad experiences, but still present an insurmountable barrier. Vulnerable groups include mostly members of various ethnic communities, people with physical disabilities, chronically ill, unemployed, homeless, immigrants, refu-gees, asylees, people without valid documents, the elderly and women. Devastating is that in this series of obstacles, each of them can prevent, for example, women, in rm or children to enjoy their basic rights to health care and quality health servi-ces. Some theorists (Huber) believe that these obstacles arise under the in uence of many factors within the health system (8). By the way it is about the speci cs and gaps in health insurance coverage, the scope of public health bene ts, the division of payment, geographic factors (distance or lack of infrastructure), organizational factors (waiting list and hours), or the lack of-the inadequacy of information. In addition, it’s the product of the factors related to characteristics of users of services, income, education, age, language, disability, sexual identity, cultural heritage, civil status and the like.

Access to health services can be viewed in two ways. First, as signi cantly limited because it deprives members of certain social groups in the total health care and second, as inappropriate, because even as it is available, health care is often not adequate to meet the needs of citizens. This indicates important differences in health status between populations of the member states of the European Union, and the con-clusion that they are a result of close correlation between social and economic status. When the distribution of health meticulously observed adverse experiences, it should be pointed out that a signi cant number of them, regardless of the initiating inequality in no sense is not a natural phenomenon. They can be, and they are, rstly a result of poorly managed health and social policy which is re ected in an unrealistic setting, the adoption and implementation of health goals and programs, through the conclu-sion of unfair economic arrangements and the creation of socio-toxic combination. In this regard the opinion that the social determinants of health and the environment in which life takes place, are the great enigma in the biggest extent responsible for the pervasive health disparities between citizens of member states within the European Union. Universal access to health services, although in many ways typical of the health systems in individual member countries of the European Union, is the main goal of the long-term aspirations of their citizens. How much the principle of universal access to health services is as an important goal, shows us not only because he is explicitly stated in the constitutions of many countries-EU members, but also that is included in the Charter of fundamental rights. In Article 35. charter of Fundamental Rights states that everyone has a right of access to preventive health care and the right to use medical treatment under the conditions established by national laws and practices (15, pp. 184-186).. The authority that has a mandate, should direct the medical care


and put the contest to human health and to facilitate the promotion and improving access to quality health services.

World Health Organization (WHO) (20) recommends that primary health care should be a heart of every health system. In addition, the inclusion of more specialized health services such as sexual, reproductive and mental health should also be taken into account as much serious as possible. Access to health care services for a very long time is beyond traditional therapeutic frameworks and standards. Therefore, it’s completely logical the strong encourageness of private health insurance, that in many member countries of the European Union was not suf ciently developed. In some Member States this issue is explained by providers-insurance agents who didn’t always have the possibility to, with the available forces and tools, encourage level, that is certainly important, even strategic shoping. It is believed that the purchase of services that covers on large extent, would determine not only its economic and scal sustainability, but that would be the same and with the other types of insurance. He-alth care reforms are often not carried out properly, which constantly emphasized the need that many important details must be done more precise. First, in the context of linking the performances of paying and quality of health services, it was necessary to nd appropriate mechanism to measure the ultimate outcomes. Some countries have

made great efforts to expand health insurance coverage of the population and achie-ve the nal results – almost universal coverage. However, as much as important the universal coverage, it is also important its depth and its scope, especially if it is well known that they signi cantly undermine the nancial coverage of health systems. In some Member States of the European Union has become a trend, reducing the scope and depth of universal health coverage (12, pp. 172).

Global science has many standards recently put ad acta, and orientation to a broader approach to health is possible only through its speci c promotion and quality over a wide range of different health services. The promotion of quality health de -nes all kinds of activities that people provide Increased control over their own (and others) health. Under this standard we mean, the provision of resources to nance health services, housing, food security, employment and quality of the environment and working conditions. This statement focuses every day more and more on nece-ssary realistic estimate of available funds, without which there is no question about the desired accessibility to health services. They are for the most part, permanently dependent on the extent of available funds. Rating of available nancial resources, allocated for the nancing of primary health care is important from the standpoint of looking at the real possibility of its full realization through the timely provision of health services according to established standards. In addition, it is necessary to consider the portion of funds allocated to intermediate and central levels of health care or resources that go to expensive and less accessible health services that are missing to a large number of poor citizens. When we speak about universal or near universal coverage of population with health insurance, in most member countries of


the European Union it reaches a fantastic 98-99 % of the total population. Germany on this issue is an exception (5), because there is the legal coverage of about 88 % of the population. The most common basis for getting the right for health insurance and health care is staying in these countries.

Universal health care coverage

Health systems in the European Union is different (21) from one country to another member-country. The following legal doctrine of national health systems in the European Union is mainly divided into two categories. The rst is the National Health System (NHS), which operates in many countries of the European Union member states (UK, Italy, Spain, Portugal, Greece) (7, pp. 21). Health care for the covered insured is nanced from a provided tax, and the percentage of coverage is customarily high, and up to 99 %. The second category is the social security system which includes mandatory health insurance for all citizens or certain groups of citizens. Their connection with the Fund for health insurance is mandatory. For example, in the Netherlands in which the social security system works awlessly, all residents are required to enter into contracts with private insurance companies. French health care system is a paradigm, it’s an example of how one country should function in the social security system. His nature was de ned by reforms in 1998. that signi cantly changed the overall health environment. Social security contributions have become the dominant mechanism for the collection of funds intended for nancing the health costs of French citizens. Driven by changes Economic Council in 2006. adopted (19) a Declaration on common principles and values of health care systems of member states of the European Union. It literally points out the common value of universal coverage. It wouldn’t be desirable that any of them remains outside the established framework or that may, eventualy, hampers the access to health care, or denies anyone the right to health insurance.

In its Strategy “Together for Health” (26, pp. 5), adopted in the 2007th , the Eu-ropean Commission pointed out the importance of universal coverage. Accordingly, Article 35 of the Charter of Fundamental Rights of the European Union stipulates that everyone has the access right to preventive health care, and the right to use medical treatment under the conditions established by national law and practice. Universal health coverage is the largest value in European legislation, and is de ned as an area in which to the people is given the unrestricted access to all forms of health care. Health coverage, however, is different among the member countries of the European Union, as well as the bene ts of citizens to enjoy it (27, pp. 47). Given that the difference has to be, it is certain that all member states as one believe that it is necessary that all the inhabitants have the right to a minimum level of health care, and bene ts from provi-ded-recieved health care. As a powerful tool that guarantees universal coverage and


nancial support for health care of its citizens, the member countries of the European Union use nancial subsidies. Subsidies can be questioned only if their assignment violates the Article 87 of the European Commission (10, pp. 232-233). Otherwise, it is certain that the interests of health care are regulated by applying positive rules that are respectable in the area of giving state european health. Community courts and the European Commission deal with the regulations of the Treaty of state help that are aimed at universal coverage to be integrated as it ones was prescribed. The realization of this objective will contribute to greater respect for health protection and health care, and more power will be left to the national authorities in member countries of the European Union. The agreement states that to the national authorities is left a lot of jurisdiction and plenty of space to intervene when it is required nancialy, and to guarantee the access to health bene ts to their citizents, and to promote universal coverage.

Responsibilities of Member States in the eld of health care as the Lisabon Treaty provides for the obligation, are to include national authorities and allocate all types of resources athan can be useful for providing adequate health care in accordance with the level of universal coverage. What role in this case may play a universal coverage shows an example from Spain. Community courts have decided that the national Spanish health system (NHS) is a company, because it’s nanced from the social security contributions and funds from other state funds. Thus, health services are free for all persons associated with the fund for health insurance on the level of general coverage. The example shows that the principles of solidarity in health care and universal coverage are closely linked and that the principle of solidarity often leads not only to a redistribution of wealth, but also to a transfer of nancial resources from healthy to unhealthy individuals. Finally, the de nition of universal coverage is very simple, because it’s about access that makes all kinds of health care and all kinds of bene ts that derive from it, absolutely provided for all categories of citizens. Prima facie, the argument for universal coverage serves as the principle of solidarity that conferms the fact that it is something of general interest, which means that is the supreme value and general public good.

Conclusion

The intent to perform after all the real conclusion is justi ed by the thwarted dilemma, is there in the Member States of the European Union the optimal method of nancing and providing of the full health care? Based on available information,it can be argued that, it exists when it comes to nancing of compulsory health insu-rance that is widespread and even more superior from the other forms of insurance. However, no one knows until when will this supremacy last, if we look the current trends, everytime much poorer health vault decline in gross domestic product (GDP)


and more expensive medical procedures. Public nancing in general contributes to a thorough and effective delivery of health care regardless of risk as a result of the disease picture of the insured. It has a particularly large impact in providing and grant funds in accordance with the needs, but much smaller effect on the solvency power of the insured. Health systems generally provide a high percentage of health inclu-de at compulsory insurance for customers who primarily covers preventive public health services, primary care, specialist outpatient and hospital care, prescription drugs, mental health care, dental care, rehabilitation and home care. In all Member States there are areas on which tolerance is covered by compulsory health insurance, and depending on the type and scope of health services, it may be required a cost-sharing. In addition, in some member countries of the European Union might exist a gap between what the insurance covers formal and of cial, and attending events that should be funded in everyday practice.

Contrary to the public, mandatory health insurance, private health insurance is recognized by the fact that the conclusion of contracts with clients, prospective insured, eliminates the risk of his poor health folder. Also, private health insurance is much more superior than the public (compulsory) insurance in the management of public nances. It demonstrates that supremacy through a secure payment of health insurance premiums by direct billing and revenue from health services. In addition, it provides a secure income through strategic procurement and on the basis of reduction of administrative costs. The references of this form of health insurance at rst sight guarantee a high degree of economic and scal sustainability. But there is a long side of the coin. The danger to which is exposed a private health insurance is linked to the eventual deterioration of the health-insured citizens, and increasement in health expenditures due to its restoration. In addition, evry day there is much more present fear of falling member-countries of the European Union in the debt crisis (Portugal, Italy, Ireland, Greece Spain-PIIGS) (2, pp. 101-106), due to a slight impoverishment of citizens and their day to day less purchasing power. It will adversely affect private health insurance funds. Since it has not spared any mandatory health insurance, so it must be seriously reckoned to reduced access to health services and less health cove-rage, which means that universal coverage is seriously in question. Equal access to health services will be further aggravated by all the citizens for which the nancial solvency does not guarantee the adequate health protection. In such circumstances obtaining money or techniques will not be meaningful, and health funds will become empty.

Many member countries of the European Union, especially those from the pe-riphery in which the increasement of healt expenditure concerns both sides, citizens and the relevant authorities. A good example of this is Italy (17), where the health care spending in 2006. took part in the gross domestic product (GDP) to 9.0%, which was about U.S. $ 2,600 per capita. Of these, about 75% was spent on mandatory health insurance provided by the Italian government. Only three years later, in the 2009th


year, total expenditures for health care reached 9.5% of gross domestic product (GDP) or U.S. $ 3.027 per capita. Thus, the Italian health care spending is above the average of OECD countries, which amounts to 8.9% of gross domestic product (GDP) (18). According to quality, which is very important for comparative analysis, the Italian health system in the world ranks with a very high second place, behind France.

References

1. A. P. van der Mei, Free Movement of Persons within the European Community. Cross-Border Access to Public Bene ts, Oxford, 2003, pp. 4 & 5

2. De Oliveira G., 2005, Some improvements in the Portuguese medical law. In: Sanderfelt M, ed. Yearbook of European medical law 2005th Lidingo, The Institute of Medical Law: 101-106.

3. Douver N., World poverty, (in Peter Singer, Introduction to Ethics, publishing knjižarnica Zoran Stojanovic, Sremski Karlovci-Novi Sad, 2004, p.. 393-407.

4. Ensor T. and Duran-Moreno A., 2002, Corruption as a Challenge to Effective Regulation in the Health Sector. In Regulating Entrepreneurial Behaviour in European Health Care Systems, ed. R. B. Saltman, R. Busse, and E. Mossialos, 106-124.

5. Germany country pro le. Library of Congress Federal Research Division (December 2005).

6. “Health Act 2004”. Irish Statute Book. Of ce of the Attorney General.7. Herve T.K. and JV McHale, ‘Law on Health of the European Union “, Kembrix 2004, p..

21st.8. Huber, H.; Stanciole, A.; Wahlbeck, K.; Tamsma, N.; Torres, F.; Jelfs, E. and Bremner,

J. (2008) Quality in and equality of access to healthcare services, Study Report for European Commission, Directorate-General for Employment, Social Policy and Equal Opportunities. Available at: www.euro.centre.org/data/1237457784_41597.pdf. (Pose-eno: Novembar 16, 2011) (Pose eno: Novembar, 16 2011).

9. J. van de Gronden W., Financing Health Care in EU Law: Do the European State Aid Rules Outan Write Effective Prescription for Integrating Competition Law with Health Care? The competition law review Volume 6 Issue 1 pp. 5-29, December 2009.

10. Law for the Twenty-First Century. Volume 2: Internal Market and Free Movement Com-munity Policies, Oxford, 2004, pp. 232 and 233rd

11. Legido-Quigley H, McKee M, Nolte E., I. Glinos A., Assuring the Quality of Health Care in the European Union, A case for action, Observatory Studies Series No. 12, Sixth Framework Programme, World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policie, pp. 152nd.

12. Lowry V., 2002, ‘”Undertaking” as a Jurisdictional Element for the Application of EC Competition Rules’, Legal Issues of Economic Integration 172nd.

13. McKee M, Mossialos E, Belcher P., 1996, The in uence of European law on national health policy, Journal of European Social Policy 6 (4), 263–286.


14. McKee M, Baeten R, eds, 2008, Patient Mobility in the European Union: learning from experience. Copenhagen, WHO Regional Of ce for Europe :179-18.

15. Mossialos E., McKee M., Palm W., B. Carr L. and Marhold F., ‘EU Law and the Social Character of Health Care’, Brussels, 2002, p. 184-186.

16. Mossialos E., 1997, Citizens Views on Health Care Systems in the 15 Member States of the European Union, Health Economics 6 (2) 109-116;

17. “OECD Health Data 2008 How Does Italy Compare.” OECD. 2008th.18. “OECD Health Data 2008: How Does Spain Compare.” OECD. 2008th.19. Council of the European Union 2001th.20. WHO Commission on Social Determinants of Health 2008th.21. The Council Conclusions on Common values and principles in European Union Health

Systems, OJ 2006, C156 / 1.22. The World Health Report 2000: WHO.23. Totic I. Policies in the European Union’s health system, Health Care, a journal of social

medicine, public health, health insurance, economics and management in health care, in November, 2011, no. 5, p.. 43-55.

24. Vukmanovi L. ., 1994, Menadžent in health, health policy and strategy development, health Menadžent programs and health systems, European Center for Peace and Develo-pment-ECPD, University for Peace United Nations, Modern Administration, Belgrade, pp. 37th

25. “Zorgrekeningen; uitgaven (in lopende en constante prijzen) and nancing” (in Dutch). Centraal Bureau voor de Statistik: StatLine. 20 May 2010. http://statline.cbs.nl/StatWeb/publication/? (accessed: October 19, 2011, 18: 40)

26. “White Paper” Together for Health: A Strategic Approach for the EU 2008-2013 “COM (2007) 630 nal, third p.

27. Wismar M, Palm W, Figueras J, Ernst K, E.van Ginneken, Cross-border health care in the European Union, mapping and analyzing practices and policies, World Health Organi-zation 2011, on behalf of the European Observatory on Health Systems and Policies, pp. 47.

28. WHO Statistical Information System.29. World Health Organization Assesses the World’s Health Systems.30. World Health Organization Statistical Information System: Core Health Indicators.31. “World Health Organization – Italy”. WHO. The 2010th.

neka pitanja u vezi sa finansiranjem zdravstvene...

Documents