National Research and Development Centre for Welfare and Health Knowledge for welfare and health1 Health policies and the European Commission proposal for a directive on services Meri Koivusalo Globalism and Social Policy Programme STAKES

National Research and Development Centre for Welfare and Health Knowledge for welfare and health2 WHAT ABOUT IF THINGS ARE NOT AS FINE AS IT IS ASSUMED ”DO NO HARM” IMPACT OF SERVICES LIBERALISATION ON PUBLIC HEALTH POLICIES IMPACT OF SERVICES LIBERALISATION ON HEALTH AND SOCIAL SERVICES HEALTH IS NOT JUST AS ANY GOOD AND HEALTH AND SOCIAL SERVICES ARE NOT LIKE ANY SERVICES

National Research and Development Centre for Welfare and Health Knowledge for welfare and health3 IS THERE ACTUALLY PROBLEM OF ? CLARITY ? SOCIAL DUMPING ? STATUS OF MONOPOLIES ? PRIORITIES AND GOVERNANCE ? EXTRA COSTS ? PUBLIC HEALTH POLICIES AND SUSTAINABILITY OF HEALTH SYSTEMS ? SAFEGUARDING HEALTH, SAFETY AND CONSUMER RIGHTS ?

National Research and Development Centre for Welfare and Health Knowledge for welfare and health4 CLARITY INTERPRETATION OF WHAT IS INCLUDED IS NOT CLEAR AND WHAT ARE THE IMPLICATIONS ARE NOT AT ALL CLEAR INCLUSION OF HEALTH SERVICES AS PART OF INTERNAL MARKETS IS NOT CLARIFYING – MORE CLARITY COULD BE ACHIEVED THROUGH EXCLUSION OF HEALTH AND SOCIAL SERVICES THE ’PROBLEM’ OF REIMBURSEMENT IS MORE ECJ DRIVEN THAN PROBLEM DRIVEN

National Research and Development Centre for Welfare and Health Knowledge for welfare and health5 CLARITY DEFINITION OF SERVICES OF GENERAL ECONOMIC INTEREST COULD IMPLY COVERING LARGE SHARE OF THE SERVICES WHICH HAVE BEEN CONTRACTED OUT IN MOST EUROPEAN HEALTH SYSTEMS THIS IS THE CASE THIS HAS SPECIAL REFERENCE TO NGOS

National Research and Development Centre for Welfare and Health Knowledge for welfare and health6 SOCIAL DUMPING AS LONG AS DIFFERENT REGULATORY MECHANISMS EXIST BETWEEN COUNTRIES THE RISK OF SOCIAL DUMPING EXISTS, UNLESS IT IS EXCPLICITLY AND CLEARLY TAKEN UP AS PART OF THE PROPOSED DIRECTIVE

National Research and Development Centre for Welfare and Health Knowledge for welfare and health7 SOCIAL DUMPING PHARMACEUTICAL DISTRIBUTION SERVICES ALCOHOL DISTRIBUTION SERVICES ADVERTISING SERVICES ELDERLY CARE – WHAT ABOUT CHILD CARE DENTISTS, OUTPATIENT AND SPECIALIST SERVICES WITHIN HEALTH SERVICES

National Research and Development Centre for Welfare and Health Knowledge for welfare and health8 SOCIAL DUMPING THE NATURE AND INTERPRETATION OF DEROGATIONS 17.16: services, which in the Member State to which the provider moves temporarily in order to provide his services, are covered by a total prohibition which is justified by reasons relating to public policy, public security or public health;

National Research and Development Centre for Welfare and Health Knowledge for welfare and health9 SOCIAL DUMPING 17:17: specific requirements of the Member State to which the provider moves, that are directly linked to the particular characteristics of the place where the service is provided and with which compliance is indispensable for reasons of public policy or public security or for the protection of public health or the environment.

National Research and Development Centre for Welfare and Health Knowledge for welfare and health10 THE STATUS OF MONOPOLIES IN SOME COUNTRIES ALCOHOL DISTRIBUTION MATTERS ALLOWING FOR MONOPOLIES TO FUNCTION AS FAR AS THEY DO SO WITHOUT INTERFERING WITH MARKET PROVIDERS VS. ALLOWING FOR EXCLUDING OTHER SERVICE PROVIDERS

National Research and Development Centre for Welfare and Health Knowledge for welfare and health11 GOVERNANCE AND COSTS NATIONAL COORDINATION BY THE TRADE AND COMMERCE SECTOR MAKES IT MORE DIFFICULT TO ACCOMODATE HEALTH CONCERNS ASSUMED BIAS TOWARDS BENEFITS OF MARKETS AND COMPETITION IN SERVICE PROVISION

National Research and Development Centre for Welfare and Health Knowledge for welfare and health12 GOVERNANCE AND COSTS LACK OF CLARITY INCREASES THE PROBABILITY OF PROBLEMATIC DEALS LICENSING AND PROFESSIONAL QUALIFICATIONS IMPORTANT IN HEALTH REGULATORY MEANS AND MECHANISMS WITH STRANGERS COST MORE THAN WITH THOSE KNOWN CAPACITIES TO MANAGE AND OPERATE AT EUROPEAN LEVEL REQUIRE ADMINISTRATIVE COSTS

National Research and Development Centre for Welfare and Health Knowledge for welfare and health13 PRIORITIES AND COSTS OVERALL COSTS OF THE HEALTH CARE SYSTEM OF THOSE WITHIN THE PUBLIC BUDGET: ” In addressing fiscal susainability, most focus until now has been on pension and early retirement systems. However, health care systems and care for the elderly pose an increasing risk to the fiscal sustainability particularly in some Member States” 2004 Update of the Broad Guidelines of the Economic policies (10676/04)

National Research and Development Centre for Welfare and Health Knowledge for welfare and health14 WILL MARKETS BE SOLUTION ? COSTS RISE DUE TO TECHNOLOGY AND PHARMACEUTICAL COSTS WHICH ARE ALREADY IN THE SPHERE OF MARKETS NO EVIDENCE TO SUPPORT - EXPERIENCES IN MARKETS AND COMPETITION NOT SUPPORTIVE FOR CITIZENS AND PATIENTS ACCESS TO GOOD QUALITY CARE WITHIN A COUNTRY MORE IMPORTANT THAN MOBILITY – IS THIS REALLY ABOUT PROVIDERS ACCESS TO PUBLIC FINANCING AND ABILITY TO CHOOSE CUSTOMERS ?

National Research and Development Centre for Welfare and Health Knowledge for welfare and health15 EUROPEAN PUBLIC POLICIES – WHOSE PRIORITIES COUNT ? SERVICES DIRECTIVE ONLY PART OF BROADER PICTURE NECESSITY TO SEPARATE CITIZEN, PUBLIC AND BUSINESS INTERESTS HEALTH AS A CORE AREA OF CITIZENS SENSE OF TRUST AND VULNERABILITY PRIORITIES NEED TO BE SET RIGHT, BUT ALSO EVEN IN TERMS OF ECONOMICS THE COSTS OF IGNORING BASICS CAN BE HIGHER THAN PRESUMED BENEFITS OF LIBERALISATION

National Research and Development Centre for Welfare and Health Knowledge for welfare and health16 ISSUES OF STRATEGIES AND CHANGE DEVIL IS IN THE DETAILS AND INTERPRETATION – IN THE END IT IS ALL FOR THE BEST OF THE PEOPLE UNDERSTANDING DIFFERENCES OF HEALTH SYSTEMS IF THERE ARE NO POLICIES – THERE ARE NO IMPLICATIONS BRINGING SECTORAL DISPUTES OUT – COALITIONS WITH MINISTRIES WHEN POSSIBLE PARLIAMENTARY DEBATES, ACCOUNTABILITY, MEDIA AND PUBLIC POLICIES CITIZENS INTERESTS BEYOND CONSUMERISM