By Bernard Merkel (EHFF community member)
The European Health Forum Gastein (EHFG) was set up 20 years ago with the aim of becoming an influential conference on health policy in Europe – perhaps the most influential. I suppose the general idea was to create a kind of Davos World Economic Forum for health policy.
The European Commission was heavily involved in the planning and running of the EHFG right from the beginning, seeing the EHFG as providing a perfect platform for the informal exchange of views on health issues at national and supra-national level and enabling it to showcase its initiatives and float new policy proposals. The Commission provided funding, speakers (including Commissioners and top officials), paid for the attendance of experts and officials from Eastern European countries, and organised events. When I worked in the health and consumers Directorate General of the Commission I used to attend every year as it was the ideal venue to test out ideas, catch up with the latest developments , and above all, network with policy-makers, academics, leaders of health industries and activists.
In recent years I haven’t been able to go to the Forum so I was delighted to have the opportunity to attend this year on behalf of the EHFF.
At first glance not much had changed from my last visit some years ago – the same breathtakingly beautiful location in the Gastein valley 80 Kilometers from Salzburg, the same efficient organisation, the traditional broad range of topics being discussed, the spirit and energy of the participants. But on closer inspection it turned out there was one crucial difference from previous years. The participants were different. Senior policy-makers were virtually nowhere to be seen. There were almost no national or EU politicians present, not even from Austria or Germany. Traditionally, there would have been Ministers and politicians from the current and future EU Presidency countries who used the occasion to discuss their health policy priorities. Not this year. There was also a dearth of senior officials from Health Ministries, other than the Austrian Ministry which was supporting and (largely) organising the2017 EHHG. In their place there were many people from the pharmaceutical industry, consultancy firms and health NGOs.
As for the European Commission, it was similarly much less visible than it had previously been. The Health Commissioner was there to give some closing remarks. Two senior Health DG officials were also present, as well as one official from DG Research and one from DG Connect – a fraction of the number who used to attend and who played a prominent role in arranging and speaking in various sessions
The EHFG this year can therefore certainly not claim to be a key European policy-making event, as it might have been able to do in the past. Nevertheless there was much of interest being discussed.
As usual the EHFG was organized on the basis of a few plenaries and a large number of parallel sessions running from breakfast time which means in effect that it is impossible to follow more than a minority of the discussions. In all, in a day and a half of back to back meetings, I managed to attend plenaries on Local politics for health and Global perspectives on Health in all Policies, as well as forums on Pathways to better and affordable medicines, Better synergies for health – the role of civil society, and a two-part forum on Health futures in a post-truth world.
There is nothing much positive I can find to say about the first plenary on local affairs. A dull affair which was not helped by the withdrawal of half of the advertised participants.
The second plenary on global perspectives was better, but was also hit by the non-appearance of the German and Austrian Ministers. A last-minute replacement, a junior minister from Sweden, spoke about the importance of taking global action in three disparate areas: anti-microbial resistance, safe abortions and the effects of pharmaceuticals on the environment. All fair points, but a rather strange and short shopping list! Dr Ostlin from WHO Europe said that WHO would be more ‘political’ under the new Ethiopian Director-General (Tedros Ghebreyesus), though I am not clear exactly what that means. In the absence of a German minister or official, Prof Ilona Kickbusch (Director of the Global Health Programme in the Institute of International and Global Studies, Geneva) stressed that Germany now had ambitions to play a leading role in global health, as indicated by their invitation to the new DG to address the recent G20 meeting in Hamburg. If that’s true, it is certainly a major change from their previous ultra-low-profile stance. Kickbusch went on to argue provocatively that in working to improve public health in developing countries, it was not enough to tackle the usual commercial interests – tobacco, alcohol and food companies (many of them European, of course). It was also necessary to obtain a better understanding of the financial system and investment landscape which influenced what kinds of products were produced and marketed in those countries. Finally, there was some consensus on the need not just to address individual diseases affecting developing countries, but also to try to strengthen their health systems’ overall capacity.
The forum on NGOs discussion boiled down to two points. First, how NGOs can make a key input to developing the policy agenda through advocacy, and that an important part of this was the use of social media. It was essential to involve young people in this kind of activity as they had a far better understanding of how to use the internet. Second, the problems of obtaining funding for their work. There was a view – rather novel in the public health community – that the sources of funds were not particularly important provided they did not influence the work done. From this perspective there was no real difference between relying on public bodies, such as the European Commission, and being funded by the private sector.
The first part of the forum on post-truth focused on the difficulty of establishing what are the ‘real facts’ about health at a time when huge amounts of information, misinformation and opinions are being circulated constantly and when there are relatively low rates of ‘health literacy’ in the general population. The resulting confusion can have negative consequences for public health. A notable example was the low rates of childhood vaccination for measles in some European countries because of the false scares of a link with autism that had been widely promulgated. This was leading to some unnecessary outbreaks of the infection. Another kind of problem mentioned was caused by the fact that the results of only about half of all clinical trials were published. Negative results were usually not published. So there was an inbuilt distortion in the available information. A further problem is that people are looking for clear answers and certainty. Yet the reality is that such certainty often does not exist. Unfortunately the discussion did not really throw up many solutions to the problems.
The second part of the forum was on the EHFG’s ‘Health Futures Project’. This was aimed at developing three scenarios about the future of health in Europe. These scenarios set out three possible visions for how health might look in twenty years’ time. They had been developed by a small team based on inputs by a wide range of academics and other health ‘experts’, including me. Each scenario emphasized a specific theme a) a shift towards localism, b) a shift towards more individual responsibility, and c) a shift towards more reliance on technology. I think that the themes chosen are important, and do reflect some significant trends whose implications are worth considering. But the brief document produced on the scenarios (available on the EHFG website) is very thin and unconvincing.
By far the most interesting forum I went to – and easily the best attended – was a discussion on ‘pathways to better and affordable medicines’ which was about the increasing costs (and prices) of developing new medicines. One basic dilemma that we are facing is that European countries, even the most affluent ones, are having difficulty in affording new innovative medicines that are becoming available at a time when healthcare budgets are much stretched. On the other hand, the pharmaceutical industry does not want to invest heavily in research and development of new products if they cannot earn a good return from them. This is a particularly acute problem where there is likely to be only a limited market for the product because of the small number of people it is designed to help, or because countries will probably limit its use. New antibiotics were cited as an example of an area where there is a pressing need for new drugs but where the commercial returns look potentially very poor because countries deliberately restrict the use of any new drugs being developed to try to avoid resistance.
The current unsatisfactory mismatch between the price the manufacturers want and the amount health authorities are prepared to pay is starkly highlighted by a number of very expensive new oncology drugs that offer some help to relatively small numbers of people with specific cancers. Access to such drugs is very patchy in Europe, and they are often unavailable to the people who could benefit most. Another problematic case is that of Sovaldi, a drug marketed by Gilead, which provides an effective cure for Hepatitis C for virtually everyone infected. The very high prices that Gilead has asked for this drug have enraged many in the health community. It is considered to have been priced not on the basis of an assessment of the drug’s value, or of what a reasonable rate of return for the manufacturer might be, but essentially by calculating the maximum amount the market would bear to pay for a drug that does something not previously possible.
Everybody who spoke in the session expected that the problem of getting the medicines we need at affordable prices would only get worse. But there was little agreement on what to do about it. Some public health advocates demanded more regulation of pricing; others wanted more consultation with patients to see what their needs and wishes were. Marcel Van Raaij from the Dutch health Ministry asked for more warning about potential new products and more alignment between countries on appraisals. Pharmaceutical industry representatives suggested that more data (possibly using registries) was needed to establish a drug’s effectiveness and value. In relation to antibiotics one idea, which had been used in the case of Tamiflu, was for countries to pay for stockpiles of particular drugs, thus guaranteeing companies a certain amount of revenue. Another idea was for non-profit structures to be set up to develop specific drugs; public funders and pharmaceutical companies would combine to develop and provide the drugs.
A key issue that divided industry from national authorities turned on the efficiency and effectiveness of healthcare systems as a whole. Pharmaceutical industry speakers pointed out (rightly) that pharmaceuticals represented only a small percentage of total healthcare spending. Their view was that it was unfair and short-sighted for health authorities to be trying to reduce spending on pharmaceuticals while not trying to tackle problems in the rest of the healthcare system, including inefficiencies and waste. Moreover, they argued that if it could be shown that new drugs improved the effectiveness of healthcare and would reduce costs elsewhere in the system (for example, by reducing the need for operations or long-term care), the industry should benefit. The national officials, notably Clemens Auer from the Austrian Health Ministry (and President of the EHFG) were having none of it. There were many pressures on health systems and other priorities for spending any available money – primary care, better diagnostics, etc. The pharmaceutical industry had high profit margins and shouldn’t expect that countries would be prepared to spend more on their products, even those that made the greatest contributions. So we are faced with a rather depressing deadlock which requires some creative solutions.
In conclusion, the EHFG produced many stimulating discussions, even if the level of participation was not always very high. I was left however with the firm view that though a large number of important questions had been posed, very few answers had been given. Perhaps the EHFF can help provide some!