Doctors’ challenges ahead
Daniela Xuereb interviews Dr OTMAR KLOIBER, a pathophysiologist and secretary of the German Medical Association who was recently in Malta. He was invited by the Medical Association of Malta to give a number of lectures to its members
What topics did you focus your lectures on?
One of the topics I focused on related to different existing health care systems and the financing and service provision of these systems in the EU.
We analysed the difference between State-run health care systems, such as those in the UK, Ireland, and Scandinavian countries and insurance-based systems like those in Belgium, France, The Netherlands and
I also outlined the current tendency to combine an increasing number of elements from both forms of health care systems. This not only makes it very difficult to find a clear cut type of health care system anymore, but also shows that all types of health care systems have similar problems.
The basic problems are the same, such as the financing of the systems (a big problem in the EU), service provision and the proper allocation of resources.
Malta has a State-run health care system which is ‘free’ to the public. What are your views on this?
There are a few illusions in this world. People believe they have a right to health – they have a right to health care not health. And it is also an illusion to say that health care is provided free of charge.
Health care consists mainly of services and the use of ‘sophisticated materials’. Health care does not come cheap and people have to be told that this costs the government money. The only question is how do you collect this money. Do you collect it by taxation? Or from premiums paid as contributions to health care? I am very much in favour of a contributions scheme system, rather than taxes earmarked for this purpose.
Which are the main challenges ahead for doctors when we join the EU?
The biggest problem in the EU is that there is a very strong tendency to regard medicine purely as a business commodity. That is the biggest problem we, as physicians, face. This is not only an economical or political problem, but an ethical one too. It forces us to see patients as clients. This is the real problem with the EU – it believes it can regulate all and everything.
The truth is that medicine is a very special part of the economy which needs a certain amount of regulation and protection because patients are vulnerable subjects. Although they are not regular consumers, doctors are obliged to provide services according to the needs of the patient and not to their commercial interest, as any commercial businessman would do. This is the basic difference of the relationship between patients and physicians versus customers to vendors.
What about the possible migration of
doctors to other EU countries?
Migration of doctors is an opportunity for both doctors and patients. We experienced this before Greece, Spain, and Portugal joined the EU, as doctors feared there would be an influx of medical professionals from Greece, Spain and Portugal when they joined the EU in the 1980s.
This was not the case, nothing happened after that. Why? Because it had happened before. Those doctors who wanted to leave their country did so before their country joined the EU. These moves take place with or without the EU.
What the EU does is make it clear to the countries concerned that it is their problem. Therefore if a stream of doctors leave their country, then the government will have to do something about it. Doctors usually migrate because their working conditions and sometimes their salary is not good enough.
If doctors migrate to other EU countries won’t Malta risk a ‘brain drain’ in the medical profession?
Yes. We already have a shortage of doctors in nordic and central European countries, including Germany. Germany for example advertises hospital posts in physicians’ newspapers in Poland, the Czech Republic and Hungary.
There are adverts placed by German hospitals in every issue searching for physicians from those countries. Indeed, although this number of physicians is not relative for Germany because it is not enough, it is already producing a ‘pain’ in those countries losing their physicians.
This ‘pain’ is already taking place in those countries which are not yet in the EU, the ‘brain drain’ is not an EU matter. This situation exerts immense pressure on these countries, but the Czech Republic and Hungary have already tackled this problem and did what was necessary to keep their physicians – they offered them better salaries and better working conditions.
If you want to keep those doctors whose work you consider valuable, you have to pay a price for that. That is very clear. In Germany for example physicians are leaving the country, so others are invited to take their place. Some students do not practise medicine after completing their medical studies because of the poor working conditions – it is not only money, sometimes it is the environment.
Patients also have migration rights. In Malta the public health care service is very developed, but in other countries it is very restricted, and underserviced. It is those systems which are underserviced that the EU really puts pressure on. I am convinced that patients from those countries will finally have the right to travel to other EU countries to get a medical service which is unavailable in their own country.
What about the mutual recognition of medical qualifications?
In 1975 the medical profession was the first to be regulated in the EU. What was implemented at the time was the automatic recognition of diplomas. A list was compiled which catalogued specialists and their specific fields in two or more countries in the EU, and between those countries which had specified certain fields of medicine this would be automatically recognised if somebody moved from one country to another. This system made it necessary for the Advisory Committee on Medical Training in the EU, for these countries to meet and decide which were the same fields, and the specialisation they shared. This produced a need for voluntary harmonisation. We are very happy with this system of automatic recognition of qualification. It has given a lot of freedom to physicians to migrate across the EU and we would like this system to stay and be extended to the new EU countries.
The German government recently refused to sign an EC directive to ban tobacco advertising. What are your views on this?
As a medical association we have publicly stated our stand on this issue. The feedback we got was that this issue creates constitutional problems, and the government believes that the European Commission has no right to interfere.
The German physicians are very upset about this, and we do not understand our government’s position. This has already happened in the past when the German government said it was not against banning tobacco advertising but claimed it was not something for the EU to decide.
If this was really the argument we would have expected that in order to prove that Germany is against tobacco advertising the government would declare a national ban. It did not happen.
Finally we had no choice but to believe that the government is in collusion with the tobacco industry, as it has nothing to do with the European laws and with the German Constitution. The government must be protecting the interests of the tobacco industry – there is no other conclusion we can draw.
Maybe it has something to do with the fact that the tobacco companies sponsor German political parties, their journals and sometimes their party conventions.
How high is tobacco consumption in Germany?
It is very high, and tobacco consumption is a very big problem – many people smoke in Germany. What is worse is that tobacco advertising heavily targets young people. There is really nothing effective that our government is doing about that, and we do not understand the motives of our government.
EU enlargement, a risk or an opportunity for physicians?
EU enlargement should be seen as an opportunity for both doctors and patients. I know that all the accession countries have fears about the future. I am convinced that although problems will arise, it is more a positive chance than a risk we are taking and it has to be envisaged as such.
Doctors should recognise the opportunities the EU has to offer. The EU will open new avenues. Medicine in the EU will experience a slow, linear steady increase of migration and there is nothing to panic about.
Physicians will value their chances of working abroad knowing they can return to their country whenever they want to.
The problem is whether medicine will retain its social face. This is a global problem, with or without the EU. I think we as doctors can deal with this issue together much better, as the EU is as one nation and we have these strong contacts.