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The promotion of patients’ rights in Cyprus. Compatibility with the European Charter of

patients’ rights

By Dr Stella Moustaka Playbell

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The 18 April is proposed as the European Patients’ Rights day. With this occasion, this presentation has been dedicated to patients’ rights in Cyprus.

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The presentation includes main points on:- European Charter of Patients’ Rights- Cyprus law of patients’ rights 1(I)2005

Compatibility of Cyprus law with European charter

An evaluation of mechanism to resolve complaints

Compatibility of Cyprus law 1(I)2005 with the proposed National Health Scheme

- Compatibility of health rights with the proposed directive for Cross Border Health Care

- Conclusions

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Historical review of European Charter

The Charter was drafted in 2002 by Active Citizenship Network. This is a European network of about 100 civil organisation from 30 EU countries, promoted by the Italian NGO Cittadinanzattiva. In 2007, the European Economic and Social Committee passed her opinion to European Committee for an acknowledgement of the Charter. With this opinion there is a proposal to establish and celebrate 18 April as the European day of patients’ rights. This Charter contributed to the promotion of directive for Cross Border Health Care

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Aim of Charter

The Charter states 14 rights that aim to guarantee a high level of human health protection (Article 35 of Charter of Fundamental Rights of European Union). It also aims to assure the high quality of services provided by national health services in Europe. The Charter recognises that socioeconomic differences may influence individuals health care needs.

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Rights

1. Right to preventive measures

2. Right to access

3. Right to information

4. Right to consent

5. Right to free choice

6. Right to privacy and confidentiality

7. Right to respect

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-Continue-

8. Right to the observance of quality standards

9. Right to safety

10. Right to innovation

11. Right to avoid unnecessary suffering and pain

12. Right to personalized treatment

13. Right to complain

14. Right to compensation

Additional rights promoted by active citizenship:

Right to advocacy

Right to participate in policy making in health area

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Cyprus law on patients’ rights 1(I)2005

• Promoted by K.I.D.A and other NGOs and is in accordance with European and International Conventions related to health and ratified by Cyprus

• It states 17 rights and a mechanism for the monitoring of violation and the resolve of patients’ complaints

• It defines the term patient being a sick person or a consumer of health care services. Also defines a broad spectrum of providers of health care services

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Rights

1. Right to health care

2. Right to be treated with dignity

3. Right of access to health care

4. Right against discrimination among patients

5. Right of health care for emergency

6. Right of examination in emergency department

7. Right to information

8. Right of health care with the consent of patient

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9. Right of information about health status10. Right of health care without the consent of patient11. Participation of patients into research or experiments12. Right of confidentiality13. Right of protection of private life of patient14. Right for the establishment of health records15. Right of patient to modifications of health records16. Right to advocacy17. Right of provider to remuneration

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Compatibility of Cyprus law with the European Charter

Essentials rights of European Charter are excluded from Cyprus law. These are the right to preventive measures, the right to observance of quality standards, the right to safety, the right to compensation and the right to freely choose among different treatment procedures. Main explanation for their exclusion is because they increase expenditure and also dispute the providers’ competency. The precondition relating to expenditure is well defined in the right of access to health care “……. Must be provided according to the capabilities of the current Health System and the resources of the state”

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With the current Health System there is a discrimination among citizens based on income criteria. Free services and European Health Card are provided by the state to civil servants and to those citizens with low income. The remaining citizens have to find their own way to health care …..Those who are eligible to free services, in many cases buy services out of pocket due to the drawbacks of state services. There is no well defined cooperation or synergies between public / private sectors.

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It appears that during the establishment of patients’ law, policy makers had to reconcile with the reservations of health care providers regarding the rights to safety and to compensation. Today health care providers must be insured against medical malpractice and errors. In such cases the burdening is transformed to the insurance company, therefore health care providers have to compromise with the right to safety and to

compensation.

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Mechanism for resolving patients’ complaints Law 1(I)2005

In contrast to the omission of essential patients’ rights, the Cyprus law is very innovative for the establishment of a well defined mechanism to resolve patients’ complaints.

Complaints at public hospitals are examined in a first level by an appointed officer and at a secondary level by an appointed Committee. The Committee also examines patients’ complaints relating to health services offered in private sector. The decisions of the Committee are forwarded to the patient and to the relevant health providers who must take them into serious consideration.

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Current practice / evaluation of mechanism

Two years since the establishments of the mechanism little has been achieved. There are a number of speculations for this outcome. From the providers’ point of view, compliance is poor as there are no penalties for malpractice. In fact, most of the complaints in public sector do not apply to doctors/health officers but are a result of deficiency in manpower and infrastructure and a responsibility of ministry of Health.

From the patients’ point of view complaints are few, most probably because patients are not aware about the mechanism. However if they are aware it is not clear whether they will choose to exercise this right to complain. People in Cyprus are not yet used to utilise procedures for complaints in general.

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A survey to assess citizens’ knowledge /beliefs

The previous reservations has been investigated with a small pilot survey on March 2009, details of which are given below:Sample size 62 citizens District: Nicosia 40% Limassol 60%Place of interview: Limassol hospital outpatient surgeries, private pharmacy, bank, school of secondary education

Socio demographics: Majority of respondents were female (60%), belong to age group 30-40 (37% ) had at least secondary education (85%) were working and mainly classified in the group of professionals (21%) and clerical staff (32%)Provision of health services:private sector only 45%, Public sector only15%

Both public & private sectors 40%Awareness about patients’ rights law:Yes 38%, No 60%, Did not answer 2%

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"Do you know that you can submit a complaint to the officer and / or to the Committee for patients’ rights "

Public / Private

Yes, but I am not sure which kind of complaints they examine 14% 5%

Yes, but I am not sure how to find these persons 6% 6%

Yes, but I have not yet submit a complaint 24% 21%

Yes, I have already submitted a complaint 3% 0%

Yes, but I do not believe that mechanism is effective 3% 5%

No, but since you told me, I will do so when it occurs 26% 39%

No, and I do not believe that this mechanism will help 19% 10%

Other ……….. (includes multiple answers of above options) 3% 2%

No answer ………… 2% 12%

Total 100 100

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Respondents who expressed reservations / disbelief in mechanism were asked to explain why among the following options:

1. I believe it is more effective to complain directly to the Ministry of health

2. I believe it is more effective to ask help from members of parliament, from patients’ associations, or from other persons with influence

3. I believe it is more effective to complain through lawyer

4. I believe it is more effective to complain to the director of hospital/clinic

5. I believe that the health provider will be revengeful against me when I shall need care

6. I compromise with the situation

Unfortunately sample was too small to clarify which of the above options are more relevant. In fact 86% of respondents who use private sector only and 65% of respondents who use public sector only did not answer.

For those using public sector, around 10% marked above options 1,2,4, 5

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Main results of pilot survey

• Overall majority of respondents do not know about patients’ rights law (60%).However there is a different picture when results are analysed by sector. The lack of knowledge increases to 75% for respondents using only private sector and is reduced to 55% for respondents using only public sector .For those using both sectors, lack of knowledge was 48%.It is worth noting the lack of knowledge among health providers as well.

• Majority of respondents, especially in private sector, did not know about the mechanism and said that in future, if required, will submit a complaint. It is worth noting a significant positive correlation among replies of respondents for both public and private sector (r=0.34, p=0.007), a result that implies a similar belief.

• From the above, there is evidence to conclude that the lack of complaints is mostly due to the lack of knowledge about health rights

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Compatibility of Cyprus Law 1(I)2005 with the proposed National Health Scheme

No matter that the health status is quite good (see Appendix), it is acknowledged that the current Health System in Cyprus has many drawbacks and needs to be reformed. In 2001, a new comprehensive legislation has been enacted. Since then an action plan is being constructed for the establishment of a National Health Insurance Scheme, similar to other EU systems.

Unfortunately, from a sociological and a psychological perspective, there are reservations that this plan is updated, does not apply to new trends and to Cypriot reality and will not promote patients’ rights as expected.

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In short, patients are seen as potential defaulters of health services. In order to control expenditure, doctors are expected to act as gate keepers and sub contractors of services.

Most probably, doctor /patient communication will be eroded instead of being improved. Targets of equity and social solidarity will be met in general terms only, as the right to personalised treatment seems not to be given priority. Many other patients’ rights such as prevention are neglected.

The right to free choice and access to health services is also questionable. Both general doctors and specialists will be allowed to examine patients either through the scheme or out of pockets. In other words there will be services upon two speeds. No specific provision is noted for the old aged, handicap or other groups of high risk.

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Health Rights and Cross Border Health Care

Proposal for a Directive on Cross Border Health Care, July 2008Target. To establish a general framework for the provision of safe, high quality and efficient care. To improve clarity of freedom to receiveand provide health care, given the fundamental principles of EU for free movement of goods and services

It includes 24 articles within 5 chapters:Chapter 1, General provisionsChapter 2, Member state authorities responsible for complianceChapter 3, Use of healthcare in another member stateChapter 4, Cooperation on health careChapter 5, Implementing and final provisions

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Comments

An inspection of proposal reveals essential differences with ruling ofEuropean Court: In order to protect the survival of national health Funds, proposal says “member

state of affiliation shall reimburse the costs to insured person which would have been paid for by its statutory social security system, had the same or similar care been provided in its territory”( article 6). However, according to European Court, the reimbursement is decided on the grounds of actual expenses that occurred in another member state.

As with existing Regulations 1408/71, articles 6 and 8 continue to allow the member state of affiliation to provide a system of prior authorization for reimbursement for health care provided in another member state, thusmaking access less tangible.

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No matter the above constraints, it is worth noting the importance of article 12 for the establishment of national contact points for cross border health care.These points are in line with the Committees that examine patients’ complaints in Cyprus law, as they have to help patients to protect their

rights.Equally important is article 15 for the establishment of European reference networks.

This is in line with E. Court and expects :a) to help to realize the potential of European cooperation regarding

highly specialized healthcare for patients and for healthcare systems from innovations in medical science and health technologies

b) to help to promote access to high quality and cost-effective healthcare for all patients with a medical condition requiring a particular concentration of resources or expertise

c) to maximize cost-effective use of resources by concentrating them where appropriate

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Conclusions / Recommendations

• Cyprus law on patients rights has essential differences with European Charter and needs to be modified

• Citizens in Cyprus must be informed about their rights and about the mechanism to submit complaints

• There is evidence that Cypriots are demanding and selective consumers of health services who act on a rational basis. Therefore, if the proposed national health system will not meet their expectations, compliance will be low. As a consequence, the target of policy makers to control expenditure will fail

• With the current health system there is a continue debate to establish “cross border health care” between private and public sectors. Therefore the principles of Directive on Cross Border Health Care among member states makes the situation more complicated

• Overall, health challenges for Cyprus are too many

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Appendix Figures about Cyprus

Total population in government control area 789000 (Statistics Depart.2007) Total population in government control area 789000 (Statistics Depart.2007)

80% of population eligible to use public health services 80% of population eligible to use public health services

60% of population prefers to buy services in private health sectors60% of population prefers to buy services in private health sectors

Self assessment of health service :Self assessment of health service :

Very good 45%, good 36%, satisfactory 14%, (Eurostat 2004) Very good 45%, good 36%, satisfactory 14%, (Eurostat 2004)

Life expectancy: men 76, women 81, (Statistics Department 2005) Life expectancy: men 76, women 81, (Statistics Department 2005)

Income per capita: 26,700Income per capita: 26,700$ (Central Bank Cyprus, 2007)$ (Central Bank Cyprus, 2007)

Health expenditure : 6,2% of GDP of which 33% is made in private sector Health expenditure : 6,2% of GDP of which 33% is made in private sector (Ministry of Health 2004)(Ministry of Health 2004)

Cyprus was on place 12 in Euro health consumer index 2006Cyprus was on place 12 in Euro health consumer index 2006

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References 1. European Charter for patients rights, Active Citizenship

Network, 20022. Law 1 (I)2005 for Patients’ Rights, Ministry of Health

Cyprus 3. Law 89(I) 2001 for a National Health insurance

Scheme, Ministry of Health in Cyprus 4. Proposal for a Directive on the Application of patients’

rights in cross border health care 2008/ 0142 (COD)5. Ruling of European Court on Cross Border Health

care 6. Doctoral thesis upon health behaviour of Cypriots,2005

Stella Moustaka Playbell, ww.playbell@cytanet.com.cy