Policy Documentation Center

Balogh, Csaba

Koczan, Gergely

English

Exchange rate exposure of Hungarian enterprises \u2013 results of a survey

Secondary market trading infrastructure of government securities

Glambotskaya, A.

The Belarusian insurance market characteristics in the context of economic liberalization: analysis and policy recommendations

Huber, Manfred

Stanciole, Anderson E.

EuropEan CEntrE • EuropäisChEs ZEntrum • CEntrE EuropÉEn
poliCy BriEf may 2009
Access to Health Care for  
Migrants, Ethnic Minorities,  
and Asylum Seekers in Europe
by Anderson E. Stanciole, Manfred Huber
poverty and social exclusion continue to be serious challenges across the 
European union and for health systems in member states. migrants, asy-
lum seekers and illegal immigrants are at high risk of poverty and social 
exclusion and there is evidence that they sometimes do not receive the 
care that best responds to their needs. improved access to general health 
care, including also health promotion and prevention strategies, is there-
fore essential to minimising disadvantage for migrants. this policy Brief 
outlines hurdles of access to health care for migrants and discusses policy 
implications.
the results presented are part of a research project on “Quality in and 
Equality of access to health Care services” (healthQuEst) that was 
financed by the European Commission, DG Employment, social affairs 
and Equal opportunities. this study analysed barriers of access to main-
stream health care services for people at risk of social exclusion as well 
as policies in member states to mitigate these barriers. the study had a 
focus on three groups at risk: people with mental disorders, migrants, and 
older people with functional limitations. Eight countries were studied in 
depth: finland, Germany, Greece, the netherlands, poland, romania, spain 
and the united Kingdom.
Migration and health in Europe
With a substantial and increasing share of foreign-born population, the 
European union faces many challenges on how to achieve better social 
integration and basic human rights for refugees, asylum seekers and illegal 
(undocumented) immigrants. Within the broader issue of advancing access 
to services in general, enhanced access to health care services plays a 
significant role in improving the situation of migrants.
to a large extent, there are significant differences between countries and 
migrant groups, creating the need for tailored policy responses that take 
into account the specific barriers to access to health care in each case. 
Anderson E. Stanciole is a health 
Economist at the Department of health 
systems financing at the World health 
organization, Geneva. this work was 
undertaken while at the European Centre 
for social Welfare policy and research, 
Vienna, stanciolea@who.int
Manfred Huber is Director health and 
Care at the European Centre for social 
Welfare policy and research, Vienna
http://www.euro.centre.org/huber
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
2
While countries differ in their role as host countries (long-standing host 
countries, new hosts, new gateway countries, emigration countries and 
countries with segregated minorities), there are also different types of 
migrant groups, which may include migrants and other ethnic minorities, 
asylum seekers or refugees and illegal or undocumented migrants.
Access barriers and migration
for migrants, barriers to accessing health care represent a complex 
issue. special health risks and access problems affect different groups, 
including newly arriving migrants, people living in temporary reception/
detention centres and undocumented immigrants in general. moreover, 
there are many challenges for providing health care within a multicultural 
setting, some of which can be persistent for migrants who have stayed in 
the host country for some time. some of these challenges are similar to 
those faced by long-established ethnic minorities and may include: lack 
of knowledge about available services; language differences; and varying 
cultural attitudes to health and health care.
analysing the access problems of various groups of migrants is further 
complicated by a widespread lack of information about migrants’ health 
needs and access to services. the difficulty in identifying a person as a 
migrant in administrative records prevents data collection about service 
utilisation and epidemiological patterns of prevalence and incidence of 
disease.
Health and illness patterns
Epidemiological evidence from several countries in the study (Germany, 
the netherlands, and the uK) confirm that the health status of large 
immigrant populations is poorer than that of natives. in general, health 
problems often overlap with deprivation and poor living conditions, high-
lighting the relationship between poverty, poor health and lack of access 
to health care.
in the case of asylum seekers and undocumented migrants, this can be 
further complicated by specific issues, such as physical after-effects of war 
and torture, which may induce stress-related mental health problems, 
depression, high blood pressure, digestive problems, headaches and back 
pains. Depending on their living conditions, they may also be at higher 
risk of infectious diseases (e.g. hiV/aiDs, hepatitis, tB) and malnutrition.
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
3
roma populations are also confronted with major health challenges, 
which partly reflect poor living conditions, with many living without basic 
utilities and enduring unacceptable environmental and sanitary conditions. 
they face higher than average rates of infant mortality, malnutrition and 
communicable diseases including tB, measles and sexually transmitted 
infections. in recent years the prevalence of chronic diseases (e.g. cardio-
vascular diseases, hypertension and obesity) has also become increasingly 
important.
Do current systems provide  
adequate coverage?
most countries provide some level of coverage for immigrants who have 
acquired a residency status, normally under the same cost-sharing regula-
tions that apply to others in the population. in some cases, however, this 
happens only after they have stayed for a minimum period in the coun-
try, which can severely limit their access to health care. asylum seekers 
are entitled to at least basic treatment for acute diseases at no cost in 
most countries. however, current regulations in some countries limit 
the entitlement of asylum seekers to health care services under public 
programmes.
in many countries, undocumented immigrants have the right to the provi-
sion of emergency and medically necessary health care only. however, the 
decision of what constitutes a medical emergency is usually left to the 
provider. this is particularly problematic for important but non-urgent 
cases such as diabetes and childhood immunisations, which frequently 
pose a dilemma for providers if patients cannot afford to pay. Charges for 
hiV/aiDs treatments are particularly controversial with commentators 
pointing out the often debilitated state of patients from whom payment is 
then meant to be recovered.
Common access barriers
the different groups differ in their patterns of help-seeking behaviour. 
these relate to the difficulties of mobilising the resources necessary 
to access care which (in common with barriers faced by socially disad-
vantaged groups in general) include lack of easily accessible information 
about what is available and difficulties in organising the social and practi-
cal support necessary to facilitate attendance for treatment, especially 
out of opening hours or where services are distant. these are overlaid 
with specific problems related to the challenges faced by those who do 
not speak the national language. reluctance to use family and children as 
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
4
interpreters and fear or lack of confidentiality means that even if transla-
tion is available, it may not be taken up.
for documented migrants, one of the main hurdles for getting coverage 
under public programmes, and consequently access to health care is the 
often complex and time-consuming administrative process for obtaining 
documents, including work and residence permits and health insurance 
papers. similar issues also affect asylum seekers, with several countries 
having recently toughened the requirements for obtaining refugees status 
and the regulations on access to health care for both asylum seekers and 
failed asylum seekers.
Specific concerns about older migrants
past and current migration trends and the ageing of the population sug-
gest that the issue of health and social care for older people from ethnic 
minority groups will become more important. migration is a challenging 
experience for anyone, and more so for older people because of the 
losses not only of a wider family context and of friends, but also of a 
familiar physical, social and cultural environment, which may impose com-
munication barriers. in some cases, language problems and the clients’ 
cultural norms and values can pose additional access barriers for older 
people belonging to ethnic minorities.
What are the policy implications  
of these findings?
the evidence collected in the healthQuEst study suggests a number of 
potentially helpful policy strategies in improving access to health care for 
the different migrant groups and tackling the health challenges that they 
are faced with.
Improving the material conditions  
and economic security of migrants
many health problems affecting migrants, asylum seekers and illegal immi-
grants are heavily associated with poverty and deprivation. improving the 
economic and living conditions should be a central priority for securing 
better health for these groups. this might include measures that improve 
immigrants’ employment situation in addition to providing more support 
in the form of social services and accommodation.
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
5
Providing more responsive services
part of the solution to reduce barriers of access to health care for 
migrants will involve increasing the level of supply-side responsiveness. 
health care providers should strive to take into account the specific 
characteristics of the health care demand among migrants and to provide 
more responsive services. this may include increasing awareness about 
services available, providing translation/interpretation services, promoting 
culturally friendly services and combating discrimination.
Improving access to health care for older migrants  
and elderly migrant women
access to health care for these two special groups is often limited due 
to the existence of multiple barriers, which might include the lack of 
pension-years, high unemployment risk, care responsibilities for other 
family members and social isolation. these problems should be addressed 
by appropriate policy interventions, which also need to take into account 
cultural preferences, for instance those related to long-term care ar-
rangements.
at the same time, information about the overall situation of these groups 
is currently lacking. therefore, more resources should be directed at 
collecting statistics and improving the knowledge about the situation of 
older migrants in Europe.
Addressing the particular barriers faced by asylum seekers
a number of measures, some of which are currently in place in individual 
countries, could be potentially helpful in addressing the needs of asylum 
seekers and improving their situation.
first, because of their high health needs it is important to enlarge the 
health baskets made available to asylum seekers. some countries cur-
rently offer only acute treatments. however, this should be expanded to 
encompass more health care services, particularly mental health services, 
in view of the pressing health care needs of asylum seekers.
second, culturally sensitive training aimed at improving the coping skills 
of asylum seekers is required to improve health and deal with the health 
deterioration and mental health problems frequently observed after ar-
rival. this should take into account the interaction between physical and 
mental health symptoms.
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
6
third, it is necessary to consider the impact of policies of relocation 
and enforced dispersal on stigmatisation. in particular, it is important to 
provide support in the transition to new health care providers for asylum 
seekers who are relocated; this might require, for instance, that patient 
information is appropriately recorded and made available to the new 
provider.
finally, country reports suggest that the information on morbidity and 
mortality risks of asylum seekers is meagre. Considering the very specific 
and pressing health needs of this group, more research is required in this 
area.
Targeting reception centres
it is particularly important to safeguard the special needs of asylum 
seekers in reception centres. some countries provide good examples of 
coverage regulations that can promote greater integration. for instance, 
asylum seekers in poland are covered for indirect costs of treatment and 
in spain they receive information on how to access the health system.
another example of good practice in this area can be found in the neth-
erlands. the central agency responsible for the accommodation of asylum 
seekers also contracts preventive health services for asylum seekers in 
each reception centre.  asylum seekers are always seen first by a practice 
nurse, who acts as a gatekeeper and decides whether access to main-
stream health care is necessary. practice nurses receive special training to 
deal with the special needs of the asylum seekers.
Reducing hurdles in obtaining documents
in some cases, significant improvements in access to health care could 
be achieved through the reduction of bureaucratic hurdles in obtain-
ing documents. in particular, hurdles for obtaining residence and work 
permits, identification documents and health insurance papers should be 
reduced. in the case of roma, the process for obtaining birth certificates 
and identification documents should be facilitated and the costs reduced. 
proper systems should be put in place to provide information and to as-
sist migrants on how to obtain the necessary documents.
Stanciole / Huber • aCCEss to hEalth CarE for miGrants
poliCy BriEf may 2009
7
Conclusions
Epidemiological evidence from several countries indicates that migrants, 
asylum seekers and illegal immigrants are relatively more affected by cer-
tain health problems. they face multiple barriers to access to health care, 
which can compound and reinforce each other, and are often exposed to 
greater risk of poverty and social exclusion.
the analysis of the main access barriers suggests policy measures of 
relatively low cost that could contribute to improve the situation. a very 
significant access barrier facing migrants and ethnic minorities refers to 
difficulties in obtaining documents, such as residence and work permits 
and health insurance papers. for many roma individuals, the costs for 
issuing birth certificates are considered high and the lack of identification 
documents has been shown to affect infant vaccination and prevention 
activities. in most countries migrants received no assistance for obtaining 
documents.
information on the socio-economic situation, health and illness patterns 
and barriers of access to health care available for all three groups is still 
very limited. the study has illustrated that there often is a lack of re-
search evidence to support policy. in particular, more specific research is 
necessary to accurately determine the demographic and epidemiological 
profiles in different countries in order to guide policy interventions.
Where to find more information
M. Huber, A. Stanciole, K.Wahlbeck, N. Tamsma, F. Torres, E. Jelfs, 
J. Bremner (2008) Quality in and Equality of access to health Care  
services. Brussels: European Commission
for more information, and the full report, see: 
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare 
the views expressed in this policy Brief are those of the authors and do not necessarily 
reflect the views of the World health organization, the European Commission or of their 
member states. neither the World health organization, nor the European Commission 
nor any person acting on their behalf may be held responsible for the use that may be 
made of the information contained in this publication.
poliCy BriEf may 2009
EuropEan CEntrE • EuropäisChEs ZEntrum • CEntrE EuropÉEn
for soCial WElfarE poliCy anD rEsEarCh für WohlfahrtspolitiK unD soZialforsChunG DE rEChErChE En politiQuE soCial
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Access to health care for migrants, ethnic minorities, and asylum seekers in Europe

Wahlbeck, Kristian

EuropEan CEntrE • EuropäisChEs ZEntrum • CEntrE EuropÉEn
poliCy BriEf april 2009
Access to Health Care for People 
with Mental Disorders in Europe
By Kristian Wahlbeck, Manfred Huber 
poverty and social exclusion continue to be serious challenges across the 
European union and for health systems in member states. people with 
mental disorders are at high risk of poverty, stigmatisation and social 
exclusion. they  are also more likely to face physical health problems and 
to die prematurely. there is evidence that they do not receive the general 
health care that best responds to their needs. improved access to general 
health care is therefore essential to minimising disadvantage for people 
with mental disorders. this policy Brief outlines hurdles of access to 
health care for people with mental disorders and discusses policy implica-
tions.
the results presented are part of a research project on “Quality in and 
Equality of access to healthcare services” (healthQuEst) that was fi-
nanced by the European Commission, DG Employment, social affairs and 
Equal opportunities. this study analysed barriers of access to mainstream 
healthcare services for people at risk of social exclusion as well as poli-
cies in member states to mitigate these barriers. the study had a focus 
on three groups at risk: people with mental disorders, migrants and older 
people with functional limitations. Eight countries were studied in depth: 
finland, Germany, Greece, the netherlands, poland, romania, spain and 
the united Kingdom. a special case study analysed the situation of people 
with mental health problems in depth. this is based on a literature review 
and input from eight country reports.   
Kristian Wahlbeck is research 
professor at the thl-national institute 
for health and Welfare, finland,
www.stakes.fi/mentalhealth
Manfred Huber is Director health and 
Care at the European Centre for social 
Welfare policy and research, Vienna
http://www.euro.centre.org/huber
poliCy BriEf april 2009
2 Wahlbeck, Huber • aCCEss to hEalth CarE
What is the magnitude of the problem? 
mental disorders are common and relate to a continuum of symptoms, 
extending from transient adjustment disorders to the most severe and 
disabling mental disorders. more than one in four Europeans is affected 
by at least one mental disorder during any given year, and about 6 % of 
Europeans have been estimated to need mental health care. moreover, 
there is evidence that early retirement and sick leave due to mental 
health disorders are increasing in the European union. 
mental disorders are often gender-specific and more common among 
elderly people, among people living alone, among unemployed, among 
people with low education, and people with low socio-economic status. 
important mental health differences in e.g. suicide and alcohol consump-
tion rates and in access to care exist across the Eu, especially between 
nordic/Central and southern countries and between Western and East-
ern countries.
Mental disorders are associated with poor 
physical health. 
physical and mental morbidity often go hand in hand. those with mental 
health problems have higher than average rates of physical illness includ-
ing cardiovascular disease, diabetes, respiratory disease, sexually transmit-
ted diseases, and poor oral health. Certain groups with multiple social 
disadvantages are at higher risk of mental health disorders and may face 
even greater barriers of access to health care than others. first, mental 
health problems are associated with socio-economic status: people who 
are poor, unemployed or have a low standard of living have more mental 
disorders. second, poor mental health is common in many vulnerable 
groups with low access to health care, such as migrant groups and home-
less people.
People with mental disorders are at risk 
to die earlier
there is consistent and considerable excess mortality among people with 
mental health disorders in Europe, even after accounting for deaths from 
suicide. the mortality due to diseases is two to three times higher among 
people with severe mental disorders than among the general population. 
the mortality is partly due to avoidable deaths caused by physical disor-
poliCy BriEf april 2009
3 Wahlbeck, Huber • aCCEss to hEalth CarE
ders, such as cardiovascular, respiratory and metabolic disorders. unam-
biguous data also shows a uniform excess mortality from avoidable natural 
causes in institutional settings. these avoidable deaths point to deficiencies 
in access to or quality of health care as well as unhealthy lifestyles among 
people with mental disorders.
Access to mental healthcare still needs 
improvement in many cases
access to care for mental disorders has been consistently reported to be 
low, being provided for an average of 26% of individuals in Europe with a 
mental disorder. not everyone with a mental disorder needs treatment, 
but still nearly half of Europeans in need of mental health care reported no 
formal health care use. for example, despite widespread need, only 3% of 
Europeans receive psychotherapy.
Policy developments
the Commission Green paper “improving the mental health of the popula-
tion: towards a strategy on mental health for the European union” (2005) 
highlighted the close interrelation between mental and physical health. 
however, there is still a lack of awareness on the issue of access to general 
health care for people with mental disorders. 
the importance of promoting mental health and well-being in the Eu was 
recently acknowledged also by the European pact for mental health and 
Wellbeing, adopted in 2008. the pact focuses, among others, on the need 
for preventing depression and suicides; youth and education; workplace 
settings; older people; and stigma and social exclusion.
What are the most common access barriers 
for people with mental disorders?
stigma is a widespread and well-documented major access barrier for 
people with mental health disorders. mental disorders are connected to 
stigma and there are many misperceptions regarding mental disorders. 
stigma is found in the general population, but perhaps more importantly in 
poliCy BriEf april 2009
4 Wahlbeck, Huber • aCCEss to hEalth CarE
the health service administrative staff, the health care staff, and also the 
mental health care staff.
stigma associated with mental health disorders has many consequences. 
perhaps most importantly, health care for people with mental health 
disorders tends to be underfunded all over Europe, which is partly due to 
stigma and discriminatory attitudes.
Evidence also suggests that stigma lessens the responsiveness of the 
health services, and that the fear of being labelled as having a mental 
health problem may cause individuals to delay or avoid seeking treatment 
altogether. if people with mental disorders are not treated respectfully 
and with dignity in general health care services, the perceived health 
benefit of seeking care may weigh less than the perceived harm in the 
form of shame and lowered self-esteem. anticipated discrimination may 
then lead to self-stigmatisation, which in combination with previous bad 
experiences of health care (e.g. compulsory admissions or humiliating 
treatment) can raise the threshold to seek professional help. 
in addition, mental disorder may also lead to limited capacity to organise 
and regularly pay for social health insurance in cases where this is an indi-
vidual responsibility.  in addition, cost-sharing requirements can negatively 
impact on the up-take of needed services, in particular for poor people. 
this is of particular concern in countries with a relatively high formal 
co-payment, widespread use of private health services or common use of 
informal “under the table” payment.
in general, there often seems to be poor awareness among health profes-
sions of the need for special measures in response to the health needs of 
people with mental disorders and their health outcome tends to be poor, 
despite usage of health services. poor health literacy skills among some 
people with mental health disorders may create additional challenges for 
health systems. a certain degree of health literacy is usually important 
to navigate the health system, and health literacy problems may exclude 
people from health care benefits or have an impact on help-seeking 
behaviour.
poliCy BriEf april 2009
5 Wahlbeck, Huber • aCCEss to hEalth CarE
What are the policy implications 
of these findings?
if mental health care is organised separately from other health care, diffi-
culties to provide adequate services to people with both mental and phys-
ical health care needs frequently occur. however, evidence indicates that a 
general health policy supporting integration of health and social services 
and mainstreaming of mental health services can offer better access to 
general health care. for example, this has been reported for Germany and 
Greece. 
moreover, the healthQuEst study has also shown that emerging best 
practice examples of responsiveness of services exist. there are examples 
of special integrated services that have been created to care for the com-
plex needs of people with compound mental, physical and social prob-
lems. for example, health policies in the united Kingdom strive towards 
integrated services with good links between primary care and secondary 
mental health services. health mediators for people with mental health 
problems, linking them to mainstream health services, is a promising ap-
proach as well. 
the healthQuEst study has identified the following health and social 
policy strategies and recommendations to address the high rates of co-
morbidity and excess mortality of people with mental disorders. 
Raising awareness is central
there is still a significant lack of awareness of the health care access prob-
lems for people with mental disorders. policy should therefore acknowl-
edge the specific needs of those with mental disorders and centrally tar-
get the needs of these groups in national health inequalities programmes, 
incentivising providers and performance managing to ensure targets are 
met. specific treatment guidelines need to be developed where needed. 
awareness of the problem needs to be supported by an improved evi-
dence base. sensitisation and capacity building programmes for health care 
staff are needed to better recognise the health care needs of people with 
mental disorders. awareness raising is best achieved in close collaboration 
with users’ groups, building on the experiences of users.
poliCy BriEf april 2009
6 Wahlbeck, Huber • aCCEss to hEalth CarE
More needs to be done to reduce stigma 
and discrimination 
Discrimination against people with mental health disorders within the 
health services cannot be tolerated. it is important that referral and 
health record systems are designed so that discrimination can be avoided. 
people with mental disorders should be empowered by involving users’ 
representatives in health care decision-making. regular monitoring of dif-
ferences in waiting times between patients with mental health disorders 
and other patients should be carried out to highlight any discrimination. 
anti-discrimination legislation should be enforced to ensure equal access 
to health care.
Targeted health promotion action is needed
targeted health promotion action is needed for this highly vulnerable 
group. Current evidence indicates that health promotion among people 
with mental disorders is feasible and effective. indeed it has even been re-
ported that health gains may be larger than among people without mental 
health disorders. health promotion has a wide spectrum of effects, not 
restricted to health status only, and health promotion should be seen as a 
valuable tool for achieving social inclusion. 
Mainstreaming of mental health care is still lacking behind
organisation of services is key to the success of meeting the needs of 
people with mental disorders, with integration, co-ordination, communica-
tion and seamless provision across health and social care sectors being 
of vital importance. a transformation of the mental health care system 
towards multidisciplinary, coordinated and holistic approaches is needed. 
locating a primary health care team close to mental health services with 
good links between primary care staff and mental health staff is highly ef-
fective in improving the physical health of those with severe mental health 
problems.
some progress has, however, been made with special outreach services, 
for example in England, where financial incentives for Gps were intro-
duced to undertake annual health checks of people with mental disorders.
Actions to reduce inpatient mortality have become urgent
to reduce mortality rates at psychiatric institutions, measures to improve 
capacity of staff to recognise and treat physical disorders are needed. 
however, above all a radical change in attitudes of staff of institutions is 
poliCy BriEf april 2009
7 Wahlbeck, Huber • aCCEss to hEalth CarE
needed. Current evidence on the effectiveness of health promotion ac-
tions among people with mental disorders needs to be disseminated, and 
efforts should be made to bridge the gap between mental health care 
and general health care by closure of mental hospitals and initiation of 
psychiatric care within general hospitals. that progress is also feasible in, 
for example, reducing post-discharge suicides has been illustrated by the 
example of finland.
Investment in research should have high priority
to succeed in the above-mentioned actions, a sound European research 
base is needed. multidisciplinary research on stigma, anti-discrimination, 
health promotion, and integrated community-based services is crucial to 
bring the field forward. Clearly, the problem of access to health care for 
people with mental health disorders is not just a problem of health serv-
ices; indeed it has wider ramifications: for attitudes within the European 
population, for defining the fundamental rights of every European; and for 
social cohesion and inclusion policies.
Conclusions
the healthQuEst study has confirmed that people with mental health 
disorders are selectively affected by many common barriers of access to 
good quality health care. among these, stigma is a major cause of access 
barriers for people with mental disorders. Besides, targeted actions to 
improve access to health care for this group are mostly lacking. this is 
also the case for targeted health promotion actions. 
on the positive side, the healthQuEst study has provided a number of 
illustrations for how general health policy measures can improve access. 
among the more specific measures that appear promising are integrated 
care and psychiatric reform that has at the same time improved access to 
mainstream health care. But there is also clear evidence that more needs 
to be done in many cases, such as improving access to general health 
care within psychiatric institutions. in general, research in the question 
of access problems to mainstream health care for people with mental 
disorders is still in its infancy and this calls for further investment in the 
evidence for policy making. 
poliCy BriEf april 2009
8 Wahlbeck, Huber • aCCEss to hEalth CarE
Where to find more information
Huber M, A. Stanciole, K.Wahlbeck, N. Tamsma, F.Torres, E. Jelfs, 
J.Bremner (2008): Quality in and equality of access to healthcare 
services, Brussels: European Commission
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare 
Wahlbeck, K., K. Manderbacka, L. Vuorenkoski, H. Kuusio, M.-L. 
Luoma, E. Widström (2008): Quality and equality of access to health-
care services: healthQuEst country report for finland, helsinki: stakes 
(now: thl)
http://www.stakes.fi/verkkojulkaisut/raportit/r1-2008-VErKKo.pdf
European Commission (2005) Green paper: improving the mental health 
of the population: towards a strategy on mental health for the European 
union, Brussels.
http://ec.europa.eu/health/ph_determinants/life_style/mental/green_pa-
per/mental_gp_en.pdf
European Commission (2008) European pact for mental health and 
Well-being, Brussels.
http://ec.europa.eu/health/ph_determinants/life_style/mental/docs/pact_
en.pdf
for more information, and the full report, see:
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare
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poliCy BriEf april 2009
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Access to health care for people with mental disorders in Europe

Lazareva, Olga

Health effects of occupational change

Wilhelmsson, Fredrik

CASE Network Studies and Analyses
No. 383 Effects of the EU-Enlargement on income convergence in the eastern border regions

Bo\u21ban, Igor

Gurin, Corneliu

Cristal, Oleg

Prohni\u21bchi, Valeriu

Oprunenco, Alex

Popa, Ana

Lupu\u219or, Adrian

Vasilescu, Victoria

Euromonitor, no.15

Gamanjii, Alexandru

European Union \u2013 Republic of Moldova Action Plan as a Capacity Test for the Moldovan Government: Screening the Implementatino of the Plan's Economic Provisions

LOCAL ELECTIONS MORE IMPORTANT THAN 
PRESIDENTIAL ELECTIONS FOR ALBANIANS 
 
 
 
The International Institute for Middle-East and Balkan Studies (IFIMES) in Ljubljana, Slovenia, 
has prepared an analysis of the current political situation in Macedonia in the light of presidential 
and local elections which will be held on 22 March 2009. The most relevant and interesting sections 
from the comprehensive analysis entitled "Local elections more important than presidential 
elections for Albanians" are given below. 
 
MACEDONIA: 
In Macedonia the fifth local and fourth presidential elections will be held on 22 March 
2009 since the country proclaimed independence on 8 September 1991. In total 1,792,082 
voters will have the right to vote at the elections. A total of seven candidates will run in 
presidential election, four of them Macedonians, two Albanians and one Albanian 
woman-candidate. At the local elections, about 370 candidates will fun for 85 mayor 
positions and about 11,000 candidates will run for some 1,200 functions in municipal 
assemblies. 
Notably, almost 1,800,000 voters have been registered for the forthcoming elections 
while the total number of the population in Macedonia is just under 2,100,000. Thus the 
number of voters is about 20% smaller than the total population of the country. That 
points to the question of whether it is possible that only 20% of the population in 
Macedonia is younger than 18 or is this a typical example of an attempt to manipulate 
citizens' votes by registering as voters also those who are deceased and those who have 
not lived in Macedonia for a longer period of time and who have temporarily or 
permanently moved abroad. 
At the presidential election seven candidates will run for the highest position in the state: 
WHO WILL BE THE NEW FIRST MAN IN MACEDONIA? 
• Gorge Ivanov – the candidate of the currently ruling VMRO-DPMNE supported by 
ten small coalition parties, 
• Ljubomir Frčkoski – the candidate of the opposition SDSM (Social Democratic 
Union of Macedonia) and NSDP (New Social Democratic Party – Tito Petkovski), 
• Nano Ružin – Liberal Democratic Party's candidate, 
• Ljube Boškoski – independent candidate), 
• Agron Buxhaku – DUI (Democratic Union for Integration), 
• Imer Selmani – New Democracy, 
• Mirushe Hoxha – DPA (Democratic Party of Albanians). 
According to recent surveys, VMRO-DPMNE's candidate Gorge Ivanov is the most likely 
to make it to the second round of the election where the fourth president of the Republic 
of Macedonia will be elected. In the public opinion polls he received between 25 and 30 % 
support. Since the beginning of the campaign Ivanov has had many problems with a clear 
presentation of his position regarding the president's authorities and he appeared to be 
rather confused in his public speeches. As presidential candidate of the ruling party 
Ivanov counts on its public rating, although for the first time during the past three years 
since VMRO-DPMNE is in power it has experienced a fall in its rating by as much as 10%. 
Gorge Ivanov is a former social democrat (member of SDSM led by Branko Crvenkovski). 
His resignation from Crvenkovski's party in 2005 was not occasioned by ideological 
disagreements but because in 2005 his brother Blažo Ivanov, police commander at 
Gevgelija border crossing, was arrested for participating in criminal activities (smuggling 
migrants across Macedonian border). That was the only reason why Gorge Ivanov joined 
the neo-conservative leader of VMRO-DPMNE Nikola Gruevski. 
 
Another candidate with realistic chances for entering the second round of presidential 
election is Ljubomir Frčkoski from the opposition SDSM. Other candidates such as Imer 
Selmani have no chances to enter the second round. Namely, the reality is that 
Macedonians are still not ready to support an Albanian candidate as president of their 
state. Undoubtedly, presidential candidate Selmani will win most votes among the 
Albanian constituency where he will defeat his opponents Agron Buxhaku from the ruling 
DUI and the only woman-candidate Mirushe Hoxha from the opposition DPA party. 
However, in his election campaign Imer Selmani is excessively trying to flatter the 
Macedonian constituency. 
Liberal Democratic Party's candidate and former Macedonian ambassador to NATO Nano 
Ružin represents a pleasant refreshment in the presidential election. The former 
Macedonian Minister of the Interior and acquitted ICTY suspect Ljube Boškoski may win 
the votes of old VMRO-DPMNE members who regard Ivanov as a deserter from another 
party rather than their presidential candidate. 
For Albanian political parties presidential elections are not as interesting as local 
elections which will be in the focus of their interest. Their main fight at the local 
elections will be fought in Tetovo, Gostivar and in the Skopje municipality of Čair where 
the incumbent DUI mayor Izet Mexhiti will compete with the New Democracy's candidate 
Fatmir Etemi, former DPA deputy. 
DUI TO WIN LOCAL ELECTIONS AGAIN 
According to analysts' estimates DUI will win local elections again, like it did four years 
ago. DPA has weakened, while New Democracy is still not profiled, well-organised and 
strong enough to compete with DUI structures. 
In the Albanian political block the forthcoming local elections will be marked by the 
independent candidacy of a very popular former mayor of Gostivar Rufi Osmani, who will 
try to return to this position after 12 years since his term of office was interrupted by 
police intervention when he was arrested for raising Albanian flag in front of the Gostivar 
city hall. Other candidates for the mayor of Gostivar are the incumbent mayor Nevzat 
Bejta (DUI) and less known DPA's candidate Gazmend Aliji. 
According to the IFIMES International Institute's estimates, Rufi Osmani represents a 
strong opponent to the incumbent mayor Bajt. When the DUI-prone electoral commission 
in Gostivar refused to approve Osmani's candidacy on grounds that he spent more than 
six months in prison, the decision provoked strong negative reactions among the citizens 
of Gostivar and some other cities. Grave concerns were expressed also by the 
representatives of international community in Macedonia who condemned the decision as 
an attack against democracy and the voting right. The competent court in Skopje nullified 
the decision on the legislative basis and enabled Osmani to join the election race. 
Tetovo is the centre of political life for Macedonian Albanians. At the forthcoming local 
elections a tense fight will be fought between the incumbent mayor of Tetovo Hazbi Lika 
(DUI) and DPA's candidate Sadi Bexheti, Chancellor of the University of Tetovo.  
 
During the past four years of Hazbi Lika's term of office Tetovo has undergone some 
positive changes. This city with once non-functional infrastructure is gradually 
developing some better-regulated parts, although that is still far from the set goals. There 
is still much to be done, but the problem lies in insufficient financial resources and lack 
of interest from foreign sponsors to invest in the city. The greatest problem of this city 
under the Šara mountain is the lack of drinking water during summer periods. 
TETOVO MAYOR HAZBI LIKA - THE FAVOURITE 
DPA's candidate Sadi Bexheti comes from the Tetovo University which is known for grave 
financial malversations during the term of office of its previous Chancellor Nexhbedin 
Behadini. Under Bexheti's leadership the University opened its door to professors and 
students of Macedonian nationality as well as foreigners, which was a great step forward 
in improving the academic life and working conditions at the University. However, that 
will not be enough to persuade the citizens of Tetovo to elect Bexheti as their mayor. 
Bearing in mind the present situation in the cities of Tetovo and Gostivar, including Rufi 
Osmani's candidacy which may threaten the position of DUI in Gostivar, analysts 
DUI AND DPA TOGETHER AGAINST RUFI OSMANI? 
estimate and find it possible that a silent agreement on concealed co-operation may be 
concluded between DPA and DUI in Gostivar where in the second round, which will most 
probably be fought between Nevzat Bejta (DUI) and independent candidate Rufi Osmani, 
DPA would support DUI's candidate while DUI would leave Tetovo to DPA as 
compensation. However, the question is whether DUI would be ready to sacrifice Tetovo's 
mayor Hazbi Lika on behalf of Gostivar's Mayor and DUI Vice-President Nevzat Bejta? 
Ljubljana, 6 March 2009 
 
 
 


Local elections more important than presidential elections for Albanians