Useful documents


Demography of paediatric renal care in Europe: organization and delivery


Jochen H. H. Ehrich1, Anita Amina El Gendi1, Alfred Drukker2, Jan Janda3, Constantinos Stefanidis4, Kate Verrier-Jones5, Jacqueline Collier6 and Manuel Katz7 1University Children’s Hospital, Medical School, Hannover, Germany, 2Division of Paediatric Nephrology, Shaare Zedek Medical Center, c/o POB 8504, Jerusalem, Israel, 3First Department of Paediatrics, Second Medical School, Charles University, Motol, Prague, Czech Republic, 4A & P Kyriakou Children’s Hospital, Athens, Greece, 5KRUF Children’s Kidney Centre for Wales, Cardiff, Wales, UK, 6Division of Child Health, Faculty of Medicine, University of Nottingham, UK and 7Maccabi Health Care Services, Primary Paediatric Care Unit, Soroka Medical Center, Ben Gurion University, Beer-Sheva, Israel



Background: Members of the European Society of Paediatric Nephrology (ESPN) initiated a study of the demography and policy of paediatric renal care among European countries at the end of the 20th century. 


Methods: A questionnaire was mailed to the presidents of each of 43 national renal paediatric societies or working groups in Europe. Data on each country’s population, income as reflected by its gross national product and infant mortality rate, were obtained from the United Nations. The paediatric health care systems were previously divided into three types: general practitioner care system, paediatric care system and combined care system (CCS).


Results: In 1998, 842 specialized paediatric nephrologists worked in hospitals in 42 European countries. The median number of paediatric nephrologists per million child population (pmcp) was 4.9 (range 0–15). The median number of children served per paediatric nephrologist was significantly higher in countries with the general practitioner care system than in those with the paediatric or combined care system (CCS), namely 370 747 vs 169 456 and 191 788, respectively. In addition to specially trained paediatric nephrologists, there were 1087 paediatricians with a part-time interest/activity in paediatric nephrology in hospitals in 34 European countries. Eastern European countries had significantly more general paediatricians with part-time nephrological activities than countries belonging to the European Union (EU), 16.7 vs 6.6 pmcp. In 1998, 92% of 42 European countries offered paediatric dialysis facilities for acute renal failure and 90% for chronic renal failure and 55% offered paediatric renal transplantation (RTx). Only 30% of Eastern European countries (central omitted) offered paediatric RTx vs 87% of EU countries. The availability of paediatric RTx was associated significantly with the countries’ gross national product (r1/40.53, P<0.001). The median number of paediatric hospitals offering dialysis for childhood chronic renal failure was 1.5 pmcp (range 0–5.0) and the median number of paediatric hospitals offering paediatric RTx was 0.4 pmcp (range 0–3.5). Fewer children were on dialysis or were transplanted in Eastern European countries than in the EU.



Debate: Family-oriented and family-centered care in pediatrics

Massimo Pettoello-Mantovani*1,2, Angelo Campanozzi1, Luigi Maiuri1 and Ida Giardino3

Address: 1University of Foggia School of Medicine, Institute of Pediatrics, Foggia, Italy, 2World Health Policy Forum (WHPF), Giessen, Germany and 3University of Foggia School of Medicine, Center of Laboratory Medicine, Foggia, Italy

Email: Massimo Pettoello-Mantovani* -; Angelo Campanozzi -; Luigi Maiuri -; Ida Giardino -

* Corresponding author



Background: To humanize the management of children in hospitals has become a serious concern of civil society and one of the main goals of public and private health centers, health care providers and governments.


Discussion: The concepts of family-centered and family-oriented care are discussed with the aim to emphasize their importance in pediatrics. Notions related to family-centered care, such as cultural diversity and cultural competence, are also discussed given the importance they have gained following the recent transformations of socioeconomic, demographic and ethnic characteristics of economically advantaged Countries. Family-centered care has developed as a result of the increased awareness of the importance of meeting the psychosocial and developmental needs of children and of the role of families in promoting the health and well-being of their children. Family-oriented care aims at extending the responsibilities of the pediatrician to include screening, assessment, and referral of parents for physical, emotional, social problems or health risk behaviors that can adversely affect the health and emotional or social well-being of their child.


Summary: Family-centered and family-oriented care concepts should be incorporated into all aspects of pediatricians' professional practice, whether it is private practice or in public hospitals, to better serve the needs of ill children.


The future of primary paediatric care in Europe: reflections and Report of the EPA ⁄UNEPSA Committee

S Barak (, A Rubino2, J Grguric3, E Ghenev4, D Branski5, E Olah6, The EPA ⁄ UNEPSA Committee on Challenges and Goals of

Paediatrics in the 21st Century

1.Department of Neonatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel

2.Department of Paediatrics, Universita Federico II, Naples, Italy

3.Children’s Hospital Zagreb, Zagreb, Croatia

4.Paediatric Clinic of the Plovdiv University, Plovdiv, Bulgaria

5.Department of Paediatrics, Hadassah Medical Center, Jerusalem, Israel

6.Clinical Genetic Center, Department of Paediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary


Ambulatory paediatrics, Delivery of care, European paediatrics, Primary care, Training in primary care


Background: Changes in the scope of the field of paediatrics and the variability in primary paediatric care (PPC) and practice throughout Europe motivated the European Paediatric Association and Union of National European Paediatric Societies and Associations (EPA ⁄ UNEPSA) to establish a working group to discuss definitions of paediatric coverage in terms of age limits, find common denominators in the provision of PPC and examine the challenges and goals of 21st century paediatrics relevant to the continent. These issues were presented at the 2008 Europaediatrics in Istanbul, where a consensus declaration was drawn up and accepted by the EPA ⁄ UNEPSA Executive Committee.

Aim: To present an outline of the essential elements of the 2008 EPA ⁄ UNEPSA Executive Committee consensus declaration.

Conclusion: The definition of basic characteristics and the establishment of requirements for optimal PPC and practice are important steps in overcoming the differences among European countries and pave the way for an acceptable formulation of standardized high-quality paediatric medical care in Europe.


Demography of adolescent health care delivery and training in Europe

Oya Ercan &Mujgan Alikasifoglu & Ethem Erginoz &
Jan Janda & Pavel Kabicek & Armido Rubino &
Andreas Constantopoulos & Ozdemir Ilter &
Mehmet Vural


Background: We aimed to determine the status of and factors associated with adolescent health care delivery and training in Europe on behalf of the European Paediatric Association—UNEPSA.

Materials and methods: A questionnaire was mailed to the presidents of 48 national paediatric societies in Europe. For statistical analyses, non-parametric tests were used as appropriate.

Results: Six of the countries had a paediatric (PSPCA), 14 had a combined and nine had a general practitioner/family doctor system for the primary care of adolescents (GP/FDSA). Paediatricians served children 17 years of age or older in 15 and 17, up to 16 years of age in three and six, and up to 14 years of age in six and six countries in outpatient and inpatient settings, respectively. Fifteen and 18 of the countries had some kind of special inpatient wards and outpatient clinics for adolescents, respectively. Twentyeight of the countries had some kind of national/governmental screening or/and preventive health programmes for adolescents. In countries with a PSPCA, the gross national income (GNI) per capita was significantly lower than in those with a GP/FDSA, and the mean upper age limit of adolescents was significantly higher than in those with the other systems. In the eastern part of Europe, the mortality rate of 10–14 year olds was significantly higher than that in the western part (p=0.008). Training in adolescent medicine was offered in pre-graduate education in 14 countries in the paediatric curriculum and in the context of paediatric residency and GP/family physician residency programmes in 18 and nine countries, respectively. Adolescent medicine was reported as a recognised subspecialty in 15 countries and as a certified subspecialty of paediatrics in one country. In countries with a PSPCA, paediatric residents were more likely to be educated in adolescent medicine than paediatric residents in countries with a GP/FDSA. Conclusion The results of the present study show that there is a need for the reconstruction and standardisation of adolescent health care delivery and training in European countries. The European Paediatric Association—UNEPSA could play a key role in the implementation of the proposals suggested in this paper.


Paediatric primary care in Europe: variation between countries

Diego van Esso,1 Stefano del Torso,2 Adamos Hadjipanayis,3 Armand Biver,4 Elke Jaeger-Roman,5 Bjorn Wettergren,6 Alf Nicholson7; and the members of the Primary– Secondary Working Group (PSWG) of the European Academy of Paediatrics (EAP)



Background: Although it is known that differences in paediatric primary care (PPC) are found throughout Europe, little information exists as to where, how and who delivers this care. The aim of this study was to collect information on the current existing situation of PPC in Europe.


Methods: A survey, in the form of a questionnaire, was distributed to the primary or secondary care delegates of 31 European countries asking for information concerning their primary paediatric care system, demographic data, professionals involved in primary care and details of their training. All of them were active paediatricians with a broad knowledge on how PPC is organised in their countries.


Results: Responses were received from 29 countries. Twelve countries (41%) have a family doctor/ general practitioner (GP/FD) system, seven (24%) a paediatrician-based system and 10 (35%) a combined system. The total number of paediatricians in the 29 countries is 82 078 with 33 195 (40.4%) working in primary care. In only 15 countries (51.7%), paediatric age at the primary care level is defi ned as 0–18 years. Training in paediatrics is 5 years or more in 20 of the 29 countries. In nine countries, training is less than 5 years. The median training time of GPs/FDs in paediatrics is 4 months (IQR 3–6), with some countries having no formal paediatric training at all. The care of adolescents and involvement in school health programmes is undertaken by different health professionals (school doctors, GPs/FDs, nurses and paediatricians) depending on the country.


Conclusions: Systems and organisations of PPC in Europe are heterogeneous. The same is true for paediatric training, school healthcare involvement and adolescent care. More research is needed to study specific healthcare indicators in order to evaluate the efficacy of different systems of PPC.


How can we improve child health services?

The UK government’s Health and Social Care Bill is unlikely to deliver the improvements in children’s health services that are urgently needed. Useful lessons can be learnt from how other European countries deliver healthcare for children, say Ingrid Wolfe and colleagues


The care provided by UK children’s health services is inferior in many regards to that in comparable European countries. Although there are many examples of good practice, health services too often provide poor outcomes and are seemingly planned around the needs of organisations rather than those of children, young people, and families. Service models are often inefficient and wasteful. Budget constraints and dramatic changes in the NHS make it more important than ever that children’s healthcare is planned carefully and appropriately for their needs (box 1, see However, current plans insufficiently recognise children and young people’s special requirements and fail adequately to acknowledge important recommendations made in Ian Kennedy’s review of children’s healthcare. 1
The Marmot review emphasises the importance of investment in children to reduce health inequalities at all ages. 2 Health services in the UK need to adapt both to the changing nature of the challenges of disease in children and to the opportunities to intervene. Other European countries offer helpful insights into ways of improving children’s healthcare.



Demography of Pediatric Primary Care in Europe: 
Delivery of Care and Training

Page Demography of Pediatric Primary Care in Europe: Delivery of Care and Training has been updated.

Manuel Katz, MD*; Armido Rubino, MD‡; Jacqueline Collier, PhD§; Joel Rosen, BA; and Jochen H. H. Ehrich, MD¶



Objective: The Union of National European Pediatric Societies and Associations recognized the lack of information regarding demography of delivery of care and training for the doctors who care for children in Europe. Therefore, the Union of National European Pediatric Societies and Associations studied factors and explanations for the variation between countries regarding pediatric primary care (PPC) and community pediatrics (CP) as well as the extent of formal training provided for those who take care of children at the community level.

Methods: An explanatory letter and a questionnaire with 12 questions regarding delivery of PPC and CP and training was mailed to the president of each of 41 national pediatric societies in Europe. Statistical data about population, country’s income, and infant mortality rate (IMR) were also obtained from World Health Organization data. Statistical analysis using multivariate and linear regression was conducted to ascertain which variables were associated with IMR. Descriptive statistics regarding demography and training are also reported.

Results: In 1999, a total of 167 444 pediatricians served a population of 158 million children who were younger than 15 years and living in the 34 reporting European countries. The median number of children per pediatrician was 2094; this varied from 401 to 15 150. A pediatric system for PPC existed in 12 countries; 6 countries had a general practitioner system, and a combined system was reported from 16 countries. Pediatricians did not work at the primary care level at all in 3 countries. In 14 of 34 countries, pediatricians worked in various aspects of community medicine, such as developmental pediatrics, well-infant care, school physicians, and so forth. IMR was lower in countries with a higher income per capita. In addition, a pediatric system of primary care had a protective effect when looking at IMR as the outcome. In 75% of the countries, some form of training in pediatric care for pediatricians was reported; the corresponding data for general practitioners was 60%. Community- based teaching programs were offered to pediatricians and general practitioners in a minority of countries only.

Conclusions: At the end of the century, Europe showed a considerable variation in both delivery of PPC and training for doctors who care for children. This study identified 3 different health care delivery systems for PPC, as well as 2 types of pediatricians who work in community-based settings. Formal training in PPC or CP for both pediatricians and general practitioners varied from established curricula to no teaching at all. Economic and sociopolitical issues, professional power, and geographical and historical factors may explain the differences in pediatric care among European countries.

Pediatrics 2002;109:788 –796; primary care, ambulatory pediatrics, delivery of care, training in primary care, European pediatrics.