Healthcare reform is sweeping the globe: America, Asia, Africa, Europe. This is good in principle since the number of neglected health needs and pandemics demands urgent change. But while the US and China (once an enthusiastic convert to privatization) are now trying to limit market practice in healthcare and establish wider coverage, the rest of the world is reducing state input and mutual health insurance schemes. Just as the US market-driven model has proven ineffective, other countries are turning to it.
The US is the world’s second-highest spender on healthcare (15.3 per cent of GDP in 2007), but ranks 30th in “healthy life expectancy” (how many years a person lives in good health), at 69 years.
The concept of social welfare appeared in the 19th century with the industrial revolution and the concentration of workers in urban centers. Mutual benefit societies were created to provide health insurance, and these were then extended into social security systems (the first set up by the German chancellor Otto von Bismarck in 1883). Politicians and business leaders wanted to ensure a healthy workforce that could withstand tough working conditions, but they were also pressured by social campaigners to improve standards of living.
After the second world war, systems emerged to encourage social cohesion and prevent class conflict. On July 5, 1945 the French Consultative Assembly ruled that the purpose of social security was to relieve workers’ anxiety over their future; the difference between classes was that the wealthy had a secure future, while workers lived under the constant threat of destitution. The “right to health for all” was recognised globally with the establishment of the World Health Organization (WHO) in 1948. It is far from achieving its goal, despite the UN’s 194 members renewing their commitments in 1978.
There is still huge inequality between nations. And despite advances in medicine, 31 countries (including South Africa, Botswana, Gabon, Russia and Ukraine) have had healthy life expectancy fall between 1990 and 2006. Africa is at the bottom: healthy life expectancy is 29 in Sierra Leone, 33 in Angola, and 37 in the Democratic Republic of Congo. In Japan it is 75. Some countries have internal conflicts that account for many deaths. But many also die from infectious diseases such as malaria, tuberculosis and Aids, which thrive on poverty and a lack of sanitation. These diseases, which are more prevalent in the South (Africa, East Timor, Laos, Bangladesh, Burma), are reduced as economies develop, the “epidemiological transition”.
Wealthy or emerging countries suffer from chronic diseases of the heart and lung, diabetes and cancer. These also afflict developing countries with a growing middle class, such as Ghana, Gabon, South Africa and Pakistan. Infections that have disappeared in the developed world, like tuberculosis, are making a reappearance there.
The wealth of a country and its health expenditure remain the main determining factors in life expectancy. The 31 member countries of the Organization for Economic Cooperation and Development (OECD), which have the highest life expectancy, account for 90 per cent of global spending on health, although they are only 20 per cent of the global population. Sub-Saharan Africa has 12 per cent of the world’s population but only 1 per cent of health spending. Sierra Leone spends 3.5 per cent of its GDP on health and Congo 2.1 per cent ; in Japan it is over 8 per cent , and 11 per cent in France. Even if the US example proves that money is not always well spent, expenditure must reach a minimum level. As the economist Amartya Sen put it: “We should be able to acknowledge that injustices, such as lack of medical care or medicine, can be eliminated, without waiting for everyone to agree on what a perfect society should look like. Just as Condorcet, in his day, addressed the principle of ending slavery, we must address this question of injustice”.
Three world systems
If money is at the heart of the war against disease, a trained army of medical staff with medicine, equipment and education, are also necessary. Access to care also depends on the type of healthcare system and how it is funded. There are three main types: the post-colonial; the former communist; and the system of developed countries, which is often adapted by emerging countries.
The 79 former colonies of Africa, the Caribbean and the Pacific inherited a vertical system: local dispensaries and mobile units providing primary care, general hospitals providing secondary care, plus specialist clinics and university hospitals. This system was kept in a precarious balance until the mid-1980s through government and international funding.
But in its 2008 report, the WHO points out that the structural adjustment policies of the IMF and the World Bank have undermined public health systems around the world, widening the gap between private and public care. “Unregulated, commercialized health systems are highly inefficient and costly. They exacerbate inequality, and they provide poor quality, and at times dangerous care that is bad for health.” It gives the example of the Democratic Republic of Congo, where “safari surgery refers to a common practice of health workers moonlighting by performing appendectomies or other surgical interventions at the patients’ homes, often for crippling fees”. Where there is poverty, you will always find corruption.
While foreign aid is indispensable, it comes from so many different sources (bilateral aid, UN organizations, large foundations) that there is often no coherence in how it is spent. Reform, when it takes place, tends to focus on the construction or renovation of primary healthcare centers and hospitals.
Several European countries have been trying to get rid of their surplus stocks of H1N1 flu vaccine since the beginning of 2010. According to the WHO, 95 poor nations need it. But because of an inability to store it safely and the lack of human resources to administer it correctly, only two countries had received it by January (6). Even though the WHO’s predictions about the swine flu epidemic may be questioned – they may have had more to do with pressure from pharmaceutical companies than medical reality – the example is still revealing.
Creating a network to deliver healthcare is necessary but not sufficient: “Health-related facilities and services may be available and accessible but be insensitive to culture,” write researchers in The Lancet. They describe a Peruvian project that studied indigenous communities with very high maternal mortality. They found reluctance to use the health facilities offered by the state, partly because these did not take account of local cultural conceptions of health and sickness. Culturally sensitive facilities were introduced, so that women could give birth squatting and gripping a rope, as they were accustomed to, and more people used the facilities. In Africa and India colonial systems have imported western methods, ignoring local practice, but China, under Chairman Mao, did the opposite, combining traditional medicine with western treatment to reduce infectious diseases.
The second system is the one in the former Soviet bloc, based on large hospitals, or sanatoriums, with almost no local healthcare. This bureaucratic system was already ineffective by the end of the Soviet regime, and collapsed when state funding was withdrawn under the new neo-liberal regime. Life became harder, and the loss of a collective way of life led to alcoholism and violence, just as funding for health was being reduced (free medicine stopped, hospitals privatized, old equipment not replaced). Healthy life expectancy in Russia fell from 69 in 1990 to 66 in 2006, from 70 to 67 in Ukraine and from 65 to 64 in Kazakhstan. Inadequate monitoring of treatments led to the arrival of mutant strains of illnesses, such as multi-resistant tuberculosis, rife in Russia’s overcrowded prisons. The focus there now is on creating a network of primary care and consolidating a social security system, but the results so far are disappointing.
There is the system in rich countries, where everyone has access to local doctors, specialists and general hospitals, as well as state of the art medical facilities. There are countries where free healthcare is guaranteed and funded by the state (Sweden, the UK), where public or private care is covered by health insurance (Germany, France, Japan), or where healthcare is mainly private (the US and eastern Europe).
The principle that everyone should pay according to their means, and receive care according to their needs, won acceptance in Europe after the second world war. It was a generous idea, but we have strayed from it.
It may be surprising to learn that the amount spent on healthcare in the developed world does not correlate with state of health and life expectancy. There is more to longevity than money: lifestyle, working conditions and nutrition are also important. Japan’s health budget is 8.1 per cent of its GDP, and it has a healthy life expectancy of 75. France spends 11.4 per cent and life expectancy is 72, in Sweden the figures are 9.1 per cent and 73, in the UK 8.4 per cent and 71.
The relationship between patient and doctor, control (or lack of control) over the price of medicine, and the emphasis given to prevention, all have a direct impact on expenditure. The US has the largest pharmaceutical bill in the world (twice the OECD average), coming above Canada, Greece and France. China, another over-prescriber, is the world’s second-largest market for pharmaceuticals. Underpaid doctors increase their wages by selling the medicines they prescribe.
In Sweden, Norway and the UK, basic healthcare is free, with the state or local councils paying for staff and equipment. Inevitably, when public finances run out, waiting lists grow. That was a consequence of Margaret Thatcher’s reign: in 2001, 22 per cent of patients in the UK had to wait more than three months for a hospital appointment; 27 per cent had to wait six months for an operation.
The Labor Party increased investment in healthcare, funding more doctors and nurses and raising pay. The results are evident, although the standard of care remains below that of Sweden and Norway. So contrary to the arguments of free market junkies about the failure of public health systems, it is the withdrawal of the state that leads to disaster. The overall bill for health care is often lower when the state covers most of it and the proportion paid privately (by individuals or insurance companies) is small, as in Japan (where it is 17.7 per cent of spending) and Sweden (16.1 per cent ), compared with almost half in the US.
We only need to look at the most neo-liberal system of all, that of the US, so famous for its failures that there seems to be no system. If you are working, your employer jointly finances your health insurance with a private company. Two-thirds of employees are covered in this way. The self-employed, part-time workers or those working for small businesses must take out much more expensive individual policies, and they are often turned down. If you do not work for a big company, you have no rights. The official unemployment rate keeps rising: it is now approaching 10 per cent . Pensioners over 65 have access to Medicare, which provides minimal cover, and the poorest get Medicaid. Those who do not fit into either category get nothing. In a country held up as a model of success, one sixth of the population has no health coverage.
Even within countries with a developed healthcare system, inequalities remain. The health economist Richard Wilkinson says that in the US, white women from wealthy areas have a life expectancy of 86, compared to 70 for black women from poor neighbourhoods.
The WHO estimates that 886,202 deaths could have been avoided between 1991 and 2000 if the death rate among white and black Americans were made equal (10). It claims that in Glasgow, Scotland, where life expectancy in some poor areas is 54 – less than in India. This is not simply down to healthcare or finance. As the WHO points out, disadvantaged populations accumulate handicaps: inferior education, unemployment, bad working conditions, difficult family life. These socio-psychological factors, to which Wilkinson adds self-esteem and anxiety over the future, play an important role: being poor in a rich country is bad for you.
WHO experts, used to using diplomatic language, do not mince their words: this disparity is not a natural phenomenon. It is the result of policies that put the interests of a powerful and rich minority above those of the underprivileged majority. Even that most neo-liberal of institutions, the OECD, which has championed deregulation, recognizes that privatization can make things worse: “Only a few zealots now adhere absolutely to the belief that competition offers an unalloyed solution to society’s more intractable problems. Society may need to implement measures (such as market regulation) to correct market failures, in the extreme perhaps abandoning market exchange for some other method of allocating society’s resources”.
But the health insurance lobbies in the US have enough political clout with the Democrats to keep their privileges. In France privatization in hospitals is accelerating – 4,000 health service job cuts have been announced in the Paris region between now and 2012. Does healthy life expectancy have to fall as low as Bangladesh before we realize the dangers? The healthy life expectancy of French workers, at 60, is seven years lower than for professionals. What will it be in a few decades if we continue on this path?
Most French people feel they keep paying more (in social security contributions and insurance) for a service that keeps getting worse. “Quite apart from the effect this has on the health of the poorest in society,” says the political researcher Bruno Palier, “this gap threatens to raise doubts about the efficacy and legitimacy of our healthcare system”. Perhaps that is the hidden agenda?
This article appears in the February edition of the excellent monthly, Le Monde Diplomatique,whose English language edition can be found at mondediplo.com. This full text appears by agreement with Le Monde Diplomatique.