Health policy reform: global health versus private profit. John Lister. Libri Publishing. 2013
For a pdf of this page click Health policy reform
What makes this book book different from many others castigating the direction of current health policy is that its disappointment is as great as its anger, and that its remit takes us beyond our own parochial interests. For those of us who have lived through the last 35 years of health care reform in the UK it is not only a reminder of how hopes and ideals here have been dashed but also an instructive look at the impact of similar reforms on a more global basis.
John Lister contrasts the ambition of the 1978 WHO Alma Ata Declaration – that gave us Health for All 2000 – with the situation as we know it today. He reminds us of the language and spirit of 1978 immediately before the Thatcher/Reagan era (elected in ’79 and 80 respectively) when, supported and influenced by the World Health Organisation ‘almost every country with control over its own destiny and policies’ was working towards a health system delivering the principles outlines in the Alma Ata statement: health care as a universal human right; health care based on clinical need and not on the ability to pay; and an emphasis on primary care and the preventive measures of public health.
There was, Lister notes, ‘only one notable and massive exception’ and that was the USA which had a ‘medical -industrial complex too large and powerful for any federal administration to reform fundamentally’.
He describes the factors, in the years since, that have led to a situation where health care around the globe is instead largely medical, curative, and high tech, and offered in markets or quasi markets. These factors include: the emasculation of the WHO by reductions in funding and its influence being replaced by that of the World Bank and IMF; the near total colonisation of political and technocratic elites around the world by neoliberal ideology (Reaganomics); and the activities of players such as pharmaceutical companies, hospital chains, private financiers of public private partnerships, private equity, and private donors who have all benefitted greatly from this shift. He points out for example that private donors can now dictate the aid agenda in ways they could not when countries determined their own priorities.
Lister usefully reminds us of the reasons why markets cannot function effectively in health care and, rather more unusually, points to the particular problems for developing countries of introducing a market: that private sector providers do not want to target a market where the majority cannot afford to pay for what they need, so, instead, they focus on wealthy and emerging middle class minorities.
Lister makes an attractive case for employing ‘a Marxist framework to offer a coherent explanation’ of these events, contrasting this with the Reformist critiques which seek merely to humanise the neoliberal market system. His aim, he says, is to contrast the reality of care delivered within market systems with the rhetoric of those advocating these markets.
He does point out that ideas about ‘rolling back the nanny state’ were attractive because those on the left as well as on the right were describing public services as inefficient, remote, ineffective, and bureaucratic, although more to castigate those making such complaints than to accept their validity. And this is the greatest weakness of the book: the constant and unexamined assumption that the public sector delivers much better health and care than the private. Nowhere does he consider that the values against which he is judging services (universality and equity) may not be the only ones, that it is legitimate for people to also want care that is responsive to individual needs and preferences, and that is as effective as possible, and that we must try to find ways of accommodating all of these – or of making democratic choices between them.
The chapters describing the steady change of focus of the WHO, the increasing role of the World Bank, and IMF, are interesting and that on the role and priorities of private donors is especially illuminating. The case studies here illustrate his conclusion that ‘pet projects and varied motivations of these donors inhibit efficient, effective, coordinated assistance’. He observes, for example, that the complexity of this landscape can lead to hugely onerous demands for reports and audits from the tiny number of local people skilled enough to tackle them (over 2000 reports in a year from a country with only 10 people with the skills required).
By now we have reached Chapter 6 and it is here and in Chapter 7 that I found my irritation exceeding my interest. Distinguishing between policies with the primary aim of cutting costs (chapter 6) from those (chapter 7) whose aim was to introduce a market he packs these pages with examples of of both sorts of reform. Most readers will be familiar with many of these and, as example follows example with little argument being developed in the process, you may find the book as valuable if you omit these. Of course if being scandalised is your thing, well….enjoy!
It was good however to see Lister challenging the ubiquitous and tiresome claims that that because demand for health care is infinite and resources finite some form of rationing will be inevitable, citing German experiences to support his case. And the many quotes expostulating at the lack of any form of evidence of the benefits of market style reforms will surely be useful as well as energising.
Most of his argument here, though, turns on the fact that introducing markets does not cut costs. We can see that only too clearly, but he has specifically separated these two types of reform and markets always purported to be about responsiveness and satisfaction as much as efficiency. Fewer examples and the development of a much clearer argument – one that helped develop new thinking rather than tired old goodie/baddie, public/private stereotypes – would make these chapters much more powerful.
For example: Lister points out that market style reforms were also termed ‘New Public Management’. But NPM is ‘managerialism’ (or MANAGERIALISM as Henry Mintzberg insists it is written) applied to the public sector. It is just as pernicious within the private sector. The problem may not as much be public v private but managerialism.
And managerialism itself is part of a wider set of trends supported by the digital revolution and the audit culture, combined (certainly) with neoliberal forms of globalisation, and (crucially) with our ever present anxiety as individuals (that makes us so easily seduced, not only by the ‘stuff’ that markets excel at offering us, but by systems that promise us certainty, reduced risk and high tech quick fixes). So any argument about how to organise health care has to accommodate these wider trends, it can’t ignore them and focus only on one manifestation of them.
Assuming that market reforms were (and are) introduced by baddies in their own interests also conveniently allows us to ignore the failings of systems like the NHS that arise from powerful professionals being allowed to set their own agenda. Of course many of these professionals are well intentioned, caring, courageous and hard working, and we like and admire them. They also often feel powerless and fail to recognise their power, and unwittingly confuse their own agenda with that of their patients, so they do not perceive how often they act in their own interests. So this is tricky both to diagnose and to treat(!), but this is supposed to be a Marxist analysis so I am surprised it rated no mention at all. Lister does, after all, quote Marx, talking of – ‘the many wills that combine to make history, though not in a manner of their own making or choosing’. I suggest he needs to include in his analysis a wider range of ‘wills’.
He describes, for example, the scandalous ‘transforming community services’ programme but ascribes its dire process and outcomes to the wickedness of a marketisation ideology. A sociologist with an interest in aspects of status and professional capture would have observed that this was entirely consistent with attitudes to (lower status) community services within the NHS for decades – they have been consistently raided to support higher tech acute care.
Fortunately in Chapter 8 Lister comes back into his own. Referring to the ‘2002 World Assembly on Ageing observation that the dramatic growth in numbers of older people around the world was a “triumph and a challenge” he notes that ‘the challenge is that the economic and political framework of a neoliberal global economy is not welcoming to this expanded population’. He is surely right when he says that it is the dominance of an economic perspective at all policy levels that leads to approaches to policy that start ‘from the wrong questions and almost inevitably wind up advocating the wrong answers’.
The sections on mental health and disability are equally frightening. He points out the almost total lack of interest from World Bank, USAId and Gates Foundation in mental health and points out that the prevailing disease specific and donor funded programmes are much less effective at meeting the needs of disabled people in poorer countries that public health care and community based treatment and rehabilitation would be.
In Chapter 9 ‘It doesn’t have to be like this’ Lister returns to his disappointment. Referring back to the 1978 Alma Ata Assembly he contrasts, movingly, the vision and the reality.
‘Fleetingly the realisation of a global vision seemed possible – a vision of health care …built upwards form local needs… driven by the interests of patients, populations,and communities…’.
‘The Alma Ata vision has been tragically and wastefully supplanted by a mean spirited, divisive, profit focused approach, in which patients are seen only as potential customers, and public and collective funding is a target for appropriation by avaricious corporations and grasping individuals determined to turn health into their business’.
He gives us his set of alternative policies which include (and it is worth remembering he is thinking globally and not only of the rich countries) :
– Planning in place of a market
– Risk sharing on the broadest possible basis
A tax levy on all the main economic and financial players in country
Steeply progressive income taxes – including share income, profits, rents; and a turnover tax on multinational companies
Co-ordinated international action against tax evasion
A Tobin tax ( FTT)
Enhanced primary care supported by hospital services, and specialist mental health and public health expertise
A dependable supply of the right mix of affordable and effective drugs available at an early stage at primary care level
Public sector ownership of drug companies, or at least a comprehensive opening of the books of drug companies, and no subsidies for research into lifestyle drugs
A global strategy to halt the drain of Health Care Professionals to high income countries
Making available the expertise of high income countries to the labour readily available in poorer countries
Professionals in management roles to be professionals first and managers second
A review of all PFI schemes
Hospitals to be carbon neutral
Rethinking the proposals for centralisation of hospital services
A review of funds for mental health and older people
– Reintroducing democracy in local communities -in ways impossible in a market system, which will result he believes in services that are more responsive to the health needs of deprived, neglected and forgotten groups.
How do those sound to you? Or rather, how do you feel on reading those?
I felt helpless, disappointed and slightly bored. After this passionate argument Lister gives us nothing more than I have discussed in pubs and over dinner tables a thousand times over the last 35 years.
Surely what we know about complex systems tells us we absolutely cannot rely on planning. No we mustn’t rely on markets either, so we have to think afresh. Let’s think as people like Roberto Ungar are doing, of a new progressive way forward.
Lister wants to take us back to 1978 to a world before Reaganomics. But even without that ideological shift our world and our health care would have moved on in other ways. The problems that Lister refuses to see with State run services would have been addressed in other ways, perhaps making services more enterprising, more tuned in to the needs of patients and populations than professionals, perhaps not. What we need now is some thinking about what policy alternatives might get us to somewhere new and not to an outdated past.
So do I recommend this book? Yes I do. Partly for the array of facts and figures and examples that bring the situation home to us and the way it makes us care about other countries than our own, partly for the reminder of how it felt to be young and optimistic in 1978 with a belief in progress and a spirit of internationalism so different from today’s globalisation, and partly for the opportunity to think about how to take the argument beyond what is presented here.