Health Policy Reform - Driving the wrong way?

Health Policy Reform - Driving the wrong way? A Critical Guide to the Global 'Health reform' Industry John Lister Middlesex University Press, 2005, £.25.00 This book is not only a detailed analysis of health policy in Britain in the post war period which is crucial when new levels of privatisation and marketisation of the service (or 'reforms' as he points out the perpetrators call them) are being driven forward in new Labour's third term. Given John Lister's two decades and more as a leading health campaigner, you expect a robust defence of the NHS against these attacks threatening the very existence of a comprehensive, publicly owned, service, free at the point of delivery. The book has a much wider scope. The rather down played sub-title gets closer to the mark. But to do it full justice it would need to be something like, 'Healthcare Under Global Capitalism' or 'The Impact of the Global Market on Heath-care Systems World-wide'. He points out that, Health care is one of the world's biggest industries, accounting for global spending just short of 3 trillion US dollars in 1997, or almost 8% of the world gross domestic product. It is also a major employer: the health care workforce, numbering up to 35 million worldwide, is the biggest of any industry. Policy decisions affecting health care systems therefore not only service users, but potentially the jobs, pay, and conditions of staff. Health related industries, notably those manufacturing pharmaceuticals and modern diagnostic equipment, along with US private health insurers and health maintenance organisations are amongst the world's biggest companies with turnovers in tens of millions of dollars. The book contains an impressive comparative analysis of health-care systems worldwide under the impact of neo- liberal globalisation - with Britain as the starting point of the 'reform' process. It gives an important overview of the reforms, the reformers, the material and ideological forces the impact of their policies on the consumers driving them, and the health care workforce. The analysis is by case studies of 42 different countries, covering five continents, over the last 15-20 years - countries as diverse as France, Russia, Kenya, China, India, Japan, Canada, USA, Australia, Argentina, Nicaragua and Cuba. It concludes that there is no evidence that the 'reforms' imposed by successive British governments can deliver better, cheaper, more efficient or more accessible services for patients than a fully public sector service - quite the reverse. An interesting example is the diverging paths between the Canadian and US Health care systems. These systems had been similar until the 1960s. Since then the Canadian system has developed as a universal, tax-funded system, vastly cheaper than the chaotic $1.4 trillion US system that leaves 61 million Americans without adequate health cover but costs $400 billion a year to administer. A major theme of the book is the staggering inequality of healthcare. It points out that the cost of the US system is, 'more than four times the total health spending of the lowest-spending 62 countries, including India and China'. around 5 percent of the worlds population spends over 40 percent of the world's total health budget. He points out that, "Health care spending is almost completely inversely proportional to the global burden of disease. The World Health Organisation's World Health Report pointed out that 84% of the world's population shared just 11% of global health spending, but suffered 93% of the world's burden of disease.' That Japan, with a similar size population as Nigeria spends 270 times more than Nigeria on Reviewed by Alan Thornett health care; that while in Europe the median age of death is 75, the median for Africa is just five -half of all African deaths occur in children under five years old. The book combines an academic study with campaigning material, written from an uncompromisingly class-based Marxist standpoint. John Lister puts it this way: 'A Marxist analysis offers the possibility of a consistent and critical analysis of the context, the content the motivation, and the material (class) interests served by particular policies or 'reforms'.' Essentially he argues that the liberalised market is a particular disaster in health provision. He analyses the market from a classical Marxist position, 'capitalism is a system driven by the accumulation of capital, through the production and exchange of commodities' however, 'it is not necessary to embrace a Marxists analysis to conclude that unbridled market mechanisms are incompatible with the equitable provision of heath care'. Global institutions of capitalism There is a substantial chapter on the global agencies of capitalism and their role in promoting health policy 'reform' world-wide entitled. This deals with the role of the World Bank, the IMF and the WTO, the OECD the European Central Bank He shows how these institutions use their economic power to promote privatisation and the imposition of user fees, despite the abundant evidence that this deters the poorest and most needy in society from accessing the services they need. On the impact of these policies on developing countries he points out that the 1993 World Development Report, 'proposed the consolidation of a two-tier global health care system, in which the wealthy countries would remain free to spend as much as they wish but publicly funded hospital care in the developing countries would be reduced to a rudimentary minimum, or privatised.' He takes the example of Kenya to show how the impact of global capital and agencies such as the World Bank have undermined health gains achieved immediately after independence, while the attempt to introduce a new social health insurance system to deliver free care for the whole population has faced opposition from trade unions because it lands the bulk of the cost on the minority of the population who are in formal employment. Similarly the remarkable health gains of the Sandinista revolution have been wiped out by years of neo-liberal policies and economic pressure from the World Bank and IMF to cut back health spending in one of Latin America's poorest countries. By contrast, the book also notes that while the World Bank has been pressing for poor countries to minimise spending on hospital care, and for their governments to fund only the most minimal package of primary care, immunisation and health education, it has been the country that has most flouted these guidelines - Cuba - which has delivered the most spectacular success. Cuba's publicly-owned health care system, delivering a combination of primary care, care and public health measures free of charge, was ignored in World Bank reports until the end of 2003. While those that caved in to World Bank guidance are still counting the cost in ill-health and low life expectancy, Cuba has lower infant mortality than Washington DC. John Lister's book is a valuable resource for the movement today and we should make full use of all it has to offer both in defending health care against the new attacks and in advancing the alternatives we have to offer as socialists. 29