Health
WHO comes out against market reforms
THE RECENT World Health Organisation Report 2000 hit the headlines in Britain with its controversial "ranking" system of health care systems, in which the UK's National Health service came 18th.
There are grounds to question the basis of a comparison which puts the universally admired and egalitarian Cuban health care system (39th) well below Britain, and two places lower on the scale than the universally reviled US system.
Privatised medicine in the USA squanders over 14% of the country's gigantic national wealth, but leaves a massive 40 million Americans without health insurance and means that family illness is the biggest single cause of personal bankruptcy in the US. If the measure were spending it should be higher: if it were access for the whole population, we might expect the US to be far further down the list.
Five tiny and comparatively prosperous European states (San Marino, Andorra, Malta, Monaco and Luxembourg) with a combined population of a few London boroughs can be found in the top 16 of 191 countries. One factor which boosts them - and forces down the UK ranking - is the comparative extent of health inequalities between rich and poor, which is seen as a continuing problem in Britain (especially since the comparisons are all based on 1997 figures - at the culmination of 18 years of Thatcherite policies).
The politicians and media have eagerly debated the extent to which this latest league table shows the NHS in a positive or negative light (with Health Secretary Alan Milburn stepping in to bask ridiculously in the reflected glory of Tory government health policies, declaring the report to be "a ringing endorsement of the principles of the NHS").
Certainly if there were bonus points to be won for rhetoric about social exclusion and bridging the health divide, the New Labour government might claw a few places higher up the table, though it will be some time before the extra cash belatedly allocated to the NHS in Gordon Brown's March budget makes any tangible difference to services.
The WHO's ranking order does not exactly mirror spending patterns: the expensive German health care system which has also delivered some of Europe's highest technology medicine and lowest waiting lists, ranks a lowly 25th.
However most of the larger countries which are ranked above Britain (France, Italy, Spain, Portugal, Greece and Netherlands) do spend a higher share of national wealth on health care than the British government. The Italian and Spanish systems are based on a similar tax-funded model to that of our own NHS before the rigid imposition of cash limits.
But other parts of the WHO report are in many ways politically more interesting, containing as they do a marked shift of policy against the growing global trend towards market-style "reforms" to health care systems.
It makes the point that private insurance schemes respond to "demand rather than needs" and seek to safeguard profits and minimise risk by excluding those most likely to need health care - especially those most likely to need expensive treatments. This, argues the WHO "maximises people's exposure to financial risk ... or to catastrophic health loss". (p59).
Attempts to hold down health spending by rationing care inevitably run into severe political problems, and depend on "the acceptance and support of providers and consumers". As Labour ministers are discovering with their efforts to ration the use of beta-interferon (see this page) this level of acceptance is hard to obtain.
Sharing risk
Chapter five of the report discusses ways of sharing the risk in the funding of health care, and endorses the view that funding from general taxation - the NHS model - is in many ways ideal as a means of separating contributions to the system from the use of health services.
But it points out that to fund health care from general taxation "demands an excellent tax or contribution collecting agency. This is usually associated with a largely formal economy, whereas in developing countries the informal sector is often predominant." (p98)
The WHO goes on to point out that the systems of "co-payments" or charges for treatment favoured by agencies such as the World Bank and the IMF serve to ration the use of care "but does not have the effect of rationalising its demand by consumers". "Using user charges indiscriminately will indiscriminately reduce demand, hurting the poor in particular". (p99)
Against the stock Tory and free-market argument that health care is simply a bottomless pit of demand, the WHO insists that "Free-of-charge services do not translate automatically into unjustified over-use of services." Indeed there may still be a number of hidden costs for the poor, including time lost from work, transport costs and the price of medicines even when care is nominally "free".
The Report examines a number of examples in which the "pool" of resources for health care treatment has been reduced by introducing competition between different insurance schemes. It argues that "in fragmented systems it is not the number of pools and purchasers that matters, but that many of them are too small".
If the Thatcherite logic is pursued to its ultimate, and health care is regarded as a matter to be financed not by society but by each individual and his/her family, then "each individual constitutes a pool and thus has to pay for services".
All of this may seem self evident to socialists: but the stand taken in this WHO report will strengthen the hand of those resisting the tide of market-driven reforms and privatisation which are being actively promoted by the US government and global bodies up to and including the World Trade Organisation as a "one size fits all" reactionary panacea for health systems in the developing countries.