CONTROVERSIAL health policy reforms, including the development of a new, market system involving unfair competition between the NHS and private sector providers, have gone further and faster in Britain than any other country in the world.
That is the conclusion of a major new comparative study, published on July 5, the 57th anniversary of the NHS.
Health Policy Reform, Driving the Wrong Way? is a unique 350-page overview of the reforms, the reformers, the material and ideological forces driving them, and the impact of their policies.
It looks at changes that have taken place in over 40 countries in the
Health Policy last 15-20 years, and concludes that there is little or no evidence that the reforms imposed by successive British governments can deliver better, cheaper, more efficient or more accessible services for patients.
Among the costly policies imposed in Britain without evaluation of their impact or evidence of their effectiveness have been:
• The separation of purchasers and providers to create a 'market system-a policy which has massively inflated bureaucracy and management costs in Britain, and in every country where it applies
• The use of private sector providers, despite evidence around the world that these are more expensive than public sector provision, and that the private sector will only "cherry pick" the most profitable treatments, leaving the public sector to carry the costs of emergencies, complex cases and other vital work.
• Competitive tendering and privatisation of support services such as cleaning and catering, despite evidence that competition on price in these labour-intensive services effectively casualises staff, and reduces quality of cleanliness and patient care Castro: following Guevara's lead, Cuba has flouted the World Bank's policy guidance, but delivered enhanced health care at home and exported vital expertise around the world
• Creating Foundation Trusts, and similar moves to enhance "provider autonomy", have proved a costly failure elsewhere, with experiments abandoned in Spain, Sweden, and New Zealand, and early signs that the British experience has brought no real democracy but greater links with the private sector and a 2-tier split between NHS Trusts.
• The use of the Private Finance Initiative to fund almost all new hospital developments - in which Britain is far and away the world leader, with rocketing costs of schemes now raising huge questions of affordability and value for money.
Driving the Wrong Way charts the development of what author John Lister describes as the "global health reform industry", influencing developments in a global industry with an annual spend of more than $3 trillion.
The main "menu" of market-style health system reforms are identified and analysed, the evidence for them explored, and the findings are tested in a series "country summaries" exploring the extent to which reforms have been introduced and their effects on 42 countries in five continents.
Among the striking contrasts and findings, a couple stand out, such as the diverging paths between the Canadian and US health care systems, which had been similar in structure and costs until the 1960s.
Since then Canada has developed a universal, taxfunded system which is vastly cheaper than the chaotic $1.4 trillion US system that leaves 61 million Americans without adequate health cover, but costs a staggering $400 billion a year to administer.
The book notes that this figure for overhead costs is "more than four times the total health spending of the lowest-spending 62 countries, including India and China".
A substantial chapter on the global agencies promoting health policy retorm reveals the role of the World Bank in using its economic clout to promote privatisation and the imposition of user fees, despite the abundant evidence that this serves to deter the poorest and most needy sections of society from accessing the services they need.
An extended country summary takes the example of Kenya to show how the impact of global capital and agencies such as the World Bank and USAID have helped effectively undermine health gains 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.
In Nicaragua, too, the remarkable health gains of the Sandinista revolution have also been effectively wiped out by years of neoliberal 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.
Its publicly-owned health care system, tax-funded and delivering a combination of primary care high-tech hospital care and public health measures free of charge to all, was ignored in World Bank reports until the end of 2003.
But while the poorest countries 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.
With huge inequalities between rich and poor coun tries and rich and poor within countries, big changes are needed to enable the world's health care systems to cope with the demands on them.
But as this book shows, the main policies on offer are the wrong reforms: they ask the wrong questions, aim at the wrong targets, and are driving systems the wrong way -towards markets, profits and exclusion rather than equity and comprehensive care for all. • Health Policy Reform: Driving the Wrong Way? by John Lister is published by Middlesex University Press, www.mup.co.uk E25. Readers of Socialist Resistance can oder copies at £20 plus £1.50 p&p fromLondon Health Emergency, 213 Church Rd, Hayes, Middx UB3 2LG.
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