A new pernicious epidemic is stalking the health care systems of the world. It is striking rich countries and poor alike, with understandably the most devastating impact on the poorest. It saps vital resources, dislocates and fragments systems, obstructs the development of equitable healthcare systems, and prevents government planning and responding to health needs.
The epidemic is not a medical problem, but a man-made disaster. It is the rampant spread of neoliberal, pro-market 'reforms', devised and promoted by a narrow policy-making academic and political elite in the wealthiest countries.
It can only be eradicated by the spread of information, political campaigning and critical thinking, with regular injections of evidence and social solidarity.
This epidemic is the focus of my new book Health Policy Reform: Global Health versus Private Profit, which offers a detailed analysis of the main ‘menu’ of market-style reforms offered to health care systems, and a discussion on the ways these are being effectively imposed by the governments in richer countries - and by global bodies in the poorer ones.
It argues that these so-called ‘reforms’ are driven not by evidence, but by ideology. And behind the ideology is a massive material factor: the insatiable pressure from the private sector to recapture a much larger share of the massive $5 trillion-plus global health care spend, much of which only exists because of public funding.
Everywhere the role of the private sector and the size of its potential market is always constrained by an ‘inverse care law’. Most health care is required by those least in a position to pay the market price for it – whether this be the old, the very young, the poor or those with chronic sickness and disabilities. Nowhere in the world is there a health care system that delivers universal or comprehensive health care services purely through the development of a competitive health care market. Nor is there any private health sector that can operate without overt or covert subsidies.
England has been an unfortunate laboratory rat for some wild and costly experiments with competition. What had been one of the most integrated and publicly provided services in the world has been progressively dismantled, with ever more services sliced off to encourage private providers. Governments since Margaret Thatcher have all – perhaps for different reasons – applied a hard-line neoliberal ideology to health. In doing so they exploited a political system that tended to deliver clear parliamentary majorities, to force through policies despite popular opposition.
This has continued even under David Cameron’s opportunist coalition. The massive and complex Health Act lacked any democratic mandate. Never put to the electorate, it was passed only thanks to the willingness of the Liberal Democrats, eager to avoid a huge conflict and early election in which they would be largely wiped out.
It doesn’t have to be this way - since devolution, more progressive systems have developed through integration of services in Wales and Scotland. But looking further afield, sadly England is not unique. Similar ‘reforms’ are being adapted in different ways to different systems across much of Europe. They are also being imposed upon the poorest developing countries where they are even less appropriate and more disastrous in their consequences.
Global Health Versus Private Profit shows how since 1980 global agencies like the World Bank, new powerful players like the Gates Foundation, and even at times the World Health Organisation (WHO) have played a role in promoting these changes. These agencies have been supported by a burgeoning industry of right wing ‘think tanks’ and an elite coterie of academics drawn to the chance of lavish funding. Their loyalty appears to be to the giver of the research grant rather than to the evidence.
Setting the analysis in the context of the rise of neoliberalism and the intersecting economic, political and environmental crises that worsen global health, my book distinguishes between cost-cutting ‘market-driven’ reforms, which reduce the size, scope and scale of services but leave systems largely unchanged, and ‘market-style’ reforms, which aim first and foremost to open up a growing share of health spending for private providers and ultimately private insurers.
Market-style reforms are remarkable in that they consistently serve neither to cut costs nor to improve efficiency. In fact the systems most dependent on private competing providers have the highest overhead costs and waste billions while excluding millions from proper access to health care.
Global Health Versus Private Profit subjects the ‘menu’ of market-style policies to a detailed critique, using the most up to date material available from the World Bank (and its privatisation wing, the International Finance Corporation) and the IMF. I discuss in detail the political evolution of these and other organisations shaping the reforms, including the WHO.
A particular concern is the international spread of ‘Public Private Partnerships’ following in the footsteps of the UK’s trail-blazing Private Finance Initiative (PFI). Despite the fact that PFI is proving itself a major liability, bankrupting trusts in a cash-strapped NHS, the model is being exported across the world in the face of many costly flaws, failures, and false starts. Many PPPs (P3s in Canada) are now under way in developed OECD countries - and also in Latin America, Asia, and South Africa. In tiny Lesotho a $120m PPP hospital is set to soak up a disproportionate share of the health budget, but generate a healthy profit stream for its South African ‘partner’ the health care multinational Netcare.
Global Health Versus Private Profit also singles out what I have termed the “Missing Millennium Development Goals” – the massive public health issues which call for reform and for large-scale action, but which are completely ignored by current health ‘reforms’. The real challenges remain unaddressed - the development of adequate health care for the growing world-wide population of more dependent older people (summed up as “customers the private sector doesn’t want”), the millions suffering mental illness, and the ‘hidden giant’ of the millions facing physical disability.
Global Health Versus Private Profit explores and dissects market-style reforms. Extensive evidence including 60 pages of references shows how these reforms don’t take as their starting point the real and evident problems facing health care systems - and nor do they solve any of them.
A concluding chapter explains why “It doesn’t have to be this way”. The policies are not inevitable consequences of our current situation, but deliberate choices of politicians working to a neoliberal agenda. These choices can be rejected and defeated by mass political action. There are alternatives. The challenge is to develop a political leadership with the courage to embrace them and fight for them.
I hope it will serve as a resource for campaigners working for political and popular action, to challenge the flimsy arguments and assertions that these neoliberal reforms are based on.
Market-style reforms result in systems more unequal, more costly, more fragmented and less accountable – but which offer more profits to the private sector. That’s why the real question is whether we want to see global health – or private profit. Most people are clear which they would prefer.
We are many, with the facts on our side: the neoliberals are few. But good ideas must be turned into political action to change the world. That’s why this is a book I hope will not sit gathering dust on library shelves, but be brandished - even used as a weapon - by those fighting for change.
A reinforced hardback edition may yet be needed to ensure we win!
Health Policy Reform: Global Health versus Private Profit, by John Lister (£25) is available from www.libripublishing.co.uk or from good booksellers.
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