Review – Health Care Reform and Globalisation: The US, China and Europe in Comparative Perspective

Health care provision has not traditionally been an industry which has generated much profit for shareholders as the state has been a major provider of services. Increasing longevity, growing health needs, the introduction and commercialisation of high technology treatments and drugs have made health-care a major industry. The economic turn to neo-liberalism has led to health care becoming a major source of income. The articles in this collection expose the ways in which neo-liberalism undermines the comprehensive delivery of health services and address the ways in which the more equal provision of welfare states is being eroded by interests promoting the market and profit. The collection of articles is timely as it focuses on the global nature of developments which are taking place.

Wendell Potter’s article on the US‘s health provision (and lack of provision) should be compulsory reading for all who seek to ‘reform’ European and developing countries along the lines of the US. Though one of the world’s richest countries, the US is 47^thin the world ranking of countries for life expectancy: a child born is Bosnia has a longer life expectancy than one born in the US. The chapter presents a withering case against the capitalist interests who are shown to preserve their own financial gain against the promotion of the public good. Obama’s plans for a ‘public option’ were effectively scuppered by a ‘paranoid-style’ public relations attack, sponsored by insurance companies, drug companies and private providers.

A recurring issue is to explain the relationship between government and business and other vested interests in nominal democracies having an elected executive and representative law-makers. Potter emphasises the corrupting manipulation of the mass media. He bemoans the decline of a credible news service that might provide information on the basis of which the public might reach better informed decisions. One might question, however, whether more adequate news reporting in the USA would be enough to reverse the power of capitalist interests over health.

Allyson Pollock and David Price consider the ways in which the shift in the English National Health Service has opened up services to privatisation and the market and how it has led to the loss of data on the basis of which geographically based services might be organised. The authors show quite convincingly that a market based system vitiates the comprehensive provision of services on which the NHS was based.

In a comparison of recent changes in Russian and American health care provision, Michele Rivkin Fish turns to the ‘moral economies’ of health care. She is concerned to draw out the unspoken moral assumptions that inform ideas of the relative worth of patients, and hence ideas concerning differential entitlement to care. This is a novel and useful approach to the analysis of health care change. The differential pricing of the public and private sectors leads to the underpayment of health workers in the public sector which in turn contributes to poorer service and (in the USA) to the training of health workers by specialist sectors which can pay higher fees rather than to general practice where need is greatest.

Mei Zhan’s account of relations between health professionals and patients in China paints a similar picture of frictions engendered by the monetarisation and marketisation of health services. She points out that what was once a model to be emulated by organisations such as the World Health Organisation by 2000 had fallen in value.

The move to neo-liberalism led to the American disease of low efficiency, and unfairness. Health professionals who used to ‘serve the people’ have become part of a ‘service sector’ subject to commodified practices, products and institutions. Whether the 2009 reforms, discussed in another article here by Yu Wang and others, reverse these developments, remains to be seen.

Meri Koivusalo in a timely and well argued chapter addresses the importance of the European Union in channelling health care of the member states along lines of marketisation and commercialisation. The ambiguities and contradictions in EU ideology are clearly put in focus. Whereas many conceive of the EU as an institution promoting social rights and the social charter, the reality of policy is increasingly driven by promotion of freedom of people movement and the internal market. European – wide markets supposedly function to improve efficiency and choice. The chapter traces the shift from European welfare states promoting health care to the EU policy which bases health services on ‘health for wealth’ and ‘health for growth’.

What was traditionally considered a ‘health service’ now promotes health care provision as part of the services sector generating profit and wealth. This shift in policy is a consequence of EU policy of the free market. An important theme here, which is also raised by other contributors, is that the major political parties only marginally challenge these developments – though nationalist and populist parties have made serious critiques.

While Poland is one of the most successful of the post-socialist countries, Peggy Watson sees adverse developments in the provision of health care as one aspect of ‘catastrophic citizenship’ – by which she means the widespread loss of social rights that is part of class formation in Poland. She points out that in 2009 the male mortality gap between Poland and the EU15 was ten percentage points higher than it was when socialism came to an end…

She returns to a familiar theme of the volume: marketisation and privatisation privilege the rich and penalise the poor. She argues that the pervasive ideology of ‘becoming modern’ and achieving a Western type of electoral democracy erase from the public. She also shows how the public is disenfranchised as a result of the shadowy informal relationships between business and government, citing the example of pharmaceutical lobbying. Governments secure social acquiescence for marketisation policies: they deliver a ‘discourse of disguise’ which occludes the harmful effects of marketisation and privatisation portrayed as freedom of choice achieved through economic efficiency.

Hungary was one of the leaders of ‘reform’ even before state socialism was disbanded. However, the move to privatisation, financialisation, as illustrated in the article by Terry Cox and Sandor Gallai, has little public support. They tell a similar story to other chapters – interest articulation by economic actors is much more effective than advocated by social groups, and electoral competitive party struggle leads to political stalemate.

In a concluding chapter Howard Waitzkin and Rebecca Jasso-Aguilar shift the focus to consider alternatives to neo-liberalism based on the experience of South America.

Rather than ‘globalisation’, which in their view ‘mystifies’ the adverse effects of neo-liberalism, they address developments in terms of the ways in which imperialism and empire exploit dependent nations. International organisations, such as the WHO, IMF and World Bank, contend, act to privatise and commodify health services – enhancing the profitability of international corporations. With examples of resistance in Mexico and Venezuela, they contend that public health should (and could) be based on principles of justice not profitability.

This is a valuable and well-chosen collection of articles which illustrates the global nature of developments in health care. It is one of the very few books to encompass health care change in post-socialist societies, and to address the neoliberalising health changes from a critical standpoint. Yet how one breaks out of the vicious circle of privatisation and commercialisation, legitimated in terms of modernisation and democratisation, is not adequately addressed in the book. Democracy can be manipulated, people can be deceived. The contributors highlight how the major political parties align with the dominant capitalist commercial interests. State socialism, though widely criticised, is portrayed as seen with nostalgia in many of the contributions. Possibly there could have been more discussion of the problems given by the ageing of the population and the costs of health care and how to contain them. But the chapters clearly indicate a deficit in electoral democracy; the mantle of the virtues of health as a public good appears to have been taken up by populist and nationalist parties.

Review by David Lane (University of Cambridge).

Peggy Watson (Ed.), Health Care Reform and Globalisation: The US, China and Europe in Comparative Perspective. Londonand New York: Routledge 2013. £85.

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This post was written by David Lane