But the book is justified in starting with Britain, especially so at a time when such attacks on health care (or "reforms" as he points out the perpetrators prefer to call them) are being driven forward in new Labour¹s third term in the form of new levels of privatisation and marketisation of the service.
In fact these "reforms" represent one of the biggest attacks on the British National Health Service since its inception in 1948. The book points out that health policy "reform" has gone further and faster in Britain than anywhere else in the world and that new attacks are under way.
- San Francisco health professionals say it all. Photo: Basetree
Also, given John Lister¹s two decades and more as a leading health campaigner, you expect a robust defence of the NHS against these attacks which threaten its very existence as a comprehensive, publicly owned, service, free at the point of delivery. The book does not disappoint in this regard. It is a detailed defence of publicly own heath care and could hardly be more timely as a result.
None of these attributes, however, reflect the full scope of the book in my view. The book’s rather down-played sub-title gets a lot closer to the mark. It describes it as "A Critical Guide to the Global ’Health Reform’ Industry".
The book points out that, "Health care is one of the world¹s 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 world-wide 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".
It continues, "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".
In fact the book contains an impressive comparative analysis of health-care systems world-wide 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 driving them, the impact of their policies on the consumers and the health care workforce.
It analyses the "reform process" by means of case studies from 42 different countries, covering five continents, over the last 15-20 years - countries as diverse as France, Germany, Holland, Russia, Poland, Hungary, Kenya, South Africa, Uganda, China, India, Japan, Canada, USA, Australia, Argentina, Colombia, 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 from this study is the diverging paths between the Canadian and US health care systems. These systems had been similar in structure and costs until the 1960s. Since then the Canadian system has developed as a universal, tax-funded system which is 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 world-wide. 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". It points out that the USA with around 5% of the worlds population spends over 40% of the world’s total health budget.
It goes on: "Health care spending is almost completely inversely proportional to the global burden of disease. The World Health Organisation¹s World Health (WHO) Report pointed out that 84% of the world¹s population shared just 11% of global health spending, but suffered 93% of the world¹s burden of disease.
"By the 1990s the top 29 countries, grouped in the Organisation of Economic Co-operation and Development (OECD), accounted for 90% of total world expenditure on health, leaving the vast majority of the world¹s population to share the remaining 10%".
The book explains that Japan, with a similar size population as Nigeria spends 270 times more than Nigeria on health care. Also that while in Europe the median age of death is 75, the median for Africa is just five- in other words around half of all African deaths occur in children under five years old.
Although the book is, in part, an academic study, it is 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’."
It is certainly the only study of world health-care systems containing numerous quotations from Trotsky (The Revolution Betrayed), Marx (The German Ideology) and from Lenin (Imperialism, the Highest Stage of Capitalism).
Essentially the book argues that while the liberalised market is a disaster for society in general it is a particular disaster in health provision. In this it starts from an analysis of the market from a classical Marxists position: "capitalism is a system driven by the accumulation of capital, through the production and exchange of commoditiesŠ" and reaches the conclusion that, 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."
From this point of view the book has a substantial chapter on the global agencies of capitalism and their role in promoting health policy ’reform’ world-wide entitled "In the driving seat: international agencies and the transmission on policy ideas". This deals with the role of the World Bank, the International Monetary Fund (IMF) and the World Trade Organisation (WTO), the OECD the European Central Bank
It analyses the role of these institutions - the World Bank in particular - in using 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 desperately they need.
On the impact of these policies on developing countries it points out that: "Perhaps the most influential policy document shaping heath policy for developing countries in the 1990s was the (World) Banks 1993 World Development Report. This effectively 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."
In the country by country summary the book takes the example of Kenya to show how the impact of global capital and agencies such as the World Bank have helped undermine health gains which were 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 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.
It points out that Cuba¹s 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. 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.
If there is a weak spot in the wealth of material the book has to offer I felt it was its lack of detailed analysis of the role of the pharmaceutical companies in all this given the huge role they play. Their role is covered but they are not subjected to the depth of analysis afforded to the many other aspects of this vast subject. Maybe it was beyond the scope of this book and requires a separate work. Such a study would add a lot to the overall picture of, and problems of, health care world-wide.
Meanwhile John Lister¹s 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 which are taking and in advancing the kind of alternative we have to offer as socialists.
John Lister is a campaigning journalist and an editor of Socialist Resistance who has worked for 21 years for the health watchdog London Health Emergency. He has carried out numerous research projects for the trade unions and activists fighting hospital closures, privatisation and deregulation.