The politics of health in Europe
International Journal of Integrated Care, 1 November 2000 - ISSN 1568-4156
Book review
The politics of health in Europe
Richard Freeman
Manchester: Manchester University Press, 2000,
ISBN 07 19042143
Jacques A. Bury

This book is about health, politics and Europe. However, and this is in fact the only regret I had about this stimulating reading, it would be more correct, it seems to me, to say it is about health care, politics and Europe. As the whole analysis focus on health care and pay little attention to public health and the role of other than health sectors on health. This explains for instance the ironic tone of the third sentence of the preface: “Nowadays health is pursued in affluence and at leisure, both by individuals and by societies…(the irony being that health seems to matter most to most healthy societies)”. I guess that the health promotion community as well as all scholars working on health inequalities would react rather strongly on such a statement as it is precisely on the same observation that the whole empowerment approach is based: you need a minimum level of health and affluence to be able to care about health. This is not ironic at all, it is a fundamental understanding.

The author notes that health matters more than it ever did, that health care is an important sector of labour as well as of production in economies, and, therefore, becomes inevitably political, too.

This book, the author continues, is also about comparative analyses to explore the different ways in which different countries do similar things, to describe the pattern of difference-within-similarity that is health politics in Europe. And it does it, in depth and convincingly.

The first chapter on health politics is a careful analytic description with constant clarification of the concepts used, of the complexity of the health care system; very rightfully for instance the author warns against didactic simplifications such as national health services versus social insurance systems, whilst what matters most is to understand that health (care) systems in Europe have “an essentially comparable geology”. Almost all European countries seem to pursue a standard set of policy objectives, including adequacy and equity in access, income protection, a degree of freedom of choice for consumers and of autonomy for providers, covering most of the costs of inpatient care for most of their citizens.

These observations and others bring the author to the conclusion, which emerges also from others studies, that the health system of any given country may be thought of as a number of systems—public and private, for example—superimposed one on the other, sometimes complementarily, sometimes coexisting and sometimes competing. The author aims, therefore, in his book not at looking for any universal model but to develop specific analyses of diverse health political phenomena, health politics being conceived “as a complex of different if related arenas”.

Looking back to the history of the development of the health care state in Europe over the last century, the author noted that “by 1980, almost all European states guaranteed access to health care to almost all of their citizens (whilst) in 1880, none of them did”. He distinguishes a first period (1880–1940) during which the development of health insurance schemes and of the growing “étatisation” took place as the result of more complex forces than it is usually thought. The second period (1940–1990) is characterised by the development of the universalisation of access to health care for more and more categories of citizens, either through an incremental or through a radical process. But the full installation of the health care state occurred mainly during the “growth” period of the sixties and seventies: however, the author draws the attention on the fact that “the increased scope and cost of publicly guaranteed health care has been rarely matched by the executive authority of governments.” As he eloquently summarised: “health care was sponsored by the state but not governed by it”. He explained that situation partially by the fact that unlike in other industries, the introduction of new equipment does not save money by reducing unit costs, nor is labour-saving, on the contrary. I wondered why he does not mention the fact that the major difference with other industries is a distorted competition which is not based on cost/benefit for the actual decision-makers.

The analytic description of the national health services types concern the UK, Italy and Sweden, whilst the health insurance types are those of France and Germany.

These descriptions cover among others aspects, organisation and delivery, finance, public and private, governance, interests and corporatisms, and reform. The reform is devoted an entire chapter which underlines the remarkable similarity and convergence, irrespectively of the former categorisation. The author provides an stimulating insight into the political processes which underlines a simultaneous strengthening of the role of the national political powers and of the progressive trend towards regionalisation. And how these two concomitant changes have resulted in a lowering of the previously dominant influence of the providers on policy decisions.

The last three chapters are about the doctors, the users and public health. The author reminds us that health care systems being the means by which states ensure the supply of medical services to populations, he says that “to all intents and purposes, health care in Europe means medical care”. There is a consensus among social scientists and historians that by the third quarter of the twentieth century, the medical profession was the most powerful interest in the health sector. This comes partly from the mutual dependence between doctors and states: medicine is threatened by the loss of autonomy, governments by the prospect of intractable social and political conflicts. An in-depth comparative analysis of the situation in the five countries shows the similarities in employment, payment, organisation, cohesion, etc. The possible influence of medical audit schemes and clinical guidelines as well as the emergence of management function in health care remain moderate, partly as doctors have been able to control them to a non negligible extent. Even if medicine has lost its privileged role in decision making mainly in relation to cost-containment issues and to an apparent strengthening of the role of the state. The interest of the subtle analysis of the author is exemplified here again by his explanation that the legitimisation by the state of the medical profession was an important component of the professional status of the doctors and, therefore, if the state is less supportive, the status diminishes. And the state found an interest to support the medical profession as it medicalises social and political problems.

Looking at the other partner in the game, the users of health care, the author uses Hirschman's conceptualisation of exit, voice and loyalty in economic and political theory. In contrast to most of the political analyses in the previous chapters, I found this frame of reference less convincing, possibly because it is too limited in scope. Nevertheless “en passant”, the author shows how the differences between the private and the public health care facilities are of degree and not of kind. It seems to me also that too little credit has been paid to patients associations which play a growing role in Europe in the last decade especially. Maybe because the author remains rightfully attentive to the ways doctors and managers have often “appealed to users in the course of their own conflicts”, his conclusion is that “health policy continues to be determined by providers, payers and regulators—doctors, health insurance and governments.” He stresses also that cross-national work in medical sociology remains relatively underdeveloped and suggests later to use a new typology for the analysis of types of consumption of health care: consumerist, privatist, welfarist and clientelist. This latter approach would in my mind certainly provide a complementary views on the users role. Partly because this typology would refer directly to the extent to which the actions of users are promoted or inhibited by factors mentioned by the author such as institutional (both organisational and cultural) factors, complex arrangements of solidarities and normative frameworks.

The closing chapter entitled: health, the public and public health, “is about prevention in health policy”…“In a sense the book ends where it began, with the ordering and reordering of public responsibility for health”. It seems to me that this confirms my minor reservation about the whole book, which is some lack of understanding of what public health is really about. In the same vein, the author devotes a paragraph on the role of WHO in health policy developments in Europe.

Even if, as a former WHO staff, I have always been critical to overemphasising the limited role the regional office of WHO had in the last twenty years, I definitely cannot accept to see a book on the politics of health in Europe, viewing that role as negligible. I would have expected the same level of understanding and analysis of the complex relationships between national politics and European politics and especially between governments and WHO.

In contrast, the comparative analysis of the AIDS role in health politics in the five countries is well documented and gives the opportunity for some interesting insights such as the demonstration that the “policy has expressed the liberal individualism of pluralist democracies in which citizens invariably remain “free to be foolish (Leichter)”. More interestingly even, the analysis of screening activity, one of the few areas of expanded entitlement, used as a political “sweetener and as a means of medicalisation of prevention and de facto a means of medicalising social problems is well done. It paves the way for the author to his conclusion that preventive policy has served as a panacea for it satisfies two of the most important criteria of social policy making: it offers opportunities for a retreat from big government and for the extension of control over the health sector. Prevention serves to moderate the pressure on both medicine and government, while at the same time promoting the legitimacy of both. Primary strategies which address the social, cultural and environmental causes of ill-health come only at great cost, both financial and political.

In conclusion, this book is about health care politics in Europe. It is a must for the various players of the game, decision makers of all sorts, including doctors. A must because it provides a lot of insights into the complexity of the underlying dynamics.