[afro-nets] Interesting book on political economy from a clinical perspective

["Anders Jeppsson" <claudio@hcmc.netnam.vn>]

Interesting book on political economy from a clinical perspective
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Julian Tudor Hart: The political economy of health care. A clinical perspective. Bristol: Policy Press 2006.

Julian Tudor Hart is a retired General Practitioner who has worked in the mining districts of Wales during his professional life. He is an atypical representative of his profession in several ways. One feature is his interest in community generated research, which has resulted in concepts such as  "The inverse care law" [1], which means that the ones in most need of health care gets the least, and vice versa. He has also formulated the "The rule of halves" [2], which in principle means that half of all diseases remain undetected ("half" refers to magnitude rather than  exactly 50%), half of the detected diseases are untreated, and half of the treated diseases are not controlled. 

Another of Hart's traits is, that he was one of the few medical students who supported the creation of  the  National Health Service (NHS), at its formation in 1948, and that he has remained a strong advocate of public health care.  NHS was at its commencement extremely unpopular among the medical community in the UK, and in particular among the British Medical Association. The reason was that the doctors feared deteriorated working conditions. The economic conditions from working with NHS were, however, much better the conditions they had before, and NHS was accepted by the doctors and loved by the people. Hart's book is advocating for a continued public health care for all, and against Blair's attempts to dismantle NHS and to sell it to the private market. 

In his book, Hart describes the background of the creation of NHS and its history. Although NHS was relatively under-funded in the 1960s and 1970s, it was still extremely efficient: The UK was under a long period of time the OECD country with the lowest government allocation for health. Despite this, the outcome was impressive: Equal health care for all, evenly distributed throughout the country. The cost for administration was unbeatable: Initially it was 2%, but increased to 6% when the conservative government introduced the principles of "New Public Management". Since NHS became subject to privatization and the introduction of internal markets, the administration cost ahs risen to 12%.

One of Hart's points is that  public health care is cheap, partly because the administration cost is low. He shows theoretically and practically why this is the case. NHS was for a long period a 'gift economy' without any need to cost the procedures. This is one of the myths of our time, that the administration of the private sector is cheap and effective. For anyone still believing in the myth, it should suffice by looking at the health care system of the US. This sight is far from impressive.

Another of Hart's points is that the quality of care and patient safety is considerably higher in the public sector compared to the private one, despite the cream-skimming of the private sector.

But the book also goes into depth and addresses current economical theories, where Hart argues that they are not only insufficient, but inadequate to describe health care. 

One reason for this is that health care is not a commodity. All health care begins with the consultation process, where the doctor (or any other health staff) gets engaged in a 'creative negotiation' or, preferably, in a 'creative collaboration', which results in a clinical decision on how to carry the process forward. This has nothing to do with consumption. It is not commodity production and it is therefore not suited for the market.

Hart's book adds considerable value to the current debate on health policies and the negative effect neoliberal policies on health systems of. Its perspective is very different, since in starts in the community and in the consultation process, and from there expands on a theory on how a public health care system can be instrumental in improving the society (by replacing neoliberal solutions).

I have serious difficulties to find good reasons not to read the book. Even if it is well embedded in the British context, is also provides useful information for us non-Brits. 

If somebody still chooses not to read the book, I would recommend the author's website, which is well worth visiting: http://www.juliantudorhart.org

--
Anders Jeppsson
Senior Health Adviser
Ministry of Health and Social Welfare
Dar-es-Salaam, Tanzania
Email: anders@hspstz.org