International Journal for Quality in Health Care 14:87-90 (2002)
© 2002 International Society for Quality in Health Care
A review of the ‘welfare state’ and alternative ways of delivering health care
1Based on the author’s plenary address to the 18th International Conference of the International Society for Quality in Health Care, Buenos Aires, Argentina, October 4, 2001.
The following words should be considered within the framework of my personal views on the subject, which are the views of a teacher and researcher in the field of health policy.
On the other hand, the purpose of this article is to put forward the idea that accessibility is in itself a characteristic inherent in the quality of the health service. Thus, the advocates of the welfare state considered, albeit implicitly, that solidarity is a more desirable feature for a health system than competition, whereas the opposite is the case with the market-oriented reforms, which are the present standard for the organization of health services around the world.
Now, before delving into our subject, let’s just step back into history for a while in order to explore the ideas people had about medical care in ancient times, well before the welfare state was introduced and before market-oriented reforms tried to transform it. As an illustration, there is nothing better than this old story. I think I heard it for the first time when I was beginning my medical studies, from the Argentine physiologist Eduardo Braun Menéndez [1], one of the pioneer researchers on the renin–angiotensin system, which gave origin to the angiotensin converting enzyme inhibitors (ACEI), now widely used to treat hypertension and other cardiovascular conditions.
‘A man crosses at great speed the agora of a Greek city, followed at a short distance by another man. The philosopher halts the second man, and asks him: Why are you chasing after that man?
Because he has killed a man
Oh! He’s a soldier
No, no! He killed the man in peacetime
Oh! He’s a hangman
No! He didn’t kill him on the gallows, but in his house
Oh, I know! He’s a doctor.’
There was no such thing as a public policy for quality health care at the inception of what we now address as the ‘welfare state’. The main objectives of those supporting the idea, epitomized by the ‘Freedom from Want’ Beveridge postulated in his now famous November 1942 Report on Social Insurance and Allied Services [2], was to extend the benefits of social insurance, i.e. access to such services as health care, to every individual. In the same fashion, post World War II initiatives in the Northern hemisphere and also in Latin America (e.g. Servicio Nacional de Salud in Chile, Instituto Mexicano de Seguridad Social, the movement of the ‘obras sociales’ in Argentina) [3] somewhat disregarded the intrinsic quality of health care services, provided they were widely distributed at least among the urban population. Therefore it is licit to ascertain that access was the main, albeit implicit, quality feature of health care in the ‘welfare state’, that is, the ability of the health system to reach the entire population with the available services.
Nevertheless, the World Health Organization (WHO) in its World Health Report 2000 [4] explicitly excluded access as an item to be assessed in the process of evaluating health systems, although many countries had not achieved, nor were even near, universal coverage. The WHO stated that ‘much of the need for [health] care is unpredictable so it is vital for people to be protected from having to choose between financial ruin and loss of health’ and ‘the more accessible a system is, the more people should utilize it to improve their health’. However, the WHO did not regard accessibility as an intrinsic attribute of a health system but as a simple means.
The original goal of the welfare state as regards extending social services (such as health) to the entire population [5] has not been achieved in most countries. Therefore, notwithstanding the relevance of continuous quality improvement of the health services actually delivered to the people, access should always be the first quality concern to those health systems lacking universal coverage of the population they are supposed to serve. In all these cases, access is and has to be considered a component of quality, perhaps the main one.
The health care reform movement that followed the welfare state crisis, from the Jackson Hole group and Einthoven’s managed competition in the United States [6] to the internal markets proposals in different European countries [7], started when universal coverage had been achieved where it had been pursued. In other words, access as a measure of health care quality was not the point. Instead, the subject of both academic research and administrative initiatives was the quality of the health services effectively provided to the population.
We can say that the modern welfare state became established during the years that followed World War II, while the strong current tending to fix the problems that emerged from the development of the welfare state is contemporary to the events that led to the fall of the Berlin Wall. For a long time the whole world had been witnessing strong criticism of the performance of the state regarding its various functions but particularly in the area of the economy, and this led to a revaluation of private activity and initiative, which logically was extended to the health policy area, both in public health services and in social health insurance. This trend toward the privatization of functions and responsibilities previously in the hands of the state expressed the public’s low satisfaction with the state’s inefficiency in producing the goods and providing the services [8]. With reasonable approximation, we can refer to a change of model regarding the role of the state.
Naturally, and as a way of compensation, the pendulum of popular interest and government policies has oscillated between statism and privatization. Just like all reflex or rebounding movements, this tendency can contribute to correcting defects from the past and also to improving the performance of various social bodies. But it runs the risk of exceeding its swing and bringing about other dysfunctions. This explains the ease with which we characterize the demise of the welfare state, analyze its different components, and point out the qualities to be emphasized and the drawbacks to be minimized, especially in the field of health care.
At this point I think it is convenient to note two observations from the past. The first one was clearly expressed by Pope John II when he addressed the Mexican businessmen who met at Durango over a decade ago (9 May 1990). He said: ‘the recent events I have referred to (the collapse of Central European governments) have sometimes been interpreted superficially as the triumph of the Capitalist–Liberal regime. Certain interested parties would like to conduct the analysis to the extreme of presenting the system they consider the winner as the only viable way for our world, on the basis of the serious failures suffered by the ‘real socialism’, and disregarding the necessary critical judgment about the effects capitalism has brought to the so-called third world, at least so far’.
The second observation refers to the composition of the state itself. There is no doubt that the sometimes excessive growth of the modern state has damaged its role in promoting welfare and ensuring the benefits of freedom that are traditionally assigned to it. Jacques Maritain [9] believed that whatever is big and powerful has an instinctive tendency, as well as a special temptation, to go beyond its own limits. Power tends to acquire more power, the power machine to extend itself unceasingly. The legal and administrative structure craves bureaucratic self-sufficiency: to be an end and not a means. Those who specialize in the affairs of the whole tend to ascribe the whole to themselves: the General Staff considers itself the Army; ecclesiastic authorities, the whole Church; the state, the entire political body. For the same reason, the state tends to attribute a specific common good to itself—its preservation and development—which is different from its immediate aims of public order and well-being and its supreme finality towards the general common good.
It is worth noting that, both in Europe and in Latin America, the above mentioned process was simultaneously or within a short time accompanied by democratization, either through the extinction of military dictatorships or by the overthrow of Marxist–Leninist regimes. If we analyze the two processes together, we can observe a tendency toward canceling strong monopolies, be they economic or political, for the benefit of higher personalized social life, with the upsurge of private initiative in the economic sector and popular elections of governments in the political field [10].
For this reason, the universal process within which the demise of the welfare state took place—both in general terms and specifically in the health sector—should divest itself of its economist clothes and be considered as an effort to decentralize the power of the state, which had rendered it inefficient and tyrannical, while broadening people’s sphere of action and, even better, the intermediate organizations that make up the ordered system of the society. Thus, civil society recovered attributes and functions that had been entrusted to the state, which seized them in its progressive transformation into what Octavio Paz [11], the Mexican writer, named the ‘philanthropic ogre’.
Therefore, market-oriented reforms should perhaps not only be understood as the transfer of state assets or functions to the private sector, but also as a deregulation and decentralization process that may bring an increase in efficiency to the social policies and their direct popular control.
If we define the state’s transformation (including its health sector) as a simultaneous process of privatization, deregulation, and decentralization, we take heed of Alexis de Tocqueville’ s advice about the need to increase citizens’ responsible participation in handling their affairs, particularly those of less importance, and thus consolidate their intervention in major public decisions and in this way guarantee democracy [12]. On the other hand, criticism over the excessive costs of social services (health among them) points to the fact that the imposition of public duties cancels, or at least greatly restricts, individual freedom. One result—particularly in the case of health programs—is that people as taxpayers tend to avoid paying taxes, while as users they try to maximize those social services from which they are beneficiaries.
The logical conclusion to all the above affirmations is that the proposals to solve these problems converged on the point of giving features of private organization to public social services and programs, thus originating what has been called the ‘market-oriented reforms’ introduced all over the world during the last years [13]. In short, health programs developed under the umbrella of the welfare state emphasized the provision of services for the whole population and highlighted that accessibility was a main quality criterion for a health services system. In some cases, the market-oriented reforms that resulted from the criticism of the welfare state were started before achieving the aim of universal coverage, and in others without even searching for it. The question with accessibility is whether, given that services are available, all individuals can gain access to them, whereas quality of care refers more to the attainment of professional and community standards of good medical practice. Therefore, members of the population without any type of health coverage—be it provided through public services or through private programs and facilities—are presumed to lack access to the health system, and this is certainly the case in many situations, even when no financial barriers exist and health care is free at the point of service.
It is widely known that most health care problems are not solved by the health services system, but as a result of changes in the physical and socio-economic/cultural environment, and by the lifestyle of the people [14]. However, the certainty of an effective access to the health system implies some sort of healing power, in the same way that Michael Balint postulated that doctors’ main therapeutic instruments were the doctors themselves [15]. Within the same line of reasoning, we can assimilate health to nutrition. It is one thing to count on well-prepared food (health services) providing all the nutrients necessary for growth or lactation, for example, and another that the whole population enjoys access to that food. In a strict sense, food or health services are of good quality when their contents are adequate; in a broader sense, and seen from the perspective of the population, the excellence of nutrition and health is related to accessibility for everyone.
It is for this reason that we maintain that accessibility should be considered a quality index for health systems, which could only be obviated when universal coverage has been firmly achieved. Certainly, this accessibility should be understood in the sense that the WHO Report defines it as new universalism, that is to say, ‘high quality delivery of essential care, defined mostly by the criterion of cost-effectiveness, for everyone, rather than all possible care for the whole population or only the simplest and most basic care for the poor’. The health care reforms of recent years constitute various attempts at solutions or adaptations to changed conditions, such as the effects of aging populations, chronicity and disability, heightened expectations and demands, and cost escalation and budgetary pressures [16]. In fact, we are going through a period of international health reform. In spite of the many differences among the world’s various systems, reform proposals are influenced by two concerns: the total cost of care as a burden on the economy or on private or public budgets, and whether systems are providing ‘value for money’ and thus whether they can be managed more efficiently.
In most Latin-American countries (and, to some extent, also in the United States) these issues run parallel with a conflict that has been settled everywhere else—over how and even whether to guarantee access to health care for all citizens. In other countries, access is an issue only because of concerns about how the pursuit of cost control and efficiency might affect access as well as other values such as quality [17]. As of 1990 almost all Latin American countries started to introduce changes in their health sectors, while experiencing at the same time such record levels of poverty that in many cases went below subsistence levels. The same direction, although from quite a different position with regard to economic development and health services coverage, was followed by the countries of the Organization for Economic Co-Operation and Development [18].
In many countries of the Southern Hemisphere, the much advertised managed care proposition can hardly be the cornerstone of health care reforms in communities with high social marginality and extreme poverty that require immediate solutions to health coverage, that is to say accessibility to health services. Nonetheless, Latin America receives pressure from health management organizations that can operate there with fewer restrictions than in their country of origin. This leads them to export their system to places like Argentina, Brazil, Chile, and Colombia, in association with local organizations, aimed at the upper- and middle-class segments of the market [19]. Managed care organizations and the like tend to use market strategies and benefits designs that ‘skim the cream’ of the patient population and exclude those with costly health conditions, thereby dumping patients on already financially precarious public health care services and worsening the access problem. It does not follow that in behaving in this way, they are violating obligations to ensure access to care. Nevertheless, as George Bernard Shaw said in The Doctor’s Dilemma, ‘that any sane nation, being observed that you can provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity’.
Looking at things from another perspective, those countries that adapted managed competition to their socioeconomic-cultural situations as well as the innovative proposals that rescue state intervention in the regulation of services, constitute examples of ways to interweave accessibility, equity, efficiency, and quality as a guarantee of solidarity in the development of promising health systems in emerging countries. In short, the market-oriented reforms imposed on countries whose health services have not reached universal coverage and have the additional ingredient of substantial poverty, marginality, and exclusion sectors, as is frequently the case in Latin America, not only fail to solve the ordinary problems of health care but also, due to adverse selection, tend to reduce population accessibility, thus exerting an unfavorable influence on the quality of health systems.
It has been said that the condition for effective action in a complex civilization is cooperation. And the condition for cooperation is agreement, both as to the ends to which efforts should be applied and as to the criteria by which its success is to be judged. Without concrete institutional arrangements that embody a commitment to ensure that every citizen has access to an adequate level of health care, there is no reason to believe that a health system will reach a quality standard with national coverage for the population [20]. The point we are making about accessibility as a legitimate criterion for the standards of quality in health provisions, and not as a mere means, should not be interpreted as contrasting with the aim for quality in health actions. Both criteria are complementary and not opposed, but their relative importance on health policies must bear a relation with the characteristics of the countries where they are applied. This could be the case for Latin America, to which Argentina, host to this ISQua International Conference, belongs.
Accepted for publication January 18, 2002.
 |
References |
|---|
 Top References |
|---|
- Eduardo Braun Menéndez 1903/1959—Portraits (in Spanish). University of Buenos Aires School of Medicine, Buenos Aires, 1989.
- Beveridge W. Report on Social Insurance and Allied Services. London: HM Stationery Office, 1942.
- Roemer MI. Medical Care in Latin America (in Spanish). Washington, DC: Pan American Union, 1964.
- World Health Organization. The World Health Report 2000. Health Systems: Improving Performance. Geneva, 2000.
- Montagut T. Social Policy (in Spanish). Barcelona: Ariel, 2000.
- White J. Competing Solutions. Washington, DC: The Brookings Institute, 1995.
- Jérôme-Forget M, White J, Wiener JM (eds). Health Care Reform Through Internal Markets. Montreal: The Institute for Research on Public Policy, 1995.
- Euzéby A, van Langendonck J. Neoliberalism and Social Protection: The Question of Privatisation in the EEC Countries. Geneva: International Labour Office, 1990 (mimeo).
- Maritain J. Man and the State. Chicago: University of Chicago Press, 1950.
- Mera JA. Privatization policies within the health system (in Spanish). In Instituto Torcuato Di Tella. Research Documents (in Spanish). Buenos Aires, 1996.
- Paz O. The Philanthropic Ogre (in Spanish). Barcelona: Seix Barral, 1979.
- de Tocqueville A. Democracy in America (in French). Paris: Gallimard, 1954 (first edition, 1835).
- Saltman RB, von Otter C (eds). Implementing Planned Markets in Health Care. Buckingham, UK: Open University Press, 1995.
- Lalonde M. A New Perspective on the Health of Canadians. Ottawa: Information Canada, 1975.
- Balint M. The Doctor, His Patient and the Illness. Buenos Aires: Libros Básicos, 1961.
- Powell FD, Wessen AF. Health Care Systems in Transition. Thousand Oaks, CA: Sage, 1999.
- Mesa-Lago C. The Crisis of Social Security and Health Care: Latin American Experiences and Lessons. Pittsburgh: University of Pittsburgh Press, 1985.
- Organisation for Economic Co-Operation and Development. The Reform of Health Care Systems. Paris, 1994.
- Commission on Public Health, Board of Medical Specialties, National Academy of Medicine, Buenos Aires. Social Discourse Versus Economic Discourse in Medical Care (in Spanish). Board Bulletin, 4th year, no. XIV, March 1999.
- Buchanan A. Managed care: rationing without justice, but not unjustly. J Health Polit Policy Law 1998; 23: 617.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. L. Traverso, M. Salamano, C. Botta, M. Colautti, V. Palchik, and B. Perez Questionnaire to assess patient satisfaction with pharmaceutical care in Spanish language Int. J. Qual. Health Care, August 1, 2007; 19(4): 217 - 224. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||