Back | Programme Area: Markets, Business and Regulation, Social Policy and Development
Health Systems and Commercialization: In Search of Good Sense (Draft)
Health policies reflect, and have always reflected, values, culture and policy priorities in different countries. The analysis of health policies therefore necessarily brings together sociological and political understanding and more technical evidence with insights from epidemiology, clinical medicine and economics.
However, in the world at present, health policy analysis has come to take a particular predominant form: the analysis of health care as an economic sector of health service provision plus a set of managerial evaluation techniques for analysing health care inputs and outcomes. The fragmentation engendered by this dual approach is often reinforced by a division within the institutions of health policy analysis between those whose interests and expertise lie in health protection and public health policies, and those whose “lens” is the analysis of health care perceived as a market-provided service. This dominant “common sense” of health policy then perpetuates fragmentation through a policy framework that allocates public health measures to a limited policy sphere of “public goods” while framing health services as a sector of market trading.
The authors draw on both new research and existing evidence to argue that this dominant common sense in health policy is in certain ways both incoherent and damaging. However, their aim is primarily constructive rather than destructive. It is well understood that a properly functioning health system is essential to an effective market economy. To make a health system work in a market economy, however, does not imply simply the commercialization of the health care sector itself. It requires a different starting point for health policy.
This alternative starting point has traditionally been articulated as part of a health systems approach. It recognizes the importance of values. It also acknowledges the existence of market failures in health systems. It draws on economic analysis of health care financing and economic assessment of health care systems as a whole. But it draws also on public health and medical knowledge concerning the needs and problems that health systems have to deal with. With this paper and the project to which it relates, the authors aim to provide the outline of such an improved “common sense”, as a foundation for better analysis and practice in health systems and health policy design.
In section 2, the authors discuss the concept of “health system”. They define it and discuss the ways in which the definition of health systems employed makes a difference, helping or hindering analysis and understanding of processes and change in health systems, as well as understanding of their role and purpose in a society. They also examine the economic ideas associated with the concept of health system, and draw contrasts with the dominant model of health sector reform and its economic presuppositions.
The values at the centre of health systems have today to be pursued in a rapidly changing context of health service commercialization, both within countries and in integrating international markets. In section 3 the authors seek to contribute to a better understanding of the nature and consequences of this commercialization, by examining cross-country and case-based evidence of different “paths” of health care commercialization.
In section 4 the authors evaluate the current commercialization of health care, arguing that the cross-sectional and qualitative evidence available offers no comfort for the commercializers. On the contrary, commercialization, many indicators show, is positively associated with ill health and exclusion. And some patterns of commercialization appear particularly damaging.
In section 5 the authors set out to define the basis for a new “common sense”, explaining in more detail what is meant by this term. They argue that to build effective and decent health systems, some elements and patterns of commercialization have been and will have to be blocked—not merely “regulated”—in the interests of public health and effectively functioning market economies.