Jordan (2011) investigates public and private health care growth in 18 advanced industrial countries over a duration of 40 years and finds significant cutbacks in public spending in numerous states. Further, from the mid-1980s onwards these cutbacks happened independent from political ideology of the governing parties in the respective countries. Other evidence from Spain and from Sweden also showcases the presence of retrenchment in the public health care sector with regional varieties (Taghizadeh and Lindbom 2014; Pino and Ramos 2018).
A phenomenon and trend closely tied to retrenchment is austerity politics, which became especially feasible in wake of the global 2007/8 Financial and Economic Crisis. In terms of health care there is mounting proof of the existence of austerity politics in public health care and of detrimental effects on health of such policies. For example, Spain experienced significant reductions of medical staff and of hospital beds (Borra 2020). Adverse effects have also been found in Greece (Kerasidou et al. 2016) and in Southern Europe in general (Petmesidou et al. 2014). Comparative European evidence shows that substantial austerity was widely imposed on the public health care sector from 1995 until 2011 (Reeves et al. 2014), and potentially onwards. Reeves et al. (2015) find that austerity in health care increases unmet medical needs across Europe and Stuckle et al. (2017) highlight that public health austerity aggravates unequal access to health care, adverse social determinants of health, and restricted coverage, particularly affecting vulnerable parts of societies.
Health care reforms over the past decades followed different pathways. A study on several highly developed nations shows that reforms were frequently met with counter-reforms, so that there rarely were linear trajectories. This can be attributed to partisan and ideological alterations inside countries. There is also evidence for some diffusion and spill-over effects across countries (Toth 2010). Research on US states pinpoints the positive impact of introducing health insurance mandates and other measures when it comes to equity and socio-economic disparities (Pande et al. 2011). Ramesh et al. (2014) investigate 20 years of market-oriented health care reform in China and find that the country struggled with aligning elements of governance and neglected key health care stakeholders.
Health policy making nowadays should not be limited to directly health-related issues exclusively. Instead the strategy of Health in All Policies (HiAP) should be further established in health policy, particularly when pursuing more health equity. “Health in All Policies (HiAP) has developed as a mechanism to promote action on the social determinants of health (SDH) by facilitating action in sectors where health is not a primary consideration” (Baum et al. 2014, p. i131). HiAP programmes should not merely be copied because each programme is sensitive to differences in health care contexts (Carey et al. 2014). Therefore, there are mounting voices to treat social policy as health policy (e.g. Venkataramani et al. 2021).
The COVID-19 pandemic severely strains health policy practice, as political responses need to be dynamically adjusted to changes in a high-uncertainty and high-stakes environment. Very often health policies were introduced and communicated to the public in biased manners without a sufficient evidence-base (Halpern et al. 2020).
It requires government subsidies (Rege 2004) and/or mandatory minimum contributions (Bruns & Perino 2021) to increase and stabilise private contributions to a public good, such as health care. To solve the tragedy of the commons two solutions exist: government regulation or privatisation. However, both depend on collective action exercised by the government to put constraints on resource consumption (Hardin 1968; Frischmann et al. 2019). Thus, arguments strongly point out that health care should be provided by the state or in a market that is (heavily) regulated by the state. Evidently, most contemporary governments operate their health care systems with a public-private mix.
Maynard (2005) speaks of a macro-level monopoly of the bureaucratic associations and organisations in medicine that have major influence on regulating health care markets through expert voice and lobbying. Those monopolies of doctors control the supply-side of health care. Further, health care knowledge is distributed very asymmetrically, naturally being in the hands of medical professionals and some select experts. Thus, doctors become patients’ agents and suppliers in one. Another characteristic of healthcare markets is moral hazard, where patients in most systems have no incentive to be sensitive to costs of medical goods and services. The result is that patients and health professionals largely decide about consumption, while the majority of the costs are levied on the funding entities, mostly insurers. Therein, doctors can affect supply and demand alike. On another frontier purchasing power for medical treatment and care is distributed very unevenly across most societies. Such income-and/or wealth inequalities directly result in poorer health outcomes for the materially deprived population. Politicians in countries such as for instance the UK and the USA have addressed this issue of health equity not efficiently and sustainably (enough) according to criticism by Maynard (2005). As for health care reform, Maynard (2005, p. 286) notes: “The choice of funding source is essentially about the distributive goals that a society or its government wishes to achieve”. Consequently, politicians mainly try to shift the financial burden around to avoid imposing it on their respective clientele. To assert expenditure control through (yet imperfectly implemented) market mechanisms has not worked so far. In contrast, government control of public health expenditure has worked in many welfare states at least until now, even though there are many ups-and-downs due to the differential political landscapes and climates. As for improvements of efficiency, evidence-based medicine and policy making with the correct implementations are key (Maynard 2005). In terms of health equity Maynard (2005) advocates a focus on quality, and QALYs, rather than other metrics.
Hussain (2018) calls social institutions that instil too much competitiveness in people ‘morally defective’. This “… moral defect in excessively competitive institutions has two parts: (a) arrangements of this kind are less likely to generate the kind of social connectedness that is necessary for an adequate sense of justice and (b) arrangements of this kind directly violate the solidaristic requirements of the political relationship.” (Hussain 2018, p. 584). Therein, political relationship refers to the political relationship between members of a political community, which relies on mutual affirmation. Given the example of health care, private financing of health care would demand individual ability to pay for one’s health. It is then that the competition for higher incomes would result in a competition over health for individual persons. Labour market competition would thus descend into a life or death struggle. Exactly such a scenario must be rejected on grounds of social connectedness and of solidarity, according to Hussain (2018). However, trust in public institutions is pivotal because distrust is attributed to lower use of health care services and medication uptake, as well as to worse health outcomes (Whetten et al. 2006).