Keep Our NHS Public is proud to have been invited to participate in a roundtable discussion at a three day meeting entitled ‘The Future is Public! Europe in movement for universal public Healthcare’ held online and in person in Fiesole, Italy, on the 8th September 2023. The discussion was moderated by Nicoletta Dentico, Head of the Health Justice Programme of the Society for International Development and author of “Banking on health: the surging pandemic of health financialization”. Nicoletta opened the meeting, and then invited speakers made contributions from the UK (John Puntis for KONP), Portugal, France, Germany, Greece and Italy – briefly summarised below.
Nicoletta reminded the audience that it is 75 years since the ‘right to health’ was declared by the Word Health Organization (WHO), seven months before the Universal Declaration of Human Rights that also referred to health as part of the right to an adequate standard of living (article 25). The right to health was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights. She pointed out that the covid pandemic had taught important lessons with regard to public health, but that many of these were not being learned by governments. ‘The future is public’ meeting was intended as a challenge to increasing privatisation, commercialisation and financialization of health care. Governments have a responsibility to the public, not limited to health matters, and cannot limit their role simply to reacting to market failures. The World Health Organization is proposing that under the slogan ‘health for all’ (from the 1978 Alma Ata declaration), economies must be transformed in order to deliver what matters to the public. Mariana Mazzucato is chair of the WHO Council on the Economics of Health for All that has been working on how such transformation might be delivered. The human right to health must be central to this, but so too, wider consideration of global environmental health.
Financing ‘health for all’ requires public investment; the private sector will never make long term investment in health and is concerned primarily with making short term profit. Debt cancellation is an important health issue, for example, during the Covid-19 pandemic some African countries were prevented from spending more on health services because of their debt repayments. The WHO itself must be rescued from the influence of the private sector. We need to reshape the relationship between public and private, with the public sector being in the driving seat and defining what conditions should apply for involvement of the private sector. Global equity of access was sadly lacking in the pandemic, with unequal distribution of vaccine and rich countries sitting on vast stockpiles. Health workforces must be strengthened, within an appreciation of the wider meaning of ‘health’ and what that means for us all. The Ministry of Health should not be subservient to the Ministry of Finance; governments must be accountable for what they do; regulation and accountability are both essential.
England
I gave a brief overview of KONP’s objectives to restore fully public health and care services and how we work as a campaigning organisation to inform the public and build links with health workers, together with a picture of the current state of the NHS. Collaborative work with Independent SAGE in developing a charter for health and care, and with the 99% Organisation are examples of pushing for a much broader view of health and care as being fundamental to a healthy and more equal society and providing the basis for a healthy economy.
Portugal
Portugal has a national health service (a good example when asked ‘why has no one followed the example of the NHS if it is so good’! – JP). All health care professionals are salaried public employees. The public service coexists with a private sector which people can choose to use if they so wish. The public health service was founded in 1979 following the ‘carnation revolution’ as a universal service free of charge. In 1986 co-payments were introduced but in 2019 private-public-partnerships were banned by law. In 2020 co-payments were abolished but the coming election may see a more right wing government take control presenting clear dangers to the public health service.
Germany
Until 1984 hospitals in Germany were forbidden to make profits and there were no private hospitals. Neoliberal policies have been very successful in changing this with a dramatic increase in the number of private hospitals driven by the introduction of market competition and pricing mechanisms. In 2002 a diagnostic-related group (DRG) framework was introduced by law, dictating a flat fee for reimbursement based on the diagnosis for each admitted patient. Competition between hospitals recasts patients as customers, while the law regulating staff/patient ratios was abolished, leading to much increased numbers of patients/nurse being imposed. The system triggered a marked increase in procedures not medically necessary but more profitable than conservative management (a phenomenon not confined to Germany of course – JP). It has also led to closure of paediatric and obstetric departments in many hospitals and insufficient paediatric intensive care facilities simply because these are areas that are unprofitable. Profit driven hospitals have increased the number of patients treated and reduced length of stay. The higher case load and poor staffing ratios have contributed to a staffing crisis that has further affected retention and recruitment as well as provoking push back from health workers.
In 2015 the fight by staff for a collective bargaining agreement that included safe staffing levels developed into a broader struggle against privatisation and the profit motive in health care (Unite is now focusing on safe staffing in current disputes in London – JP). Civic society groups began to form to support health workers in struggle and strikes took place in 2021 and 2022 with demands for defined staff/patient ratios not only for nurses but for each employee group in hospital, effectively challenging the DRG system. In 2023 there was a strike in a privately run university hospital in Marburg, fuelling recognition that market competition and privatisation have been a disaster for the health system and that health itself must be considered as a public good in its own right.
France
Legally, since 2016 anyone who works and resides in France is entitled to payment of health costs but use of the private sector is growing including in primary care, while health inequalities are also increasing. Whether e-health, artificial intelligence, ‘hospital at home’, etc. can meet the expectations of patients is an open question. All government health service reforms are justified by the objective of ‘saving the French social protection system’ but then involve reducing benefits.
Greece
The spending cap imposed upon Greece by the European Union forced a reduction in health care expenditure as a percentage of GDP from 6% to 4.6%. Unemployment increased to around 33% and one third of people had no health insurance to cover costs; 2015 saw many migrants arriving. Anti-austerity protests were supported by health care professionals. Solidarity efforts to provide free health care involved groups organising primary care services, free medicines, and mediation services to help people access care where available. The election of the Syriza left coalition led to an extension of access to care for the unemployed but excluded those migrants without papers. Lack of funds had an impact on the pandemic response, with severe shortage of hospital doctors, intensive care facilities and hospital beds. Health spending has remained low compared with the EU average.
Italy
Public health care in Italy has been subjected to a slow and protracted siege with increasing costs for providers and labour shortages. Inflation and economic slowdown can be expected to exacerbate problems further. Austerity policies have damaged staff morale. The assault on the public sector has not been conducted as a frontal attack but by slow attrition. It is clear that there is wasteful spending in the private sector, but tax reform, regional autonomy and government spending reviews prevent funding increases for public services. The NATO commitment to spend 2% of GDP on the military will inevitably adversely affect health spending and the ability to maintain services. Of course the Covid-19 pandemic has been an example of Naomi Klein’s observation that those opposed to the welfare state never waste a good crisis for furthering their own agenda.
Conclusions
Many of the observations presented from around Europe at this discussion will sound familiar to health and care campaigners in the UK. The right to the enjoyment of the highest attainable standard of physical and mental health was first articulated in the 1946 Constitution of the World Health Organization (WHO), whose preamble defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. It is further stated that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”.
The participants at the ‘The Future is Public!’ meeting argued strongly that we need a rights-based perspective in campaigning for publicly funded and provided health services. Health expenditure should be protected against fiscal tightening with a special rule that would permit financing through debt. Public money should be used to defend those under siege. Covid-19 was a consequence of a collective failure to heed warnings over pandemics and millions died unnecessarily as a result, with an estimated 100 million being pushed into poverty. 870 million doses of vaccine were hoarded by rich countries and knowledge was not shared as it should have been. The pandemic revealed huge societal inequality and emphasises the importance of reshaping the economy to prioritise ‘health for all’.
A coalition of trade unions, health activists, and organizations have now launched an all-European campaign against the commercialisation of health. In a joint effort to combat the growing marketization of health services in Europe, three organizations – the European Public Services Union (EPSU), the European Network Against Commercialization of Health and Social Protection, and the People’s Health Movement (PHM) Europe – have announced a renewed campaign aiming to bring health to the forefront of the European Union’s (EU) agenda.
Key priorities include ensuring adequate public funding to guarantee quality care and decent working conditions, improving the accessibility of health services across geographical, financial, and cultural boundaries, building democratic participation of health workers and patients in decision and policy-making, and adopting medicine policies that benefit both the people of Europe and of the Global South. One of the campaign’s central objectives is to develop strategies and mechanisms to address the shortage of health workers.
The campaign will culminate in a major protest in the week leading up to World Health Day 2024, a global health awareness day celebrated on April 7th every year and first established by the WHO in 1950 to raise awareness about the importance of health and well-being. Despite Brexit, European activists rightly see the UK as part of this struggle.
