Farewell to welfare myths

FAREWELL TO WELFARE MYTHS

"Under capitalism, man exploits man. Under communism, it's just the opposite"

(Galbraith, 2001)

Introduction

The discussion below aims to show that healthcare provision and health outcomes are more strongly related to political tradition than to the political system advocated by a country"s ruling party. The two countries chosen to exemplify this are New Zealand (NZ) and Spain, two democratic countries with different government systems and political structure but with something in common: both have a tradition of universal welfare provision. The definition of tradition will be followed by a comparison and critique of the two main modern-age political systems, capitalism and socialism, and of the political parties that advocate one and the other, namely, the neo-liberals for the former and social-democrats for the latter. How neo-liberalism and social-democracy influence the macroeconomic factors that affect healthcare provision will also be evaluated. The origins of universal welfare as the basis of today"s healthcare systems in Europe is the grounds on which tradition prevails over ruling party ideology when it comes to healthcare or, as it is known in Europe, social security provision. The discussion will conclude with an analysis of the type (public vs. private) and amount of funds NZ and Spain dedicate to healthcare and their relation with health indicators and outcomes in their current socio-political contexts.

Discussion

Merriam-Webster"s dictionary (2008) defines "tradition" as the "continuity in social attitudes, beliefs, behaviours, customs and institutions from one generation to another without written instruction". When it comes to politics, two systems more than traditions, are identified: Capitalism and socialism, and as already mentioned, the former is advocated by neo-liberal parties and the latter by social-democratic parties.

Socialism places society and equality above individuals and their freedom to choose. The collective abstract is more important than real people, which justifies any action on behalf of equality (Kornai, 2000). Socialism promises prosperity, equality, security, and redistribution of resources in order to promote better health outcomes (Navarro, Muntaner, Borell, Quiroga & Rodriguez-Sanz, 2006), freeing people from poverty, exploitation and discrimination (Cheyne, O"Brien & Belgrave, 2008). On the other pole of the spectrum, capitalism places the individual, private property and market economy on top of its priorities. Capitalism promises prosperity, choice, innovation and excellence (Perry, 1995), with freedom to do virtually anything to obtain benefits for investment.

Social-democrats advocate socialist collectivism, a centralized intervention and control of means of production and services, from education and housing to healthcare (Cheyne et al., 2008). In exchange, citizens are asked to sacrifice their individual liberties in the name of the collective benefit. Neo-liberals critique this view claiming that such an all-providing government decides what is good, bad, allowed and forbidden, keeping individuals in a vote-guaranteeing permanent state of dependency and immaturity (Kornai, 2000).

Neoliberals refer to individuals as consumers and advocate capitalist individualism or "laisser faire", with a decentralized, minimally interfering state (Cheyne et al., 2008). Social-democrats see this as the hegemony of the privileged market-influencing classes which builds up and perpetuates poverty and transgenerational social exclusion.

But healthcare provision depends on the good health of a country"s macroeconomic factors in order to subsist. Neoliberals see the free market as a spontaneous, voluntary social order which "works locally and globally through incentives, market prices, hard work, efficiency, profit-and-loss accounting, and well-established property rights that promote prosperity" (Perry, 1995). On the other hand, social-democrats" state interventionism in the calculations of prices means that no shortage-and-surplus or profit-and-loss tests can be done, there is no accounting system and no real economic calculations can be done. Neo-liberals claim that social-democracy is a system that conflicts with natural conditional responses, ignoring motivation, incentives, or expectations of reward-for-effort, resulting in stagnation of the economy leading to the "tragedy of the commons" on a national scale (Hardin, 1968).

With the aim to adopt the best of each political system, the Third Way option emerged in the 90"s (Jordan, 2010). It was developed by US President Bill Clinton and Australia Prime Minister Paul Keating to make the liberal left electable while providing a happy medium between social policies and the prevailing globalized market economy to ensure funding for good service provision, like the much debated universal welfare.

It was Otto von Bismarck, the conservative Prussian Minister of the Presidency, who between 1883 and 1889 designed and implemented what he called "practical Christianity", a social insurance programme which became the model for all the European countries and the basis of the modern welfare state (Taylor, 1969). Bismarck introduced state-provided old age pensions, accident insurance, medical care and unemployment insurance. His paternalistic programme was opposed by the Social-Democratic party but it was approved with the votes of his fellow conservative Lutherans, the Catholics, the entire German industry and the working classes. His plan reduced the outflow of immigrants to America, where wages were higher but welfare did not exist (Taylor, 1969). Additionally, Bismarck instituted the "Anti-Socialist Laws" to prevent the corruption of his programme as a consequence of the expansion of Marxism.

With considerable differences, both NZ and Spain have universal welfare systems. Such differences may stem from each country"s government structure and political systems. With reference to government structure, NZ has a centralised unicameral parliamentary system of government (NZ Government, 2011), whereas Spain is a constitutional monarchy with a federal bicameral (Congress and Senate) parliamentary government (Spanish Government, 2011). The NZ parliament delegates some power to the country"s 12 regional councils with regard only to tax rate settings, environmental management, transportation planning and civil defence but not health care services or provision (NZ Government, 2011). In Spain, the parliament delegates complete power to the 17 Autonomous Communities (the former Regions) with regard to everything (including healthcare management and provision) but not tax rate settings and collection, and defence (Spanish Government, 2011).

Looking at political system preferences now, the neo-liberal National Party and social-democrat Labour Party have dominated New Zealand political life since 1935 (NZ History, 2008). The Labour Party ruled for 26 years, from 1935 to 1949 and then in 1957-60, 1972-75, 1984-90, whereas the National Party ruled for 53 years, from 1949 to 1972, 1975-84 and from 1990-2011 (NZ History, 2011). This means that NZ citizens clearly prefer their politics, economics and healthcare to be run by neo-liberals, but Spain is not quite so clear about it. Although the neo-liberal Popular Party (PP) is also the most voted party, it can only rule when it gets an absolute majority overruling the multiple possibilities for left-wing coalitions. The neo-liberal Union de Centro Democratico (UCD, now extinct) and PP ruled for 15 years (Spanish Government, 2011), from 1975-82 and from 1996-2004, whereas the social-democratic Partido Socialista Obrero Español (PSOE) ruled for 21 years, from 1982-1996 and from 2004-2011.

A brief review will now be made of the health systems of NZ and Spain. This analysis will help understand not just what citizens have traditionally come to expect from their governments, but also how health outcomes have evolved over the years based on the provision of funds for healthcare.

The centralised NZ governmental tradition leads to a more rapid and efficient control and distribution of funds with regard to the healthcare provision. However, this ability to adapt to the ever-changing economical, political and environmental conditions may lead to certain instability in the provision of services (Blank & Burau, 2007). Public healthcare services in NZ are financed through a combination of taxes and patients" co-payments for general practitioner"s fees, prescriptions, dressings, orthopaedic material, and any non-standard complementary procedure or test required (Ministry of Health [MOH], 2011). Only citizens and emergency attention qualify for eligibility to benefit from the NZ healthcare system. Secondary, tertiary and maternity care are also free for NZ citizens. GPs act as gatekeepers for secondary care (Blank & Burau, 2007). With 17 Autonomous Communities, the decentralised Spanish healthcare system finds it very difficult to adapt to change and it has led to relevant inequalities in the amount, type and quality of services received by patients.

In Spain, like in all European Union countries, social insurance for healthcare operates under the principles of solidarity, subsidisation and corporatisation (Spanish Government, 2011). The employer pays for the workers" social security (from 20% to 35% of the gross annual pay for that position depending on the salary perceived), and also for professional development, non-competence, full-dedication, union fees, transportation and displacement, and productivity incentives (Ministry of Health, Social Politics and Equality [MHSPE], 2011). Salaries are all pre-established within a range depending on the professional category.

Further considerable differences with the NZ welfare system include the fact that in Spain, out of each pay check, each worker is deducted a certain percentage to cover for additional full pays in July (for the summer holidays) and December (for Christmas), unemployment, accident compensation, contingencies, and retirement (MHSPE, 2011). There is a salary cap under which workers are exempt from paying income taxes to the state. The central government allocates a proportional percentage of funds to each federal MOH. National health policy implementation and decision-making become almost impossible in this decentralised setting compared with the centralised system in NZ.

But regardless of logistic issues and of whatever colour the national or regional government happens to be, all Spanish citizens receive free medical and specialist attention. Unlike in NZ, co-payment applies exclusively to prescriptions, with the exception of retired or permanently-disabled citizens who do not have to pay for them (MHSPE, 2011). Any individual going through the emergency door or maternity unit will get free medical and surgical attention if the diagnosis requires it. Spanish citizens have been getting this healthcare provision since 1946. It"s become a tradition to expect and receive this kind of health service.

The differences between the NZ and Spanish health systems are notable, but are health outcomes (see Table 2) in these two countries very different if at all, and, can those differences be based on funds made available for healthcare provision (see Table 1)?

Table 1

Health Expenditure in 2003 and 2009 as Percentage of GDP in New Zealand and in Spain

Source: Organisation for Economic Cooperation and Development (OECD) (2011)

Table 2

Key Health and Developmental Indicators

Sources: Infant mortality and life expectancy statistics from OECD (2011).

Inequality-adjusted statistics from United Nations Human Development

Report (UNHDR)(2010).

Table 1 shows that over the 6-year period chosen, and despite the fact that NZ had a neo-liberal and Spain a social-democrat government, both countries dedicated ever-increasing funds to healthcare. NZ destined an average of 9.1% of its GDP to health expenditure, most of which, around 80%, came from public funds. Private contribution was only 20%. Similarly, Spain contributed with 8.9% of its GDP to health expenses, 73% of which was funded publicly and 21% came from private insurances. Given that Spain has 10 times the population of NZ and in view of the previously described health services the citizens of each country get, NZ contributes proportionally more and gets less. But is this reflected in the OECD and UNHDI?

Table 2 depicts three key UN health indicators: Infant mortality, life expectancy and HDI. Infant mortality is particularly relevant as it assesses a society"s health system and quality of life (Benoit et al., 2005). The infant mortality and life expectancy health figures indicate that Spain has better health outcomes for investment, However NZ ranks 3rd whereas Spain ranks 20th in the 169-country inequality-adjusted UNHDI. This is because health is only one of over 400 indicators of health and development in the HDI database, and indicates that factors leading to a country"s overall good health depend on other macro-level issues like those depicted in the Ottawa Chart for Health Promotion and the Sundsvall Conference (WHO, 1986, 1991) among others, rather than just (the needed) funds for public healthcare, otherwise extremely rich longstanding socialist countries like Venezuela (rank 75) or communist China (rank 89) would rank way on top of neo-liberal USA (rank 4) in the inequality-adjusted HDI (UN HDR, 2011).

Conclusion

The analysis of the socio-political context of NZ and Spain shows that even though the two countries allocate a similar proportion of their GDP for funds to maintain their universal welfare status, Spain has better health outcomes than NZ. However, NZ is much higher in the HDI rank. This comes to show that despite differences in the ideological orientation of the party in office, the management of macroeconomic factors that take into account social policies in the context of a globalized market economy is the key for the stability and growth of a country"s GDP so that more funds can be directed to healthcare. Although social-democrats keep claiming ownership of anything social in politics, their relationship with universal welfare in Europe has been their opposition to its creation and implementation. It is the social acquisitions that have passed from one to another generation, like the tradition of health provision in the context of universal welfare, that play a determinant role in what citizens expect politicians, be they neo-liberals or social-democrats, to provide to them when it comes to healthcare in NZ and Spain.

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Autor:

V M Westerberg