H.U. Deppe
Re-thinking the basic conditions of health care under the impact of globalisation
addressed to the 12th IAHP and XIV FADSP Conference, Palma de MAllorca 23 May 2002
1. Globalisation is an amorphus concept. The process of capital accumulation got a relevant push by the collapse of the socialist states and the development of the productive forces, triggered off by the micro-electronic technology. Public property becomes more and more privatised, market and competition shall self-regulate more social relations and the thinking in categories of business management penetrates and subsumes all social niches. That concerns too health care, a social sector which is controled by the state in the European welfare states. In this context we speek from a process of economisation.
Health care systems are not isolated social constructions. They are rooted deeply in the structure, culture and history of their societies. They are the result of social and political struggles. And they are a pre-condition for social peace in contradictionary societies. In opposite to the increasing globalisation of the capital health care systems are strongly connected with the national states.
On the backgrund of such developments it makes sense to re-think the fundamental principles of the social dealing with sickness and health.
2. Health or sickness as a whole cannot get the character of a commodity. Worldwide we cannot see a health care system which is regulated only by the market. That depends on serveral special items:
- Health is an existential good. It is a use value, which is in our societies collective and public � similar like the air we breath, drinking water, education or trafic and juridical security.
- It is not possible to decide being without sickness � like with commodities for consumtion.
- The patient do not know when and why he will become sick, by which sickness he will suffer in the future. Sickness is an event which cannot be regulated individually. It is a general life risk.
- The demand of a patient for medical aid is primarily not specific. At first the competence of an expert defines and specifies it. There is a relevant difference between the competence and information of a physician and a patient. And the physician has a big discretionary power for diagnostic and therapeutical decisions.
- Over this the patient is in a position of unsecurity, weakness, dependency, need in combination with anxiety and shame.
This short description of the relation between market and patient shows that social protection is necessary. The rules of supply and demand are in this field inadequat. Therefore the health care system is an exemple for the theory of market failure. The distributing forces of the market are insufficient here. The market is a blind power without orientation. And the social aims must be formulated by the state, the democratic community.
3. Over this we have to differentiate inside the economy between a rationality of the business management and a rationality which is orientated to the national economy. Problems and questions which are interesting for a single enterprise must not support the economy for the whole. Not seldom these two dimensions contradict each other. We know this especially from environmental protection or more obviously from the atomic industry. The expansion of the business rationality is not seldom an enormous wasting of social ressources. The social costs can be neglected until the society or the state intervenes under national economic and social aspects. This phenomenon we have too in health care. The transfere of costs from the outpatient to the hospital sector or vice versa can be a financial advantage for the prevailing institution. But under a general perspective it is more expensive. And under a microeconomic view � under the rationality of business management – ineffective or even dangerous health services can make the same profit like effective and useful one.
4. The patient-physician- relationship (or better: patient-healthworker-relationship), the basic relationship of medical care, is not in the public sphere of the bourgeois society. To speek about sickness � its causes, its special symptoms or its unusual care � sometimes is even not possible in the family or a partnership. There are the phenomenons of shame and fault. Speeking about sickness and looking for help is in the intimacy, the protected part of the private sphere. And the characteristics of the intimate sphere contradict the conditions of the market constitutively.
The patient-physician-relationship is structural asymmetric. The unequal division of knowledge and instrumental abilities, the one dimensional professional and social competence until the application of sanctions provide the social position of a physician with power. And how this professional power is used, depends considerably on external impacts. In this relation it is important to know how the professional power can influence the personal income of physicians, what are the criterions for the transfers from one to another medical institution, what are the criterions for applications or prescriptions and what are the spoken and unspoken guidelines for indications.
5. The question is: Why physicians are able to be so fexible? A relevant cause therefore seems to be obviously the scientific character of the applied or practical medicine and their necessary orientation to the so-called �single case� of a patient. And the single or special cases of the same sickness can be very different. Another cause is the obligation for practice. Often we have in medical practice a demand for immediate help. Therefore we have a big space of decision, a discretionary power, in medical practice. It follows sometimes the parole �anything goes�. This favours a different � occasionally contradicitionary � behaviour: It can be done to much � or it can be done not enough. We speek about overuse and underuse. We know exemples where we have both in one situation. It determinates not only the clinical indication but also different diagnostic methods of medical interventions.
This person-orientated, unsecure, sensitive and complex field is susceptible to external impacts. Money, competition, juridical security, professional carreers or deep rooted anxiety to loose the workingplace have a light game to influence clinical decisions � consciously or unconsciously. The neoliberal economic pressure with its instruments of market, competition and profit increased the struggle for market shares. The market produces winners and loosers. And the loosers are the economically weakest. At this time in our countries many physicians and health workers see in the relation between the pressure of the market and individual health care a constitutive contradiction. In general until now the utilitarist modell of cost-benefit thinking has a low acceptance. The power of definiton – what means “medical necessary” – is assigned to the medical profession. But we can registrate slow and calm changes. External impacts are penetrating medical decisions and selections. In a research study made in Germany we can read: �In the background of clinical decisions more and more indicators like age, privat or public insured, the profession, education and social status of a patient become a criterion. But with the words of an interviewt physician: Nobody would say this publicly. None of these criterions is legitimised by a moral codex, by law or by medical norms.� I think this is not a new knowledge � but the situation is increasing. All of us, who are working in medical institutions, can confirm this from their own experience.
The discretionary power of the medical profession, its space of decision, and that what we call �medical necessity� build the core of the discussion about unnecessary operations, unnecessary cardiac catheterization and PTCAs, the prescription of ineffective drugs or avoidable stays in hospitals. Meanwhile the problem is recognised: Guidelines, proofed standards and evidence based medicine shall replace or complete the pragmatical medical experience by scientific controled research results, which can be generalised.
6. On the background of these soft character of the medical science the medical institutions are confronted with the hard consequences of neoliberal economic modell. The expansion of market, competition and profit in health care will change the patient-physician-relationship fundamentally. The relation which is actually still based on confidence will change to a commercial relationship which is based on a contract. And to make an official contract is not even the result of good confidence, but more the result of misstrust. A contract shall controle a risky relation between more or less strange people with common interests. Confidence implicates a close relation which makes the patient possible to give intimate informations, which are essential for medical care. Therefore this relation is protected by the medical secrecy. The patient-physician-relationship is based on an asymmetric relation. From the expert is expected that he cares and cures a layman to the best of his (the experts) knowledge and belief. The layman can count on the competence of the expert, he can expect his good intentions, he can believe his statements and he can trust him. Confidence assumes responsible acting. Benefits which are offered on the basis of confidence are going in the direction of a credible promis. It is based on reliability and well-meaning.
On the orther hand let´s look at the meaning of contracts. They are a part of the system of laws. Contracts confirm common intentions with fixed mutual obligations of more or less strange persons. Especially the development of the market and the privat property determined the character of contracts. At the market equal propriators exchange their commodities for a negotiated price. � Of course the buyers and sellers are interested in their personal advantage!
The increasing commercialisation of the patient-physician-relationship demands from the physician more and more a special measurable service for a fixed price. This service becomes more and more the charakter of a commodity, which will be produced and distributed under the conditions of economic competition. The patient comes increasingly into the role of a customer or purchaser, with whom a seller of a commodity will earn money. And the best customer is normally one, with whom can be made the most money. Under such conditions patients perhaps will get the good service of a customer but not the necessary medical care of a sick human being. As much as the economic competition will increase, as much the demand for good purchasing power of the patient is asked. This provoces a merkantil incentive that more benefits will be done, which patients want instead of such, which they need. Patients as medical laymen define more and more what is to understand by medical quality. In the most cases it reduces the question of medical quality on the niveau of a short-term satisfaction. And satisfaction shall tie customers.
By the increasing commercialisation of health care even well informed patients will come into a difficult and confused situation. What mean medical recommendations and informations during the treatment � like:
This is medically not necessary. The risk of this intervention is in your case to high. Or: This therapeutical intervention is in your case not effective. Means this � it is not compatible with the knowledge and experience of medicine, or means it only, it is too expensive. How do the patient know, why the doctor gives him this recommmendation? Is it indeed the best therapy, which is necessary for his sickness? Will alternative treatments not be told to him? Do from such recommendations or prescriptions depend the carreer and the workingplace of the physician or even the creditworthyness of a private hospital, which determin the share price and the dividend. Or: Did the physician just got the information that he is beyond his budget? Here we can suspect the limits of the rationality of business management in health care. In such a case the rationality of business mangement is perhaps profitable but it contradicts deeply the social contract of our civilisation. The pressure of economic competition and capital accumulation in health care leads to a cultural change in medicine.
The increasing commercialisation seems to be not only a problem of practical health care but also a problem of medical researches and experiments with men. Many researchers are loosing the necessary care and responsiblitiy in their researches. The patients´ rights are not enough protected. The cause therefore is to see in the advanced commercialisation of medical researches. Results of researches must be achieved in short times. But exact and fair enlightment of the people or patients need time. Over this many scientists take part commercially at the products of their researches in clinical studies. And a German pharmacologist formulated: The quality of health care is threatened by an increasing uncritical submissivness of researchers under the interests of industrial sponsors. This is the consequence of the retreat of the state from the promotion of clinical researches.
7. What is my message? I am deeply convinced that we have relevant sectors in our societies which should not be privatised and commercialised, because it will counteract and destroy the humane and social values of our societies. We have to respect and to keep on areas in our societies, in which the communication and co-operation is de-commodified, where services have not the character of a commodity. Such sectors must be socially defined and protected. Such sectors are dealing with vulnerable social groups, vulnerable social aims like solidarity and equity or vulnerable structures of communication like the physician-patient-relationship. They build the core of our European welfare model. And I think, it is worthful and necessary to struggle for its efficient public and non-profit structure.
Of course this is not easy! But I think there is hope. The popular masses in Europe with their traditional experience of welfare resisted the naked neoliberalism and elected some years ago parties of the so-called “third way”. But meanwhile they had to recognice that the parties of the third way are following too the mainstream of neoliberalism in different clothes – and that they can take influence only by pressure. On this background we have to see the worldwide emergence of new social mass-movements from Goeteborg over Genova to Porto Allegre. In Germany we have in September federal elections. The election campagne has started already. One point – beside the main point of unemployment – is the health reform. Especially the main trade unions resist its neoliberal change. And they are since some weeks in a direct alliance with the new mass-movement of ATTAC coming from France- which is very popular among young German people. And the main political parole of ATTAC in Germany is at this time : Health is no commodity! That let´s hope!
Hans-Ulrich Deppe, M.D.
Professor for Medical Sociology and Social Medicine
Univeristätsklinikum der J.W. Goethe-University
Theodor-Stern-Kai 7
60590 Frankfurt
International Association of Health Policy 