Sarah Sexton, The CornerHouse
Health For All has long been the goal and rallying call of health movements worldwide. The challenge has been not only achieving it, but also working out how to do so. The key is tackling the things which make people sick in the first place: lack of food, clean water, shelter and livelihoods; exposure to various kinds of pollution, such as pesticide residues and toxic emissions; and inequalities.
If people do get sick, however, restoring health involves ensuring that health care services of a certain kind and quality are accessible to all. A general principle to ensure equity in health care has been to provide services according to need and to finance them according to ability to pay. The least regressive approach is for public entities to provide health care services and pay for them out of general taxation, as in Britain and Canada. Even the Financial Times comments that this is the fairest, most economical, most efficient and least bureaucratic way of funding the great bulk of health care.
Provision of services by for-profit entities paid for by private insurance or out of patients' own pockets is the most reactionary, as in the US system, which is the most expensive in the world and yet yields some of the worst health indices among industrialised countries. Universal social insurance, such as is common in continental Europe, falls somewhere in the middle.
GATS could facilitate the development of health care markets where health care services are bought and sold: bought by those who have the money to do so, and sold by those aiming to make a profit for their shareholders. Those who don't have the money - or whom insurers consider too risky, too old or too sick - lose out. What gets sold, moreover, is not health care to society but health products and procedures to individual consumers.
In a health market, a two-tier system quickly develops. The for-profit sector creams off healthy and wealthy patients, public subsidies and staff, leaving a reduced public sector to deal with emergencies, to train staff and to cope with the elderly, the chronically sick and the poor - those who most need health care.
If GATS is revised so as to require domestic regulations to be the least burdensome to trade and even pro-competitive, principles which underlie health care being accessible to all could be restricted. Cross-subsidising (through which one service effectively subsidises another) is one such principle. There would be no place for uncompensated health care, unprofitable admissions to hospitals, research, education or public health activities - all chronic money losers from a business point of view.
The challenge in striving for Health For All is to retain publicly funded and provided health care services, and to modernise and improve them based on the principles of democratic accountability, effective delivery, adequate funding, fairness at work and equality of access.
For further reading, see: Trading Health Care Away? GATS, Public Services and Privatisation, CornerHouse Briefing no 23 (July 2001)