ROUND TABLE DISCUSSION
The key to overcoming inequality is political commitment
Eötvös Loránd Tudományegyetem (ELTE) University, Social Policy Department, Muzeum Krt 4/C, H1088 Budapest, Hungary
One of the main conclusions of Gwatkins article was the need "to rethink the way in which health goals are established, and recast them in terms more relevant for inequality reduction". His recommendations and most of his article itself focus on the content of health policy and do not deal with the political processes and factors that shape health policy, such as competing interests.
The need for more reliable information on health inequalities (and the role of the international organizations in providing it) cannot be doubted. Its absence is a reflection of the lack not only of knowledge but of political commitment. The reverse is not true: if the health policy of a given country includes the reduction of inequalities, we cannot conclude that the political commitment to implement such objectives exists.
Why does the political commitment not exist? What factors prevent the reduction of inequities from being given priority in health policy? What could change the existing situation? Answers to such questions naturally vary from place to place. What I discuss here refers to the post-socialist countries, especially Hungary, but I believe that parts of it are valid elsewhere too.
In the 1990s in the post-socialist countries, the emergence of a group of wealthy people has coincided with a decline in economic performance, as reflected by a shrinking gross domestic product (GDP). Obviously, if some people are getting richer it can only be at the expense of the other social strata, partly the middle class and mainly the poor, who get poorer and poorer. In Hungary, for example, the gap in income between the lower and the upper decile from 1990 to 1997 increased from 4.5 to almost 9. The majority of the political elite, irrespective of their political allegiances, have tried to get into the richest part of society in the course of this social realignment. The political elite is much more sensitive about the inequalities between countries (which are to their disadvantage) than to the inequalities within their own country (which are to their advantage). The challenge felt most keenly by the political and economic elite, not only for their countries but for themselves, is to catch up with the West. Questions of internal inequality are much less compelling. A good example of this is health. In non-Western countries a major objective in health policies is to narrow the gap between their own and Western life expectancy, while unequal life expectancies within the country get no attention.
Miklós Tamás-Gáspár, a philosopher who was a key figure of the liberal intellectual resistance in the socialist period, describes the new political elite in harsh but accurate terms:
The ideas of welfare, public interest and good governance are meaningless to them. They do not want power because they want to save the world or make improvements or promote social justice, ... though they might sometimes inadvertently use such phrases. The new elite are as indifferent to the fate of the poor as their communist predecessors were (1).
The apparent contradiction between the new political elites lack of interest in social justice and the priority given to poverty alleviation as a social policy objective is deceptive. This policy can also be interpreted as the desire to increase GDP while remaining firmly on the development track that increases inequalities.
In the last decade not only socioeconomic factors but elements of the health care system itself have worked against the development of an equity-oriented health policy. The basic economic and budgetary interest was to reduce spending on welfare and health in order to reduce state redistribution. The concern of the physicians was quite contrary to this: it was to increase their own income and to reduce the gap between their own technology and that of the West. The effect of these factors on health policy was to make its share of the national resources the main concern, with little interest in increasing efficiency, and none at all in equity. The allocation of resources in the health sector was strongly influenced by the "background industry" of pharmaceuticals and health care equipment, and the emergence of market conditions in this sector. Another fundamental interest influencing health policy objectives is that of the high-income stratum of society in having better health care services for themselves.
As a result of these developments the Ministry of Finance gained a much bigger role in shaping health policy than the public health experts. The keywords for health policy were cost-containment, improved efficiency, competition, and the facilitation of market conditions. The improvement of the health status of the population was mentioned among the general objectives for decencys sake, and the reduction of inequalities was not mentioned at all.
The role of physicians is of fundamental importance in shaping health policy. During the last decade the attitudes and behaviour of physicians and other health workers have been fundamentally influenced by the fact that they are relative losers in the economic transformation: their social and financial status has gone down. The official income of health workers lagged behind that of business people and of other public sector workers. Gratitude money compensated only a minority of the physicians. This situation strongly influenced the views of physicians on health policy: their first priority was the improvement not of the populations health status but of their own income status. The situation was made worse by the fact that the prestige of public health experts, who "ex officio" dealt with the health status of the population, and health promotion was already declining in the 1980s and continued to do so in the 1990s.
Does all this mean that the situation is completely hopeless? I think not. The experts, politicians and co-workers in international organizations committed to the reduction of health inequalities have several tasks they can carry out.
Of course, neither the political elite nor the physicians form a homogeneous group: even in the circumstances outlined above there are politicians, bureaucrats and physicians who are committed to the reduction of inequalities in the context of their own scheme of values and political beliefs. But for the time being neither within the health sector nor outside it can a politically influential group be found that is willing to strive to reduce inequalities. The current situation will not go on for ever. A positive change could occur if more and more people in the political elite and in the bureaucracy recognized that the social costs incurred by increasing inequalities are too high. This recognition can be promoted by experts, academics and members of associations, as well as people in international organizations, who work to reveal the inequities and analyse their causes and consequences.
As to the relation between income and health, Wilkinson says that "evidence strongly suggests that as social differences in a society increase, the quality of social relations deteriorates". He adds: "The hypothesis is that the most important psychosocial determinants of population health are the levels of the various forms of social anxiety in the population, and these in turn are determined by income distribution, early childhood and social networks" (2). If the reduction of income inequalities and the improvement of social cohesion are not priorities in government policy, the mitigation of health status inequalities is unlikely to occur. Therefore a fundamental health policy question is: what are the conditions necessary for promoting an economic and social policy that decreases income inequalities?
Success in carrying out any given health policy objectives is affected by the following factors: the amount of power shared by the groups concerned; the resources available (in the absence of which even the most beautiful objective remains a dead letter); and the technical, professional and theoretical tools available. Power by itself, without an appropriate concept, is not sufficient to bring about a successful change, just as the appropriate concept remains useless without power. This is the framework within which to assess the chances of success for policies aimed at reducing inequalities.
As to technical and professional means, a small step forward could be to set up a unit within the public administration that has the specific task of investigating and monitoring health inequalities and evaluating the impact of government policy on reducing them. The establishment of such a unit would at least make it possible to detect and define these problems as part of the procedures of public administration.
To sum up, confronting politicians, physicians and society with the social costs of the currently increasing inequalities, and generating political commitment to reducing them by developing new approaches within public administration, could turn health policy into an equity-oriented direction. Such a policy should in fact reconcile the values of equity and efficiency.
1. Tamás Gáspár M. Paradoxes of 1989. East European Politics and Societies, 1992, 2.
2. Wilkinson RG. Health, hierarchy and social anxiety. In: Proceedings of the New York Academy of Sciences Conference on Socioeconomic Status and Health in Industrial Nations, New York, 1999 (unpublished document).