Social medicine vs professional dominance: the German experience

Bismarck and the Long Road to Universal Health Coverage

The 2015 Sustainable Development Goals (SDGs) state that All United Nations Member States have agreed to try to achieve Universal Health Coverage by 2030. This includes financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Universal health coverage (UHC) means inclusion and empowerment for all people to access medical care, including treatment and prevention services. UHC exists in all the industrial nations except the US, which has a mixed public-private system and struggles with closing the gap between the insured and the uninsured population. Middle- and low-income countries face many challenges for UHC achievement, including low levels of funding, lack of personnel, weak health management, and issues of availability of services favoring middle- and upper-class communities. Community health services for preventive and curative health services for needs in populations at risk for poor health in low-income countries must be addressed with proactive health promotion initiatives for the double burden of infectious and noncommunicable diseases. Each nation will develop its own unique approach to national health systems, but there are models used by a number of countries based on principles of national responsibility for health, social solidarity for providing funding, and for effective ways of providing care with comprehensiveness, efficiency, quality, and cost containment. Universal access does not eliminate social inequalities in health by itself, including a wide context of reducing social inequities. Understanding national health systems requires examining representative models of different systems.

Health reform is necessarily a continuing process as all countries must adapt to face challenges of cost constraints, inequalities in access to care, aging populations, emergence of new disease conditions and advancing technology including the growing capacity of medicine, public health and health promotion. The growing stress of increasing obesity, diabetes, and other chronic diseases, requires nations to modify their health care systems. Learning from the systems developed in different countries helps to learn from the processes of change in other countries.

What can health services contribute to the reduction of inequalities in health?

Policies to reduce inequalities in health are needed in many different settings, one of which is the healthcare setting. This paper, drawing on the conclusions of the Copenhagen conference, explores the contribution that such policies can make within the healthcare system. In doing so it examines four themes. It begins by exploring the contribution that healthcare makes to health. It challenges the widely held view that this contribution is small, arguing that there have been major advances in the effectiveness of medical care and the use of evidence-based healthcare, so that interventions of proven effectiveness are increasingly delivered to those who will benefi t. Unfortunately, there is growing evidence that the benefi ts of modern healthcare do not benefi t all groups equally. Thus, there is an unfi nished agenda in many countries to enhance the equitable distribution of access to effective healthcare. Second, it explores the dynamic relationship between illness and poverty and, specifi cally, the impoverishing nature of illness in the absence of effective mechanisms to ensure solidarity and to provide social safety nets. It identifi es how all elements within a healthcare system have a part to play. Those responsible for healthcare fi nancing should ensure that funds are obtained in an equitable manner. Those who provide healthcare can do much to promote access for the disadvantaged and to use their facilities to promote health as well as cure disease. Third, it considers the specifi c needs of disadvantaged populations, and especially those whose needs are least visible, such as illegal migrants. It concludes by reviewing the need for better information to document the scale of inequalities, to evaluate interventions designed to reduce them, and to disseminate evidence of good practice.

Public health in Europe

Any attempt to describe public health in Europe faces the twin problems of defining Europe and of dealing with the diversity of health and health systems it contains. Health status varies considerably between countries. In some, health is improving, with substantial decreases in heart disease in many western and central European countries. In others, especially in the former Soviet Union, there is concern about the rapid increase in tuberculosis and AIDS. A national analysis does, however, conceal a substantial variation within countries, between regions, and between social classes. The responses to these threats to health are also diverse. A few countries have developed effective mechanisms to design and implement appropriate policies but, in many countries, the public-health community is weak. In particular, public health has largely failed in its role as an advocate of the health of the population. There are, however, many encouraging signs that this may change in the future.

The rhetorics and realities of community health care: the limits of countervailing powers to meet the health care needs of the twenty-first century

As the paradox of medical success leaves behind more chronicity, policy makers around the world increasingly focus on community-based programs both to address chronic health problems and to prevent major disorders. This essay presents my comparative sociological framework of ideal-type models for understanding the countervailing powers that underlie and shape different kinds of heath care systems and their limitations in addressing the health care needs of the twenty-first century. In this context, I then analyze the revival of community health care rhetoric in the United States and compare it to the realities in which it operates. The realities of institutional power, fragmentation in funding, illness as a private condition and health care as a private good, the lack of societal commitment, competition, and the waning of community cohesion all suggest that communal democracy will be difficult to achieve. Current successes require further investigation. Examples from abroad suggest, ironically, that community health care develops best if the state and health professionals make a deep commitment to it, against their own immediate interests but for their enlightened self-interest.