Seven: The health debate: what and where next?

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Health system reform is likely to remain an international preoccupation as countries of different political persuasions and at different stages of development seek to balance rising demand and limited resources. In balancing these, policy makers have to wrestle with a variety of interlocking political cleavages that constitute an ongoing health debate. The spread of universal health coverage, actively encouraged by the World Health Organisation (WHO) and others, is an example of this global phenomenon.

The purpose of this book has been to describe and analyse several of the principal policy cleavages that have exercised, and continue to preoccupy, policy makers in their never-ending pursuit of the perfect health system. On the evidence reviewed here, such a laudable goal is probably unattainable – less imperfection is the best that can be hoped for – although this truism will not prevent policy makers and their advisers from making the attempt, especially in a context where there is a loss of institutional memory and a seeming reluctance to learn from history. As Judt perceptively cautions: ‘there is something worse than idealising the past … forgetting it’ (Judt 2010: 41-2).

Running through each of the policy cleavages considered here – the funding and organisation of health systems, the attempt to shift the emphasis from health care to health to combat dramatically rising lifestyle problems like obesity, alcohol misuse and mental ill-health, priority setting and rationing health care, and the appeal of markets and choice and competition as drivers for reform – is a tension between the bureaucratic reformers and market reformers that Alford (1975) described over 30 years ago.

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