The Politics of Health in Europe (review)

Richard Freeman. The Politics of Health in Europe. European Policy Research Unit Series. Manchester, U.K.: Manchester University Press, 2000. xi + 164 pp. Ill. $69.95 (0-719-04213-5).

Health services, together with their associated industries--accounting firms, consultants, lobbyists, and so forth--have become technological systems of major economic importance to capitalist states and one of the largest components of government spending. The purpose of this thoughtful, informative book by Richard Freeman of the University of Edinburgh is to descry how the politics of health has played out in five European cultures--Italy, Sweden, the United Kingdom, France, and Germany--from 1880 to the present, with special focus on the more recent years. This volume is part of a series on public policy issues sponsored by the European Policy Research Unit at the University of Manchester. It deserves to be read and discussed by historians of medicine, for the essence of Freeman's study is his claim that despite the distinctive histories and cultural differences of his chosen examples, they work in similar ways and display common themes, purposes, and problems, expressed in the emergence of the "health-care state."

One of Freeman's eight chapters is devoted to countries with national health services (Italy, Sweden, and the United Kingdom), and another to those that chose social insurance (France and Germany), where government specifies entitlement to services but does not control the health-care system. Freeman provides a useful chronology of the legislation that led to the distinctive features of each country's system by 1940, to the extension of provision of services to universal access to care (1940 to1980), and to efforts to organize the health-care system (1960 to 1980). Since the late 1970s, there has been a wave of enthusiasm for health-care reform, accompanied by growth in the health economy, the declining policy influence of the medical profession, and confusion and tension across the board about the proper balance between the state and the "market."

Freeman makes cogent comments on national health systems versus social insurance. He observes, for example, that national health systems, while apparently simpler, are actually much more complex than social insurance; and that, while national systems are constantly being reconstructed, it is "those systems most driven by principles of equality and rationality which are most likely to be undermined by the failure to realise them" (p. 49). However, he shows that it is impossible to explain a given "health-care state" on the simple basis of its entitlements to service or the role of government. The distinctions between tax-based and insurance-based systems are not as great as one might assume. Overall, the various politics of health in Europe track and influence the politics of Europe as a whole; there is no "health politics" as such, only politics.

Many of the recent pressures on health care in the countries studied here are similar to those in the United States; for example, public health has been displaced "as much by the erosion of the concept of the public" as by changing understandings of health and disease (p. 138). Thus the question remains (unanswered) as to what is generically "European" about health services in Europe.

In raising these and other questions, in providing excellent basic documentation on the history of health policy in five countries, in describing the political background and organization of the health services with supporting statistics and economic data, and in comparing the similarities and differences, Freeman fulfills the goal of the series as a text for students and a thematic study of politics for all concerned. The book is succinct, clearly written, challenging, and well referenced.

 

Rosemary A. Stevens
University of Pennsylvania

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