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NEWS and COMMENT

London Perspective

Health services: compare and contrast

Like a patient who has forgotten that others are sufferingtoo, the UK has become self-absorbed by the Government’srestructuring of the NHS and remains unaware that changeand debate are taking place across the western world. TheDutch are still debating-and partly implementing-theDekker Report’s recommendations on the structure andfinancing of the Netherlands health service; the WestGermans’ 1988 Health Act came into effect last year,introducing new controls over drug expenditure andincreased user charges to stabilise social insurance

contributions; and the Swedes are in the middle of a healthreview. Meanwhile the insular British have a new book

(Health Check,! from the King’s Fund Institute) whichreviews health provision in six cleverly selected states-three tax-based systems (UK, Sweden, and Canada), twomixtures of compulsory and private insurance (Holland,West Germany), and one privately financed with a defectivepublic safety net (US).

It is best to start with some of the conclusions, particularlyin a period in which ministers are trumpeting the benefits ofthe British Government’s proposed restructuring: "... ourprincipal conclusion is that all methods of funding have theirweaknesses... as far as health care delivery is concerned, it isclear that a number of problems recur almost regardless ofthe method and level of funding... in all countries there isdissatisfaction with the effectiveness of the chosen

strategy... "The three most common dilemmas of the six services are

familiar enough to British health policy-makers-too muchemphasis on hospital services; inefficient use of hospitals;and a need to improve the integration of the separate parts ofthe system. On this third problem, the UK has done betterthan most, but the system is set to become more fragmentedwith the restructuring.There is nothing predictable about any of the systems. A

tax-based service can, as it does in the UK, produce anunderfunded service with only 6% of national incomeinvested in the system. But other tax systems do muchbetter. Both Sweden (9%) and Canada (8-6%) spend ahigher proportion on health than the social insurancefinanced systems of Holland (85%) and West Germany(82%). The "free market" in the US produces 11 2%(almost double the UK proportion and treble the actual levelof expenditure) yet ends up much lower down theinternational league tables of public health-and with asafety net, Medicare, that now excludes 40% of poorAmericans.There is a tendency in all systems to believe that the grass

on the other side of the border is greener. The regulatorysystems are examining ways of introducing more

competition; the market-oriented systems are looking atways of introducing more regulation. There is a specificmessage for Mrs Thatcher, who believes that, by separatingdistrict health authorities into provider and purchaserdivisions, the NHS will automatically become moreefficient. The authors warn: "Neither the provincialgovernments in Canada nor the sick funds in Holland andWest Germany have attached high priority to assessing theway in which hospitals use their budgets. The absence ofprudent purchasers in these countries is one of the reasonswhy there are inefficiencies in service delivery".

Every State has its up and down side. The Swedes haveachieved a comprehensive service based on need with a highstandard of hospital and health centre accommodation. Yetthe separate parts are poorly integrated, GPs are unable toact as gatekeepers because Swedish citizens have a statutoryright to refer themselves to hospital specialists, and there aretwo-year delays for hip replacements, cataract surgery, andcoronary artery bypass grafts. The Dutch have avoidedwaiting lists in their comprehensive service, patients have awide choice of doctors and hospitals, and there is stronginterest in medical audit; but the system was late in tacklinginefficient hospital payment systems and its social insurancecontributory base contains several inequities. Paradoxically,although the Dutch system has much less central controlthan the UK’s, it has much tougher restrictions on healthcare technology including statutory power to regulate thelocation of ten services (renal dialysis, renal transplantation,radiotherapy, neurosurgery, cardiac surgery, heart

catheterisation, nuclear medicine, CT scans, prenatalchromosome examination, and neonatal intensive care).Similarly, the control over the introduction of new

technology cannot be predicted by a health system’s fundingsource. The three States that make a serious effort to assessthe financial and service impact of new technology-the US,Sweden, and Holland-are in each of the three separatefunding systems. The report suggests it is time the UKfollowed suit and set up a national agency TO assess the

implications of new inventions.The emphasis that each State places on public health is

more dependent on culture than on the structure of thehealth system. Both Canada and Sweden have followed thelead set by WHO and produced clearly defined strategies forthe promotion of health. The Swedes emphasise theimportance of collective provision and the need to tacklesocial, economic, and environmental causes of bad health,whereas the Canadians and the Dutch, who have alsoresponded to Health 2000, underline the contribution thatindividuals can make by altering their behaviour and

lifestyles.The report explores whether the UK would be better off

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with social insurance rather than a tax base. It points to theadvantages of an earmarked tax in which consumers wouldbe able to see the link between what they pay and what theyreceive. But it notes several disadvantages. First, the effectthe increase in contributions can have on labour costs.

Average contributions in West Germany are now 13% ofincome, divided between employee and employer. Second,the inequities that occur, as they have in Holland, whenpeople with low incomes end up paying highercontributions than the better off. Third, the abitrary natureof contributions, which in West Germany range from 8 % to16% depending on the risks of the group represented.White-collar staff end up paying less than blue-collarworkers.The report will provide useful facts when the British

Government finally returns to the dilemma which triggeredits review-the underfunding of the NHS. The reviewbecame diverted into reconstructing the delivery of healthservices; the underfunding, estimated by the Conservativecontrolled Commons Select Committee at c2000 million,remains to be resolved. The idea that the Governmentwould find it easier to put up insurance contributions-as

against tax-is a myth. Ask the pensioners. Every retiredcouple has lost C 17 a week in the basic retirement pensionbecause of the Government’s reluctance to put up nationalinsurance contributions to a level which would havemaintained the link between pensions and earnings.

1. Health Check. By Chris Ham, Ray Robinson, and Michaela Benzeval. £9.95 plus £1post from Department D/KFP, Bailey Distribution, Folkestone, Kent CT19 6PH,UK (cheques to Bailey Distribution).

Malcom Dean

Round the World

Switzerland (WHO): Safe motherhood

The first meeting of interested parties of the SafeMotherhood Initiative was convened by the World HealthOrganisation in July, 1988. It drew attention to the

magnitude of maternal mortality and morbidity around theworld---one woman dies every minute from pregnancy,birth, or abortion, and 99 % of the deaths are concentrated indeveloping countries. Early on the initiative highlighted themany social, educational, nutritional, transport, economic,and legal factors affecting maternal mortality. The

representatives of developing countries, donors, and expertswho gathered in Geneva for the third meeting, on June18-19, emphasised again that the very range of variablesinvolved excludes any simple technical fix. A change ofattitude can be just as important-for instance, Sri Lanka,which has the lowest maternal mortality in South Asia, nowhas a Ministry of Health and Women’s Affairs.The Safe Motherhood Initiative is evolving from an

eloquent plea for attention to be given to a sad and commonproblem to an analysis of solutions and efforts to estimatecost. The WHO secretariat and the agencies are helping todevelop strategies to combat high maternal mortality bytrying to analyse separately the impact of various

interventions, such as family planning, the prevention ofanaemia, and the provision of clinical facilities for caesareansections. One estimate, for example, is that if the unmetdemand for family planning could be satisfied in

Bangladesh, then maternal mortality might be reduced by as

much as 60%. It was suggested that resources should bemade available to double the number of family planningusers in developing countries in the 1990s.

Concern was expressed about a real and increasing globalshortage of midwives. In Tanzania, for example, the ratio ofmidwives to pregnant women is declining in the moreremote parts of the country, which is exactly where mostmaternal deaths occur. A shortage of midwives in developedcountries is siphoning off trained personnel from developingcountries. Health professionals, unlike contraceptives,cannot be manufactured at short notice, and plans must belaid now to increase the supply of midwives, includingdefming appropriate recruitment levels, training, and

delegation of medical tasks.If the Safe Motherhood Initiative is to move forward it

must receive more support from a broad constituency. Onlya few years ago, the International Federation of Obstetricsand Gynaecology (FIGO) could attract thousands of peopleto a meeting on in-vitro fertilisation, but only tens to ameeting on maternal mortality. Today, under the leadershipof Dr Vivian Wong (Hong Kong), FIGO has a committeeadvising on technical aspects of improving third worldmaternity services. Above all, women themselves, at alllevels within society, must be included in their own care-asis powerfully advocated by the Women’s Global Networkfor Reproductive Rights.

In Africa, a woman has a l-in-14 lifetime risk of maternalmortality (in developed countries the comparable risk isbetween 1 in 4000 and 1 in 10 000). The World Bankestimated at the Geneva meeting that for 50 cents per caput,maternal mortality could be reduced by one-fifth and infantmortality by 40%--or less than US$200 per maternal orinfant death averted.

Malcolm Potts

USA: The nuclear industry strikes back

Nuclear power is losing advocates among world leaders. Forthem, the Chernobyl disaster in the Soviet Union in 1986alone makes enthusiastic support difficult to justify.President Bush, however, remains loyal to the nuclearindustry. With strong backing from the President’s chief ofstaff, John Sununu, but against powerful oppositionelsewhere, the Nuclear Regulatory Commission hasawarded a licence for a new reactor at Seabrook, NewHampshire, on the Atlantic coast. The plant is alreadyundergoing test power runs, and the private operator, PublicService Company of New Hampshire, expects to generateelectricity at full power by the end of the summer.Many residents object to having the plant in their midst.

Governor Michael Dukakis of Massachusetts, reflectingtheir views, blocked the licence at one point, claiming thatplans to evacuate bathers on local beaches would be

inadequate protection in the event of an accident. The NRCthen rewrote the rules, transferring the power to approveevacuation plans from the Governor to the reactor operator.This was comparable to a home team moving the goalpostsduring a football game when the visitors appeared to bewinning.

For Governor Dukakis, the unsuccessful Democraticnominee in the presidential campaign of 1988, it was onemore defeat at the hands of Mr Bush. Dukakis has not

changed his mind. "Seabrook has the largest summer beachpopulation within four miles of any nuclear plant area", he