Abstract
With austerity measures – loosely defined as reforms to cut a state’s budget, debt or deficit – high on the political agenda across Europe, almost all aspects of the lives of millions of people from Portugal to Greece and Ireland to Italy are affected by tough reforms. Understanding the impact of austerity on welfare states as a whole and health systems – as one of the largest blocks of government spending across Europe – in particular is of great interest to policy makers, researchers and wider audiences. Judging by its title, this volume edited by Emmanuele Pavolini and Ana M. Guillén, two comparative social policy researchers, aims to make a contribution to this area. The volume’s overall aim, however, seems somewhat broader as it is in fact concerned with reform trends in European health care systems over the last 20 years.
The editors argue that over the last two decades health care systems in Europe have experienced various pressures, including health expenditure increasing at rates above real gross domestic product (GDP) growth, shifting disease patterns to higher prevalence of chronic conditions, an influx of new and expensive health technologies and an increased awareness of inequalities within the population. In responding to these pressures, health policy makers face a ‘quadrilemma’ as health care system reforms need to balance cost containment (economic objective), the provision of care at the highest possible quality (medical objective) in an equitable manner (social objective) that is satisfactory to workforce and users (political objective). It is argued that this quadrilemma is most commonly addressed by three main regulatory reforms: rescaling the distribution of power between local and national levels, privatisation in finance and delivery and managerialisation, altering the distribution of power between professionals, managers and users (p. 2). The editors aim to analyse these reform trends from an economic and political perspective. To do so, the book is structured in two parts, with a shorter comparative part preceded by eight country case studies.
Each country chapter is written by national experts, around 20 pages in length and follows a similar structure outlining the reform efforts undertaken, the politics of change and providing an evaluation of the reform impacts on health system functioning. Although criteria are somewhat implicit, country cases seem to be selected to represent both social health insurance (SHI) and national health system (NHS) regimes, including England, France, Germany and Sweden; classics in comparative social policy; as well as more exotic cases including Austria, Italy, Poland and Spain.
Following these individual case studies, Chapter 9 presents the main comparative approach to health care system reform in the eight case study countries by analysing the drivers of change, the actors involved in reform efforts and the mechanisms of change. The authors argue that while the 1990s were a decade where varied reforms for all health care systems were introduced, the 2000s were – until the beginning of the financial crisis – more focussed on continuity and implementation of reforms introduced in the previous decade. Comparing across time and countries, the authors argue that health care systems have increasingly converged as a result of reforms over the last 20 years. They show that reforms within the SHI and NHS groupings follow similar processes. They argue that while drivers for reforms in NHS systems are fairly complex, SHI system changes are mostly motivated by economic objectives and that medical objectives, such as taking into account new types of pathologies and health needs, ‘did not seem to prevail’ (p. 203).
It remains to discuss what contribution this book makes to our understanding of health systems and austerity. This is conditional upon the definition of austerity: austerity as a policy response to the 2008 financial crisis, or austerity as ‘permanent austerity’, a response to the end of the ‘golden age’ of the welfare state. Since the authors do not provide a definition of their understanding of austerity, both scenarios shall be considered. The book’s contributions to austerity as response to the 2008 financial crisis seem somewhat limited. While the authors argue that ‘economic objectives became the main concern’ in health system reforms after the crisis began (p. 206), they also highlight that ‘data cannot take into account the more recent transformations due to austerity’ (p. 218) and the chapters discuss reforms after 2008 only briefly. While the book includes chapters on Italy and Spain, two countries hit hardest by the crisis, the book would have benefited from including countries such as Greece, Ireland or Portugal, which experienced strict austerity to comply with conditionality of external loans from the International Monetary Fund.
By contrast, the book’s contribution to the understanding of health systems in ‘permanent austerity’ is rather larger, given its comprehensive cross-national analysis of reform efforts over the last 20 years. Over this longer period, the authors might be criticised for overstating the role of economic objectives, given, for example, the large-scale transformation towards accompanying chronic illnesses in health systems across Europe (Nolte et al., 2014). While the coordinated care models this trend has given rise to do aim to increase efficiency, they are particularly focussed on improving the quality of care for patients with chronic illness. But even if aspects of their account and emphasis could be debated, Pavolini and Guillén have unquestionably produced a comparative work that will be of great value to all those interested in the evolution of health systems in recent decades.