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Health Care and Government Policy

Laurinda Abreu

Introduction – Health care and government policy

Laurinda Abreu

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1Government policy refers primarily to the actions planned and implemented by the executive branch of a state to meet its society’s needs. One of the most demanding areas both for policy makers and in terms of people’s expectations is health, which social analysts and historians place among the most dynamic sectors over the last century. This is the focus of this book. It includes examinations of two of the most pressing issues facing national healthcare services today – ‘Health systems at the stage of complexity: the need for collaborative intelligence’ by Constantino Sakellarides et al. and ‘Longer and better lives: the European fountain of youth’ by Patrice Bourdelais – alongside historical analyses covering both earlier periods – ‘Not just one countryside: life chances in pre-industrial Sweden’ by Jan Sundin and ‘Health care and poor relief in Portugal: an historical perspective’ by Laurinda Abreu – and more recent times – ‘The roots of the health reform in Spain’ by Enrique Perdiguero-Gil and Josep M. Comelles.

2Governments have been concerned for the health of their people since at least the late fifteenth century, in particular insofar as it affected population growth. They sought to address the profound socioeconomic and epidemiological changes that were aggravating the already precarious living conditions of the poor not only because of new social and religious sensitivities towards the most vulnerable groups in society, but also to try to keep their subjects alive and productive. At the time of early modern state formation, monarchies seeking to consolidate their power saw a healthy population as an essential asset.

3The provision and management of healthcare resources in western Europe followed a long and winding road from the early modern period to the present day. The resulting situation is the subject of the contribution by Sakellarides et al., namely the difficult challenges faced by those who have to deal with today’s health systems and the efforts required to keep one of the greatest conquests of the twentieth century alive. These authors’ view is that this enterprise will only be successful when health systems in general – and the Portuguese health service in particular – are understood in terms of the complexity they have acquired in a world in which individualism is gaining ground, social ties are weakening and professional and geographical boundaries are dissolving, while at the same time advances in science and technology are finding cures for diseases that were fatal only a short time ago. Meanwhile, governments are facing increasing financial constraints and making cuts to health system funding. Consequently there is a need for collaborative, adaptive policies resulting from the application of ‘collaborative intelligence’. These approaches should be centred not on sickness and disease but on people, personal trajectories and health literacy; new organisational and governance strategies are needed that are decentralised, transparent and socially responsible and based on participation, collaboration and information sharing. In short, they should be the opposite of current systems, which are tied to the ambitions and socioeconomic dynamics of post-Second World War Europe and the West, which are so stubbornly resistant to change.

4Bourdelais finds worrying signs in the present day when comparing the trends in life expectancy at age 65 in 25 countries with the highest life expectancies in the world. After a remarkable improvement in Europe after the Second World War, the rate of increase has slowed since the 1980s, with a deterioration in people’s health and a consequent fall in the quality of life. Rising unemployment and the social and economic marginalisation of part of the population may account for this downturn, but they also reflect the shortcomings of the various countries’ social programmes and poor public policy decision making. While the situation is of most concern in the United States, which has the worst indicators of the 25 countries included in the analysis, Bourdelais also points to worrying data from the Nordic countries, particularly Sweden, which were paradigms of the welfare society until the 1980s but have now been overtaken by Japan and South Korea.

5Although the gap between the countryside and the city in Sweden in terms of health risks and mortality rates may only have begun to shrink after the First World War, this country enjoyed notable progress at many levels as a result of public policies implemented from the nineteenth century onwards. This is the situation referred to in the paper by Sundin on three contrasting rural parishes in Östergötland province in the period 1750-1860. Early vaccination campaigns and midwife training schemes, together with some medical care provided for paternalistic reasons (to keep the workforce productive), set the country on the path to eliminating the socioeconomic and geographical determinism that for centuries had governed people’s life chances, forever at the mercy of poor harvests, epidemics and accidents at work, on top of the endemic diseases that silently killed them.

6In Sweden, as in the rest of Europe, it was the local communities that took the health and welfare policies to the people in the early modern period. In that country, as Sundin points out, it was an obligation imposed by the government; in Portugal it was a process that the crown negotiated with the local elites, as Abreu describes in her paper. Unsurprisingly, the end result depended on the choices made by those who administered the policies and on the resources they had available. In neither country did central government fund the sector regularly in that period. In Portugal, health care for the people relied on support from charitable institutions and private generosity until well into the twentieth century. As Abreu argues, the Portuguese government took on the role of organising, regulating and supervising the institutions that actually provided health care, which remained associated with the poor and poverty until the SNS (Serviço Nacional de Saúde, the Portuguese national health service) was founded in 1978.

7The situation in Spain was not very different, but it was subject to its own social and political dynamics and had considerably more funding available than in Portugal, as may be gathered from the analysis of the 1975 Spanish health reform by Perdiguero-Gil and Comelles. They argue that the Spanish national health service was one of the most significant achievements of the new political regime to the extent that it does not appear among the main concerns of the public, who do not see it as being under threat despite a few specific problems. This has influenced the way historians have approached this area. The authors here examine the historical roots of the Spanish health service, with particular emphasis on developments between the introduction of compulsory health insurance (SOE) in the early 1940s, inspired by models in Nazi Germany and Fascist Italy, and the death of the dictator Francisco Franco in 1975. Although in that year 80.86% of Spain’s population had access to health care through Social Security, the system was considered unsustainable, not least because it was hospital-centred, based on sickness and not on prevention.

8As the authors in this volume show in detail, population growth and increased quality of life have been among the greatest achievements of the second half of the twentieth century, but they should not be taken for granted. The fragility of these gains has been demonstrated statistically. The state has to invest in the public policies that best protect its citizens, particularly at times of low economic growth such as we are now experiencing, and take preventive action to preclude major social and economic costs. Civil society plays no less important a role in protecting the greater good of social cohesion. In short, both state and civil society need to consider future health policy in such a way as to overcome the inefficiencies of the past and make full use of the opportunities offered by science and technology to improve people’s quality of life.

9This volume has been funded by national funds through the Foundation for Science and Technology and by the European Regional Development Fund (ERDF) through the Competitiveness and Internationalisation Operational Programme (POCI) and PT2020, under the UID / HIS project / 00057 - POCI-01-0145-FEDER-007702. I am grateful to all the authors for their contributions and to Christopher J. Tribe for copy-editing this volume.

© Publicações do Cidehus, 2019

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