FINANCING HEALTH : THE TWIN NEEDS OF EFFICIENCY AND SOLIDARITY
The United States of America heads the list of the world’s richest countries and devotes 15 % of its GDP to health expenditures. No other country spends as much money on its health system. In 2002, 5,267 euros per person were spent by the USA on health, in Germany, the figure was 2,807 euros, in France 2,736 euros, in Great Britain 2,160 euros and in Japan 2,077 euros (OECD, 2004). One would therefore expect the USA to show the highest benefits in terms of access and equity, defined as « a system’s capacity to provide any individual in its population with guaranteed access to a minimum package of services appropriate to his/her needs, irrespective of race, sex, age, ethnic or religious classification, socio-economic standards… ». But such is not the case. 15 % of the U.S. population, in other words 45 million inhabitants, have no medical coverage despite Medicare and Medicaid ! Nor are U.S. health indicators (morbidity, mortality,…) the best in the world. And notwithstanding the limitations inherent to international comparisons of health systems, it is obvious that Japan, Great Britain, France, and Germany, with 7.8 %, 7.7 %, 9.7 %, and 10.5 % of their respective GDP going into health expenditure, offer better prospects in terms of access and fairness (WHO, 2000).
The causes of this U.S. deficiency, numerous and complex, would require a long development. But they derive essentially from a liberalism economic model that rejects the “bismarckian” and “beveridgian” models, based for the first on obligatory social contributions and for the second on taxation, which the previously mentioned countries have adopted. The following explanatory factors should also be emphasized: a lack of political will against a background of passive collusion by Americans, supported by powerful business lobbies, all of which blocks efforts to build a foundation of solidarity that would unite everyone in the face of sickness. In practice, the permanent quest for financial profits, including in health services, adds up to a failure, because it ignores a necessary interdependence between human beings.
Countries of the developing South have few financial resources available to deal with the problem of health expenditures; consequently, the guiding principle and leitmotiv of any health policy must remain focused on the optimal use of these resources. But the human solidarity factor, in particular between generations, should be integrated into such policies. All research studies on the subject bring out a peak in health expenditure toward life’s end, due to the rise in the amount of medical, technical and human resources required at that time, a rise which significantly weighs on health budgets. But in this regard, the Japanese model is both instructive and edifying. Japan has a culture of close family links, and the fact that nursing care costs are handled by the family is one reason for the efficiency of its health management system. Countries of the South, where “family” is usually not an empty word and elders still retain their social importance, could look to Japan as a comforting example of the determining role of human solidarity, working through culture, on financial considerations.