What lessons does 70 years of the NHS have for universal access?

NHS at 70

Today , Britain celebrates 70 years of the National Health Service, born under Nye Bevan’s midwifery on 5th July, 1948, and even in today’s divided Britain, a rare point of unanimity in the respect with which it is held. The NHS has perhaps been one of the most successful legacies of that extraordinary period of restructuring of the state and public services that occurred in the late 1940s and early 1950s. It is a major factor in the substantial improvement in health that has occurred over the past seven decades: the continuing (albeit now slowing) increases in life-expectancy (over a decade in life added since 1948); and decline in child mortality (34 children died in every 1,000 live births in 1948 in England and Wales, 45 in Scotland: today that is around 5 per 1,000 births). And it is a testament to the idea of health care being universally accessible, driven by need not ability to pay.

But does the NHS at 70 hold any lessons for evolving health care and health systems in sub-Saharan Africa? Its funding model – paid for by general taxation rather than the social insurance model more common in other European welfare states – is enormously complex. Its size is immense. The financial sums it takes to run it (around £125 billion a year, and this is still seen as insufficient) are well beyond the capacity of all but the richest states. And the range and level of services available as a result of that funding may not be easily replicable (in the short-medium term at least) by low- and middle-income countries. But as the examples of countries like Cuba and Costa Rica have shown, good health outcomes are not just (or perhaps, even mostly) about funding, but about the way the system is designed, and its priorities.

But even if the NHS may not be the most appropriate (yet?) model for African states to emulate, there are some lessons that may be useful in moving towards universal access to health care.

 

  1. The right plan, led by the right person, at the right time

Political will and vision is essential: someone (or some people) with the political clout to push through reforms, to lay claim to national (and donor) resources, and to force competing parties to the table. Nye Bevan is quite rightly seen as the father of the NHS, pushing hard within the Labour government to get his vision of a universal healthcare system through cabinet (and resigning in 1951 when the government brought in prescription charges, and charges for glasses and dental treatment).

But the focus on Bevan can sometimes hide the importance of other factors: it isn’t just about an individual, but about an opportunity, a moment and a chance when the vision stands a greater chance of being put into action. Underlying the creation of the NHS was a constellation of factors coming together, which enabled Bevan’s argument to capture the public imagination, gain sufficient political support to push through the reforms, and the government to overcome external opposition (the British Medical Association continued to threaten to boycott the new system until months before the NHS was inaugurated). The need for reconstruction in the aftermath of the destruction of total war, a surge in public support for the government’s broader welfare agenda, and agreement on a direction of travel (including, ultimately, amongst medical professionals) allowed the plans for the NHS to navigate through potential pitfalls and obstacles.

There is a new wind of change in thinking about developing country national health systems today. A consensus has been built around the concept of universal access to health care: the idea that health systems should provide (affordable) health care to all citizens. Importantly, the World Bank has moved over the past decade to champion this concept. Importantly, even in low-income countries donors, international organisations and health specialists have coalesced around the belief that universal access to health is affordable (without the need to charge fees), logistically possible, and likely to be effective in low-income countries. This presents a golden opportunity to push for substantial reforms that could lead to the creation of truly national health systems, accessible to all, with no fees at the point of use. Ministers of health and other politicians should be using this moment to build grand coalitions around the creation of new, truly national, truly accessible health systems. There is ample evidence of the workings of community-based health insurance schemes (even those operating at a national level, as in Rwanda) to show how the financing of this can work. And with growing recognition of the failure of vertical planning and delivery, where funds and services were directed to individual diseases and sectors rather than investing in broad public health, donors are also more understanding of the need to improve and extend national health systems. The prospect for a substantial shift to universal access is very real, but it does require political will to push through the reforms and restructures that would be required.

  1. Build on what you have, and compromise

Although it is tempting to see the NHS sweeping away all that came before it, instituting a bright new age of entirely state-owned and run health services, the reality is more prosaic. Britain was no more able to escape historic path-dependencies than other countries, even at a time of grand renewal, and built upon existing structures and systems. This, inevitably, entailed compromise. Consultants were to be allowed to continue private practice alongside their NHS work (in the same institutions). GPs, the gatekeepers to medical services and treatment, remain mostly independent contractors to the NHS, not public employees as is mostly understood by that term. Private chemists provide the bulk of prescriptions. Nevertheless, by adopting a general taxation-funded model (rather than the social insurance model, which often have more mixed economies in delivery of medical services, the state was able to assert overwhelming dominance and control.

The lesson here is not to replicate the British model (more accurately, see below, the British models), but to think about the realities on the ground in constructing health systems. African biomedical health systems are characterised by a mixed economy of state actors, private (voluntary) and private (for-profit) ones, large-scale company medical services which are extended to local communities, as well as disease- and sector-specific services often funded by external donors and running in parallel with official public health systems.[1] As a result, governments do not have a blank slate, but must construct health systems from where they are now. Should governments have regulatory, funding and delivering roles? Or should they contract out actual delivery, subject to strict controls and oversight? What is the right balance between private versus public? There will not be one answer to this question, and no solution will be perfect. But no reform will work unless it is grounded in the realities and historical pathways of each individual context. The key is understanding what contributes to the principles of universal access and what obstructs it, and refusing to compromise on the latter.

  1. Endless change

Since the early 2000s, successive governments (from Labour, through Coalition, to the current Conservative) have been driven by a particular mantra of health reform. There have been two issues with the overall tenor of these reforms: the first is the direction of travel, towards increasing competition within the NHS and the growth of private-sector actors; and the second is in the top-down centralised process of planning and implementing those reforms.

African countries looking to develop their own systems should take note of both. The introduction of competition has been disastrous. Successful health systems are marked by collaboration, not competition. Different parts of that system need to work together, supporting the overall health objectives of the country, not acting as internal markets with one part bidding against another. Of course costs have to be kept down as much as is reasonable, but the introduction of competition has not led to this outcome. As suggested above, it is likely that private actors will remain a substantial part of any health system, given the current mix of providers and services. But adding internal competition will exacerbate the worst aspects of that, and fail to build cohesion and coherence, even with strong state control.

In respect of the top-down, centrist-driven nature of reforms, balance needs to be struck between a government ensuring its health objectives and priorities are implemented and achieved, and placing so much stress on the system through continual change that it begins to break down. Once a level of service is established, allowing individual units to better manage their own resources, and look to how improvements can be made, may allow for more effective reform, as well as for the emergence of data-driven best-practice models which others can adopt. Of course, to monitor against egregious failures and gross negligence, oversight needs to be strong and transparent, but there must be an effective balance between power at the centre and power further down the structures. The NHS is already decentralised to an extent. The Welsh, Scottish and English bodies all pursue slightly different directions, with different emphases and priorities. And this has been a good thing, allowing for experimentation and lessons to be shared across all three. Successive governments have been reluctant to allow for more bottom-up reform. To be fair, it takes a brave Minister for Health to let go control over the process, knowing they will be blamed for any mistakes, and can take only partial credit for successes. But making-use of the expertise on the wards, and the highly-localised data those wards can generate, can improve patient care and experience in a way that centrally-mandated change will always struggle to do. It will also give greater likelihood that reforms are built on experience from the ground, rather than political visions of those remote from the actual patients and medical professionals.

  1. Don’t neglect social care, especially care of the elderly

The health and care problems linked to longevity may appear someway distant in some countries, or of a lesser priority, but as we see the shift from infectious to chronic health conditions move ever more quickly across low- and middle-income countries, thinking about how to incorporate geriatric health care, and link social care to health care, is essential. Kicking it into the long grass as successive British governments have done will make later reform harder, more expensive, and politically more divisive.

Building a health system now that incorporates as much social care as possible, will ultimately save time, money and political will, making it easier to expand as it becomes more necessary, and more affordable to do so. Similarly, learn from the failures to incorporate mental health services: the (relative) paucity of provision in the UK is a lesson to make sure mental health is given a key place within whatever structures emerge. The data on the growth of mental health issues in sub-Saharan Africa (as well as its historic neglect) suggests that now is the time to think about it.

  1. Free-at-the-point-of-use

The key feature of Britain’s NHS is that it is free at the point of use. Whilst this is taken for granted by many who live here, it is actually quite unusual. Other rich-country systems have varying levels of charges for the initial consultation. The impact of charging fees to access health care at the point of use is to exacerbate health inequalities and hits the poorest hardest. In the 1980s, the World Bank recommended the introduction of user fees to help fund health systems. For around 150 million people, the consequence of user fees is financial catastrophe each year as a result of becoming unwell, with 100 million pushed below the poverty line. The promised waivers and exemptions simply didn’t work, were rarely granted and limited in nature. And they failed, too, as a revenue-raising tool, accounting for just 5-7% of health revenues. The NHS model – free at the point of use – is essential for ensuring universal coverage is meaningful, to ensure health inequalities can be addressed, and to reach the poorest (and those most in need of health services).

 

Injibara (new hospital)

New hospital being constructed in Injibara, Ethiopia

 

 

So let us say happy birthday not just to the NHS itself, but to the idea of which the NHS is an expression of: that everyone, regardless of where they live, of their social economic status, of their ethnicity, of their age, of their race deserves, indeed has a fundamental right to, the very best health care that a society can afford. And that only through a state committed to enacting that right through a health system driven by and dedicated to that objective, can these aspirations be met.

 

 

[1] If you are interested in reading about the historical creation of health systems in Tanzania, I have written two pieces on this, one focusing on the colonial period, ‘Common Counsel, Common Policy: Healthcare, Missions and the Rise of the Voluntary Sector in Colonial Tanzania’, Development and Change 44 (4) (2013), pp.939-963; and one on the early Independence period, ‘The Precariousness of the franchise state: voluntary sector health services and international NGOs in Tanzania, 1960s-1980s’. Social Science and Medicine 141 (2015), pp.1-8

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About Mike Jennings

I am Reader in International Development and Head of the Department of Development Studies at the SOAS, University of London. I research, teach and write on Africa, and the history and politics of international development in sub-Saharan Africa. Research areas include: - The history of development in Africa, from the late nineteenth century to the current day - Politics of East Africa (Kenya, Tanzania and Uganda) - the role of non-state providers (NGOs, FBOs and self-help groups) in welfare service provision - Social aspects of health, including HIV and AIDS, and malaria
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