The key to overcoming inequality is political commitment

Abstract

One of the main conclusions of Gwatkin's article was the need "to rethink the way in which health goals are established, and recast them in terms more relevant for inequality reduction". His recommendations and most of his article itself focus on the content of health policy and do not deal with the political processes and factors that shape health policy, such as competing interests. The need for more reliable information on health inequalities (and the role of the international organizations in providing it) cannot be doubted. Its absence is a reflection of the lack not only of knowledge but of political commitment. The reverse is not true: if the health policy of a given country includes the reduction of inequalities, we cannot conclude that the political commitment to implement such objectives exists. Why does the political commitment not exist? What factors prevent the reduction of inequities from being given priority in health policy? What could change the existing situation? Answers to such questions naturally vary from place to place. What I discuss here refers to the post-socialist countries, especially Hungary, but I believe that parts of it are valid elsewhere too. In the 1990s in the post-socialist countries, the emergence of a group of wealthy people has coincided with a decline in economic performance, as reflected by a shrinking gross domestic product (GDP). Obviously, if some people are getting richer it can only be at the expense of the other social strata, partly the middle class and mainly the poor, who get poorer and poorer. In Hungary, for example, the gap in income between the lower and the upper decile from 1990 to 1997 increased from 4.5 to almost 9. The majority of the political elite, irrespective of their political allegiances, have tried to get into the richest part of society in the course of this social realignment. The political elite is much more sensitive about the inequalities between countries (which are to their disadvantage) than to the inequalities within their own country (which are to their advantage). The challenge felt most keenly by the political and economic elite, not only for their countries but for themselves, is to catch up with the West. Questions of internal inequality are much less compelling. A good example of this is health. In non-Western countries a major objective in health policies is to narrow the gap between their own and Western life expectancy, while unequal life expectancies within the country get no attention. Miklos Tamas-Gaspar, a philosopher who was a key figure of the liberal intellectual resistance in the socialist period, describes the new political elite in harsh but accurate terms: The ideas of welfare, public interest and good governance are meaningless to them. They do not want power because they want to save the world or make improvements or promote social justice, ... though they might sometimes inadvertently use such phrases. The new elite are as indifferent to the fate of the poor as their communist predecessors were (1). The apparent contradiction between the new political elite's lack of interest in social justice and the priority given to poverty alleviation as a social policy objective is deceptive. This policy can also be interpreted as the desire to increase GDP while remaining firmly on the development track that increases inequalities. In the last decade not only socioeconomic factors but elements of the health care system itself have worked against the development of an equity-oriented health policy. The basic economic and budgetary interest was to reduce spending on welfare and health in order to reduce state redistribution. The concern of the physicians was quite contrary to this: it was to increase their own income and to reduce the gap between their own technology and that of the West. The effect of these factors on health policy was to make its share of the national resources the main concern, with little interest in increasing efficiency, and none at all in equity. …