The Self-Provision of Public Healthcare Services: A Threat to Democracy

Abstract

How and why could the self-provision of public healthcare services pose a threat to democratic values? We define the informal self-provision of healthcare, identify the factors that promote its appearance, and discuss its destructive implications for society. In addition to substantiating the existence of these strategies around the world, we also maintain that in the long run, such strategies may crush traditional political participation and weaken democratic values. How and why could the self-provision of public healthcare services pose a threat to democratic values? While the literature stresses various negative implications of strategies for the self-provision of healthcare services, the implications and influence of these strategies with regard to democratic values are less discussed. Defining self-provision strategies as informal methods and actions used by individuals and groups to satisfy their immediate interests and need for services, we point to informal payments for healthcare as emblematic of the self-provision of public healthcare goods and services. The literature reveals that there are both socio-economic benefits and disadvantages when citizens in any given society adopt such strategies. In many cases, these strategies negatively affect the quality of services received (Ensor 2004), increase inequality (Balabanova & McKee, 2002; Lewis, 2000) and hurt both lower and middle class (Cohen 2011). In addition to their negative effects, these strategies are often illegal, as they involve for-profit exchanges for illegal goods and services (Mendoza, 2010). Given that the informal self-provision of healthcare services is in many cases illegal, and problems with efficiency and equity arise from them, we would expect decision makers to fight the phenomenon. Yet, that does not always happen. Decision makers often ignore the phenomenon, especially given financial difficulties and crises. Hence, in the eyes of many decision makers around the world, the implications of these strategies are limited to the local healthcare system. In this article we argue that the main disadvantage of the phenomenon is not limited to the healthcare policy or system. Instead, we maintain that such strategies have a destructive effect on democratic values. In the long run, the self-provision of healthcare services not only threatens the values of efficiency and equity, but also challenges the values of participatory democracy. We suggest that over time, this strategy may slowly and silently pervade all of the players, sectors and areas of public policy and become an integral part of the patterns of a society's political behavior. This behavior bypasses formal institutions in favor of illegal or semi-legal means of acquiring desired public goods and services. Citizens who are dissatisfied with the quality and/or quality of public goods and services, and believe that the political structure is so paralyzed that they are powerless to effectively change the situation engage in such behavior. Thus, citizens internalize illegal and extra-legal behaviors or attitudes that in essence bypass the existing mechanisms of social participation and social norms.