Comparative health systems and policy is a wondrous intellectual and decision-making enterprise. From (to mention only a few) Kervasdoue, Kimberly, and Rodwin's The End of an Illusion (1984) by way of Anderson's The Health Services Continuum in Democratic States (1989) and Glaser's Europe's Decentralized and Semi-Private Health Insurance (1989) onto Ellencweig's Analyzing Health Systems—A Modular Approach (1992), Joe White's Competing Solutions (1995), and Saltman et al.’s Critical Challenges for Health Care Reform in Europe—ending up (so far) with Professor Dutton's book, scholars seek to solve a more-than-three-dimensional Rubik's cube of historical social processes, cultural and ideological orientations, economic exigencies and contingencies, constitutional and governance arrangements, media and rhetoric, population health status and health care outcomes, and more. The field is a spiral of reinventing and revisiting wheels, enacted in thousands of journals, books, and international meetings, all comprising an epistemic community of enthusiastic, pondering, puzzled, frustrated, inspired, and fulfilled scholars, policy analysts, and practitioners.
No one book can encompass all of this, but this book is—even for exhausted comparative health policy veterans—a rich and satisfying read. Paul Dutton conveys his personal connection to four health systems, with well-referenced and convincing descriptions and analyses of three areas of health systems. Specifically, he compares the United States and other systems using three life cycle lenses: infant and child health in France, worker's health in Germany, and “after work” (retirement and old age) in Sweden.
The life cycle structure of the book makes it easier to identify with the lived experience of citizens of all four countries. It also captures the complex interplay of factors that shape each of the three areas in a manner that is almost seamless, certainly relative to more rigid comparisons of selected aspects of health systems that try to hold constant confounders that, no matter how valiantly the analyst tries, can never in the end really be held constant. French childcare results from a history of strong central governing authority, a felt societal need to encourage population growth without sacrificing child health status or workforce participation of women, and a reliance on science to guide nutrition and vaccination. Germany's provisions for access to health care and occupational safety arose from the pressure the monarchy felt in the latter of part of the nineteenth century to ward off the influence of radical left-wing tendencies toward workers' liberation. While the period from 1933 to the end of World War II was horrific, somehow Germany (primarily in the western part; East Germany had a Soviet-style system) regained elements of employer/worker cooperation. Corporatist tendencies characterized by stakeholder representation at the health policy table as well as a degree of shared power between employers and employees, have enabled Germany to outdo the United States when it comes to having a healthier population during the working years. The DNA of the German health system promotes simultaneous concern for both productivity and worker welfare, the latter nurtured by the security provided by social health insurance and attention to the social determinants of health. For example, “in contrast to the United States, where typically underfunded state and federal agencies regulate workplace safety from outside the company, German workers and employers collaborate in-house to fulfil this task” (95). By the time the reader reaches the subject of old age care, it is almost unnecessary for Dutton to point out how Sweden's superior performance relative to the United States is founded on the two earlier life stages, despite the fact that those phases were represented by different countries. In each case, the author highlights how the attention paid by the European health systems to the social determinants of health is integrated with the medical health care system.
The social determinants of health have become all the rage for health policy aficionados frustrated by repeated failures of health reform to achieve increased access while reigning in costs. “An ounce of prevention is worth a pound of cure” is an aphorism sagely nodded at by a consensus of academics, and perhaps even politicians. But once it is implied there is a need to divert resources from high-technology health care providers to public programs dealing with housing, education, and environment—well, that is a different matter.
How do France, Germany, and Sweden do it? While the author does not refer to it in so many words, the secret sauce that advantages Western European countries relative to the United States is social solidarity. This concept is widely missing from discussions of US health policy. The closest American analysts come is to discuss social capital and, more recently, trust. But this usually takes the form of, as in the work of Robert Putnam, a pining for the supposed halcyon days when Americans could leave their porch doors unlocked and did not “bowl alone.” As this reviewer has offered elsewhere, and which is organically substantiated by Beyond Health, it is possible to engender social solidarity through deployment of institutional arrangements and mechanisms of accountability that encourage commensurate cooperation, trust, and empathy. This makes it important, in the US debate, to preempt knee-jerk refusals to learn lessons from other countries by eluding labeling and the conjuring of foreign bogeymen and absurdities (“that's socialized medicine,” “government-controlled health care,” “keep the government out my Medicare,” or “there is no French word for entrepreneur”). The book reviewed here presents US readers with comparisons to other countries in a manner more conducive than most to learning from elsewhere.
The last chapter of the book presents a range of policy recommendations deriving from the comparative chapters. Sporadic programs (such as a “food pharmacy” in Ohio), health systems partnering with rideshare companies to reduce appointment no-shows, and a New York program providing housing units on a short-term basis to homeless patients suffering from chronic conditions, indicate that there is some recognition of the need for government to intervene in the social determinants of health. The Health in All Policies movement has had played a positive role in some US cities. The United States needs to find a better balance between investments in medical care on the one hand, and the social determinants of health on the other. Through no fault of Dutton's, the policy prescriptions are not the strongest part of the book. Since he cannot say it for himself, I will: getting as many individuals involved in US health policy to read his book might just get things moving in the right direction.