Abstract
How can sustainability be achieved in a highly value-laden, expensive, and complex policy sector? This chapter applies a systems-based analysis to understand the policy problems of long-term health protection. It uses evidence from several high-income countries—including France and Japan—and identifies the gap between the “health-care state” and “population health” as the major challenge. Efficient health care has been achieved by combining medical dynamics and collective national funding, but long-term health protection and life expectancy rely on a massive risk reduction, which requires joint policies with other sectors, new international engagements and strong political leadership. The chapter first analyzes the structural characteristics and the economic significance of the health-care sector, which both make its governance and future-orientated changes extremely difficult. The health-care sector enjoys sociopolitical consensus despite its financial burden, which vastly exceeds even military expenditure. The chapter then documents the silent pandemics of rapidly growing chronic diseases, and the need to shift priorities toward population health. The final section traces emerging innovations, including new scientific approaches based on the overarching “One Health” concept; multilevel initiatives for transboundary policies; and lessons to be drawn from previous crises for a new global health governance.
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Notes
- 1.
Michael Moran’s concept (1999), cf. further below.
- 2.
The analysis by functions takes into account the fact that funding and service provision can take public, private, or mixed forms. It has thus renewed the classification of healthcare systems, identifying five—not three—types, because the former general category of “health insurance systems” breaks in reality down into very different types: national health insurance (HI) systems, social HI systems, and statist social HI systems (Böhm et al., 2013: 16–28).
- 3.
- 4.
The statistics are for 2019 (pre-COVID-19). The percentages have remained quite stable over time, with the share of chronic disease steadily increasing.
- 5.
This reform was implemented in law on March 4, 2002.
- 6.
A 1971 law entitled the French government to fix the number of admissions to medical schools. During the 1990s, the number of yearly admissions fell by 60%. Admissions only recovered to the 1970s level in 2018, under the Macron administration. Since 2021, admissions are again open.
- 7.
A 1996 reform imposed a limited budget for the public health insurance system in France, but without any effect for more than a decade. However, since 2010, the target has been strictly respected.
- 8.
From January 1, 2023, in France, all young people aged 18–25 years have been entitled to condoms delivered free of charge from drugstores, and all women, including young teenagers, to “morning-after pills” (the emergency contraceptive pill) free of charge, without prescription.
- 9.
In France, between 2016 and 2020, some 200,000 women utilized the new contraceptive device. Three victims associations are now fighting in the courts for compensation.
- 10.
The study sought 61 medicinal substances from among the most commonly used medicines, namely antibiotics, analgesics, anti-inflammatories, antihistamines, antidiabetics, and antidepressants. All collected samples were analyzed in the same laboratory to avoid bias. The study found evidence of the “feminization” of fish owing to hormone concentrations in rivers, resulting from contraceptive and menopausal treatments for women.
- 11.
The plasticizers are bisphenol A and its substitutes, polychlorinated dioxins, and phthalates.
- 12.
The arguments refer to both the broader concept of AMR, which involves resistance to bacteria, viruses, fungi, and parasites, and to ABR, which refers specifically to resistance to bacteria.
- 13.
Until the mid-2000s, it was common practice in France to permit sick children to attend day cares and kindergartens on the condition that they were taking antibiotics.
- 14.
Donations of unused medicines to poor countries, mainly Africa, have been drastically reduced. Only specific authorized nongovernmental organizations (NGOs) can still organize donation, subject to reporting obligations.
- 15.
The Dutch famine during the German occupation of Holland (as it was then known) in World War II provides evidence of the transmissibility of “noncommunicable” diseases, because children exposed in utero or during their early years—and even the descendants of these children—continue to suffer diseases related to the famine experienced by their mothers and grandmothers.
- 16.
Medical overuse of antibiotics in France is concentrated in the ambulatory care sector, which is staffed with independent doctors, who enjoy prescription freedom. In Japan, a nationwide pilot project started in 2018, with voluntary “care units” receiving modest financial incentives to reduce their issuance of prescriptions for antibiotics. This resulted in an 18% reduction in the number of prescriptions issued (Okubo et al., 2022).
- 17.
The EU played an important role during the AIDS pandemic by providing for transboundary networking and harmonization of statistics within its territory and the future Eastern European member states (Steffen, 2012), as well as in international AIDS diplomacy.
- 18.
- 19.
Ensuring preparedness for epidemics involves the expansion of the missions of the European Centre for Disease Prevention and Control and the European Medicines Agency; the creation of the Health Emergency and Response Authority, which has delivered its first report in November 2022; and a new European Pharmaceutical Strategy to secure production capacity within the EU for vaccines and medicines.
- 20.
Solidarity between the member states includes the joint EU procurement of vaccines and other health equipment, and common EU borrowing for the Health Recovery Plans.
- 21.
One of the notable modernizations is a common European Health Data Space.
- 22.
The Recovery and Resilience plan provides €672.5 billion. In addition, future-orientated health projects can also be supported by other EU funding sources, such as the Cohesion Fund, Horizon Europe, and Digital Europe.
- 23.
- 24.
Professor Ilona Kickbusch is a member of the Global Preparedness Monitoring Board jointly established in 2018 by the WHO and the World Bank.
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Steffen, M. (2023). The Challenges for Health Systems and Policies: Growing Medicalization and Global Risks. In: Adachi, Y., Usami, M. (eds) Governance for a Sustainable Future. Springer, Singapore. https://doi.org/10.1007/978-981-99-4771-3_17
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