An international ranking of health services in 11 countries rates the UK NHS at the top. The Commonwealth Fund, an American think-tank, ranks health systems on five main criteria: Access, Equity, the Care Process, Administrative Efficiency and Health Outcomes. Each of those criteria is based in turn on a range of subordinate indicators: the “Care Process”, for example, takes into account prevention, safe care, coordination, and patient engagement. It’s backed up further by more detailed assessment; for example, the US does badly on infant mortality and premature death, but relatively well in relation to doctor-patient relationships and the management of stroke. But speaking as a carer, I find it hard to believe that the state of our mental health services really represents the best that anyone can do.
The main purpose of the report is to give a critical perspective on health care in the US, which is outstandingly expensive as well as being the least effective of the systems; but there are questions to raise about other countries, too. For the UK, we might wonder how it is that the health care system is ranked top of the league while the UK’s health outcomes are the second worst in the table. The neo-liberal Institute of Economic Affairs commented, acerbically: “the NHS’s provision of care is equally poor for everybody, irrespective of income.”
I’ve just been complimented on Twitter for offering ‘real’ evidence. While it’s pleasing to be flattered, I ought to add two cautionary notes about my last blog. The first is that I started the entry by expressing reservations about the direction of causation. It’s a problem that bedevils most statistical analysis – showing an association between two factors often looks plausible, but it’s not possible to say confidently whether there is a direct relationship, if the connection is best explained through another factor, or there’s some further aspect of the figures I’ve been using that produces an artefact. (The figures I had to hand, as it happens, were mainly for larger countries. I don’t know whether that matters.)
The second reservation is the curse of comparative data – the graph is based on a handful of observations, where each national government counts for one uniform policy unit (e.g. the USA, Switzerland, Denmark), regardless of differences in size, variations in structure and rules, and so forth. Belgium has at least six governments and I don’t know how to count Switzerland. The numbers, Castles argues in Comparative Public Policy, allow us at best to run “a preliminary sorting process, informing us about combinations of variables which fit together to produce possible accounts”.
I suspect that the main determinant of labour market participation is the structure of the economy, and while I’m not sure it has anything to do with benefits, there are hidden elements of conditionality in most systems which the crude figures won’t reflect. That’s also why I finished up by saying, ‘if there’s an association…”
The Indian government has announced a series of measures intended to provide comprehensive social security and pension provision. “The government proposes to work towards Universal Social Security for all Indians.” There’s some ground for scepticism, because many of the same aspirations were present shortly after India’s foundation. Many of the laws were put in place at that time, nominally covering firms with 10 or more employees – but they simply do not apply to the bulk of the population, who work in ‘informal’, unprotected settings.
The interesting point here is, I think, that the Indian government wants to do it, and believes that it can. There has been an extension of “Conditional Cash Transfers” in many parts of the world, including parts of India and Bangladesh. Meanwhile in Pakistan, there is a running discussion of whether it might be possible to found an Islamic welfare state there. Most comparative social policy is concerned with the differences between welfare states. Some years ago, I wrote a general theory of the welfare state, which tried to deal with what I think of as the greater puzzle: why so many states, despite the obvious differences between them, are trying to do the same things. The growth of social protection and social assistance in the intervening years has been described as a “quiet revolution”. The world is changing, for the better.
The Secretary General of the International Social Security Association has sent out a message to go along with the UN’s World Day of Social Justice on 20th February. The article begins by reminding us that
social justice is inseparable from the full respect of fundamental freedoms and human rights – including access to social security … It is worth remembering that the legal basis for access to the right to social security is clearly defined in international human rights instruments.
One of the instruments was the Social Security (Minimum Standards) Convention, 1952 (No. 102). The UK did not sign up to all of this – it has only ratified sections II-V, VII and X. That, however, includes undertakings about benefits for unemployment, including an upper waiting period of 7 days (art 24(3)) and a level of benefit that is 45% of previous earnings for a person with two children (arts 22(1), 65 and 66). On the face of the matter, the UK is currently in breach of its international obligations in relation to the second condition, and has started to breach the conditions of the first with the introduction of Universal Credit.
Here’s some good news, for once, which I was pointed to by a report about China in the Economist. International organisations have identified ten countries which have made exceptional progress in keeping children alive. The basic figures are here; a report explaining what those countries have done to achieve it is here. A substantial part of it is the improvement in the health of the mothers.
||Under 5 mortality rate per 1000 live births
This item, which I have from the Economist, is one of the strangest reports I’ve seen in years. Assessments of GDP are supposed to be regularly revised, and Nigeria has not done it in an age. In its latest revision, the assessment of GDP has grown by 89%, making Nigeria the largest economy in Africa. GDP per capita has risen from $1500 a year to $2688.
At the same time, Nigeria also has one of the worst rates for infant mortality in the world. UNICEF puts the death rate for under-5s at 124 per 1000. This is much better than it used to be – there have been improvements across most of Africa – but Nigeria’s rating is still the 9th worst in the world. There are more important things than GDP.
I’m grateful to CROP, the Comparative Research Group on Poverty, for drawing my attention to a development in the UN: the declaration that poverty is a violation of human rights. The Guiding Principles on Extreme Poverty and Human Rights, agreed in 2012, begin with an understanding of poverty as “a multidimensional phenomenon that encompasses a lack of both income and the basic capabilities to live in dignity”. States have duties, for example
- to protect people in poverty from stigmatisation, and to “prohibit public authorities, whether national or local, from stigmatizing or discriminating against persons living in poverty” (pp 5-6)
- to enhance the involvement of women in decision-making (p 6)
- to give poor people rights of redress (p 11)
- to ensure that persons living in poverty have access to at least the
minimum essential food that is nutritionally adequate and safe, basic
shelter, housing and sanitation (p 15)
- to “repeal or reform any laws that criminalize life-sustaining activities in
public places, such as sleeping, begging, eating or performing personal
hygiene activities” (p 17)
- to provide legal aid for criminal and civil cases (p 19), and
- to ensure that all workers are paid a wage sufficient to enable them and
their family to have access to an adequate standard of living (p 27)
The document has no direct legislative force, but breaches of human rights are in principle justiciable, and members of CROP have been arguing for some years that developing legal rights against poverty could have a major material effect on government policies.
I haven’t read much of the IPCC’s latest report, snappily named WGII AG5. The report itself doesn’t exist as a single document; there are instead a series of ‘final drafts’, to be consolidated over the next six months. I have read the summary (44 pages), the rather clearer technical summary (76 pages), chapter 13 on Livelihoods and poverty (57 pages) and chapter 2 on Decision-making processes (53 pages). Long-winded doesn’t begin to say it. For a neat, one-page summary, try The Register.
Further note: The full document is now available as a single report here.
Some years ago, I was critical of the Stern report, which put its emphasis on an unrealistic strategy of ‘mitigation’ or prevention of climate change. This report, on ‘adaptation’, seems much better; it is identifying the harms and risks that follow from what we know about climate change and considers how the effects can be responded to. Chapter 2 is mainly verbiage – telling us, for example, that there are ethical issues, which I think we could probably have worked out, but not how the issues might be addressed. Chapter 13 is much better, identifying poorer people as being more at risk and most vulnerable to adverse consequences.
I was drawn to a paper from the World Bank by its title: “A comprehensive analysis of poverty in India“. In recent years the World Bank has published some remarkably rich, subtle, multidimensional, participative studies of poverty. This isn’t one of those.
The authors define poverty in terms of a minimum basket of goods; although there are nominally two poverty lines, they are both subsistence measures, largely based on a minimaum calorific intake. They write:
the poverty line should be set at a level that allows us to track the progress made in helping the truly destitute or those living in abject poverty, often referred to as extreme poverty.
Back to Bowley, it seems; it’s as if the last eighty years of poverty research never happened. The authors explain:
To appreciate further the folly of setting too high a poverty line for purposes of identifying the poor, recall that the national average poverty line was 22.2 rupees per person per day in rural areas and 28.26 rupees in urban areas in 2009-10. … raising these lines to just 33.3 and 45.4 rupees, respectively, would place 70% of the rural and 50% of the urban population in poverty in 2009-10. … Will the fate of the destitute not be compromised if the meager tax revenues available for redistribution were thinly spread on this much larger population?
Peter Townsend used to complain, long and loud, that subsistence measures were liable to be used to justify limiting support. (It’s a caution that the Joseph Rowntree Foundation, currently investigating destitution, might do well to note. ) The idea that extending and generalising support undermines the position of the poor is plainly wrong. Many of the gains that have been made in antipoverty programmes in recent years have been through austere universal measures, such as Essential Health Packages, and the extension of social protection and assistance in a range of transitional economies. We might ask, on the contrary, whether there is any prospect of people receiving the help they need if the only benefits are focused on a limited, marginal population.
A paper from the IMF finds that redistribution does not damage growth, and may help it. “Lower net inequality is robustly correlated with faster and more durable growth”, and “redistribution appears generally benign in terms of its impact on growth”. This is not any great surprise. Richer countries tend to better public services and greater equality; transfer payments have limited economic effects; the evidence over many years has been that welfare does not damage an economy. However, it may be surprising that it’s the IMF saying it.
Apology: I originally posted this with a link to an older IMF paper. The link has now been corrected. PS