Review of In Search of the Perfect Health System by Mark Britnell

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Revue Française de Civilisation Britannique
French Journal of British Studies
XXIV-3 | 2019
The NHS at Seventy: Framing Health Policy in Britain
Review of In Search of the Perfect Health System by
Mark Britnell
Hira Rashid
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URL: http://journals.openedition.org/rfcb/4174
ISSN: 2429-4373
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CRECIB - Centre de recherche et d'études en civilisation britannique
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Review of In Search of the Perfect
Health System by Mark Britnell
Hira Rashid
REFERENCES
Mark Britnell, In Search of the Perfect Health System, Palgrave and Macmillan, 2005, 233
p. ISBN 978– 1– 137– 49661– 4
1 In Search of the Perfect Health System captures the workings of incredibly diverse health
systems in 25 chapters that provide brief but relevant country contexts, ranging from the
formation and evolution of sickness funds in Germany in the 1883 and health
management organizations in Israel in 1995, to the recent push for Kaigo Hoken1 in Japan
at the turn of the 21st century. This book aptly captures the similarities across health
systems such as limited public financing and coverage gaps between countries with sharp
cultural and political contrasts –the United States and China, for example. It documents
the economic and political forces spurring the wave of privatization in the welfare-
oriented economies of the Nordic countries and tracks the intersection of healthcare
innovation and public health policies in the rapidly growing countries of Mexico, Brazil
and India.
2 However, it would be overly simplistic to view this work as a series of descriptive essays
that summarize the workings of the health systems of countries around the world.
Instead it is more accurately described as a commentary on the political, ideological,
economic and cultural forces that shape the national and regional health systems of the
world, and the strategies used by policy actors to tackle the challenges that arise.
3 This review first discusses five prominent themes that Britnell highlights through the
course of the book, with notable examples from his analyses of national health systems. It
then moves on to a critical analysis of the structure and content knowledge, and finally
concludes with a brief section on lessons learnt and implications of this work.
Review of In Search of the Perfect Health System by Mark Britnell
Revue Française de Civilisation Britannique, XXIV-3 | 2019
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4 The first and perhaps most significant contribution of Britnall’s work is the identification
of numerous strategies and practices worth replication within selected health systems he
discusses in the book. In addition to a description of the financial distribution of
healthcare costs, notable health indicators, healthcare delivery mechanisms, consumer
access and patient satisfaction measures, each chapter provides critical insights into key
policy measures undertaken by local or national policy actors to improve outcomes,
reduce costs, or both.
5 The most valuable aspect of this analytical exercise, obviously attributable to Britnell’s
extensive experience in the global healthcare industry, is the linkage of policy
development to its eventual impact, and the lessons to be learnt from this process. For
example, despite Portugal’s progress, Britnell traces the beginnings of a declining health
infrastructure, higher out-of-pocket costs, reduced compensation for the healthcare
workforce and a general disinvestment from the healthcare sector. He attributes this to
the economic collapse, austerity measures and declining living standards in the country.
Qatar, on the other hand, driven by the ambition to make its mark on the world, and
unencumbered by resource constraints, launched an expensive National Health Strategy
in 2011 and has even taken steps towards the launch of a universal health insurance
system. However, as Britnell points out, the prioritization of channeling resources
towards the construction of new hospitals may not necessarily lead to proportional
improvements in population health.
6 Second, the book does a commendable job of delineating the drivers of fragmentation in
the healthcare system as well as how it manifests through underutilization of available
capacity, coverage gaps, depreciating quality of care, waste in the healthcare industry,
overly burdensome administrative tasks for doctors and, subsequent declines in patient
satisfaction rates and health outcomes. A consistent critique he levies on health systems –
developed and developing - is the lack of standardized regulatory and quality control
measures integrated and enforced by a central governance system at the country level.
7 This fragmentation, Britnell points out, is creating an increasing demand for private
health insurance among consumers who are able to afford it, thereby reinforcing existing
health inequities. The intersection of health policy and access barriers to essential health
services grounded in socioeconomic, geographic and demographic inequities is woven
into Britnell’s analysis. In the concluding chapters of the book, he aptly notes “two forces
– globalisation and wealth inequality – will create fertile ground for the development of
universal healthcare but its successful introduction cannot be taken for granted” (p. 155).
8 Third, true to his claim in the introductory comments, Britnell engages practitioners,
policy makers and politicians by connecting the dots between hot button political issues
and often understated, but vital aspects of the healthcare industry. He captures the
impact of workforce shortages in countries like Japan, Hong Kong, Mexico, India and
Brazil, where healthcare access is a growing priority for the electorate. He discusses the
long-lasting impact of workforce immigration policies as ambitious, well-resourced
countries like Qatar draw skilled professionals from the Global North and highlights
potential issues with sustainability in the absence of local workforce education and
training programs. He draws attention to the increasingly globalized nature of healthcare
consumption by presenting examples of the increasing rates of medical tourism in South
Korea, Malaysia, Singapore and Mexico.
Review of In Search of the Perfect Health System by Mark Britnell
Revue Française de Civilisation Britannique, XXIV-3 | 2019
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9 Fourth, a consistent unifying theme in Britnell’s analysis of these systems and policy
measures is the importance of dynamism – policy action and institutional reorganization
to address the evolving patterns of communicable diseases, chronic illnesses and ageing.
He draws on the example of Brazil, where near-universal access to primary care and
workforce distribution strategies to promote family-centered care models has
contributed to considerable improvements in health outcomes. Singapore and Japan have
introduced new insurance schemes with varying degrees of consumer choice to address
the needs of its growing elderly population. South Africa is striving to contain the burden
of communicable diseases by expanding access to screening and preventive interventions
to remote rural areas using Tutu Tester mobile clinics, while Germany amidst growing
pressures to contain growing healthcare costs, has taken steps to improve integration of
care and taken legal measures to protect patient rights.
10 Finally, Britnell strongly advocates for patient empowerment in healthcare, urging
healthcare delivery systems in developed countries to learn from the initiative of African
nations such as Uganda and South Africa. He argues that despite the capital-intensive
technological advancement and efficiency enhancing measures in banking and retail
industries in countries like Germany, France and Switzerland, healthcare has lagged
behind in terms of emotional and social support for patients, particularly those suffering
from chronic conditions. He attributes this to two factors: “empowering patients has been
viewed as the ‘right thing to do’ rather than crucial to the economic sustainability of
healthcare systems, so it has not been pursued with any urgency; and clinicians are wary
of the idea because it changes the power relationship between them and their patients”
(p. 187).
11 Brevity is perhaps the most attractive feature of this book, yet its most significant
limitation. Without further research into each country, one runs the risk of being ill-
informed on the workings of these health systems, and the populations they serve.
However, in his defense, Britnell opens with the claim that “each chapter can be read in
the time it takes to drink a cup of coffee. This is not an academic treatise…” (preface). The
book is unquestionably informative, but readers must understand its purpose to be that
of an introductory discourse, since it embodies Britnell’s own perspective thus presenting
only selective information about the complexity of how they function.
12 An important underexplored theme in this book is the intersection of investments in
public health with the performance of the health systems. Recognizing the importance of
this aspect of any health system, Britnell notes “we wouldn’t start from where we are,
knowing what we now know” (p.211). Despite this, the country level analysis does not do
justice to the significance of this statement. While he highlights the high immunization
rates and tobacco control policies in Brazil, screening and lifestyle programs in Mexico
and the concentration of socioeconomic risk factors among the aboriginal population of
Australia, there is little that speaks to the integration of public health policy into the way
health systems around the world are structured.
13 The improvement of health outcomes through the creation of accessible health services
has increasingly been recognized as an instrumental aspect of the political and economic
trajectory of a country. On the one hand, country governments face internal pressures
induced by comparative insights into the drivers of affluence and longevity of the
populations of the developed world. While on the other, rapidly shifting demographics,
stagnating economies and growing gaps in quality of care have given rise to political
unrest and unpopular financial restructuring to bring costs down. Consequently, health
Review of In Search of the Perfect Health System by Mark Britnell
Revue Française de Civilisation Britannique, XXIV-3 | 2019
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systems around the world are struggling to adapt to the changing needs of the
populations they are designed to serve, which also straddling the line between cost
efficiency and expected quality standards. Despite its title, the book does not in fact
identify a ‘perfect’ health system, it does give the reader a realistic perspective of the
issues facing those that are considered to be some of the best and is a timely contribution
to the debate many economies around the world are facing.
NOTES
1. Kaigo Hoken refers to the long-term care scheme in Japan, which is expected to improve
quality of life for the elderly population.
AUTHOR
HIRA RASHID
Research Assistant, Center for Community Research and Service, School of Public Policy and
Administration, University of Delaware
Review of In Search of the Perfect Health System by Mark Britnell
Revue Française de Civilisation Britannique, XXIV-3 | 2019
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