Key Points
• Health is the result of many determining factors, among which funding, genetics and environmental resources are basic.
• Health is not a right, although the public powers have a responsibility for its protection, promotion, prevention, and care.
• Democracy is associated with a better level of health, but not all democratic policies bring about the same health results, or the same alternatives as regards the organisation of services.
• In Spain an association between Right-wing governments and less interest in primary health care is demonstrated.
Some Examples
Students of public health are usually surprised by the fact that the period of better health care for British children was during the Second World War.
But the explanation is easy: rationing. The war situation forced the political decision, and its acceptance by the population. Rationing ensured the fair distribution to all children of a sufficient daily minimum, and with this, this group had better health throughout the xx century. Without rationing it would revert to unfair distribution to the wealthy, and a sector of the population, poor children, would lack a basic diet, therefore their health would suffer.
There are several examples that demonstrate, in different ways, the impact of politics in health.1 For example, the relationship between the increase in suicides and periods of conservative government in the United Kingdom.2 Also, the tremendous health level of the population of Kerala (a poor state in India), achieved after a hundred year history of female education, and decades of communist governments which ensured the fair distribution of basic resources. As an example of the opposite, the poor health results in the USA, despite its immense wealth, mainly due to marginalising almost 25% of its population. What can be said about the Russian example! With thousands of males dying from uncontrolled avoidable causes, a result of economic, political, and social chaos after the communist debacle at the end of the xx century!
Certainly, the relationship between health and politics, between morbidity and mortality of populations and the taking of decisions by politicians is not an innocent one.1
Health Is Not a Right
The right to health is commonly accepted as somewhat obvious, and is mentioned in some constitutions, as in Brazil and many others (not in Spain, nor in that proposed for the European Union). However, health is linked to genetics and the environment, and it cannot be ensured for anybody, in the same way that happiness, love, intelligence, self-esteem, or any other goods and wealth cannot be ensured against those public and private institutions whose responsibility is only to help to achieve it, not ensure it. If health was a right in the Spanish Constitution it would have to, of course, prevent all Spanish deaths, and to die would be prohibited amongst ourselves, due to being unconstitutional.
As regards health, the public powers, wherever possible, must defend it (protection), increase it (promotion), and prevent it (prevention), and ensure accessible health services according to needs (health care). However, contrary to that normally accepted, the health of a population depends little on clinical services. Basically, if it is desired to increase health, invest in the education system (particularly, in formal education for women). Other key policies in the health of a population are those of water and food hygiene, accommodation, work, fairness and redistribution of wealth. All these policies create strong conflicts in their application. For this reason, democracy is fundamental for health, since it is the least bad for resolving conflicts. The association between democracy and health has been demonstrated with empirical data, even controlling for level of wealth and the distribution of this, and public spending.3
Regrettably, neither democracy nor universal public cover of clinical services is sufficient, as is well demonstrated in countries who enjoy both, the different mortality due to infectious causes according to social class (triple among the poor, in Spain),4 and the different probability of giving birth to a child with Down's syndrome among the poor in France, due to lack of use of the prenatal diagnostic test and subsequent abortion).5
Global political options are fundamental in health, since democracy and universal public cover are necessary, but not sufficient.
The Impact of Political Options on PHC
To summarise, in democracy we talk of the Right and the Left to refer to alternative options that are distinguished by their emphasis on the public. They are simplified concepts, but sum up well a prominent orientation towards hardly any control over the market (Right) or an occasional intervention over the market (Left). In Spain both options have governed the country and the ACs for several periods. For this reason the impact on health and/or the organisation of health services by different governments can be analysed, taking advantage of the "natural experience" of their political action. It is a research exercise of the services in which solidity is affirmed if they have the same results from different data sources, and it is maintained over time.
It has been shown that public health spending on PHC in Spain has been around 16% for decades, regardless of the colours of the party in government.6 However, by ACs a better option for PHC can be demonstrated between those less wealthy ACs and/or with an older population, generally governed by the Left (the wealthiest regions, in general, governed by the Right, have a defined option for hospitals).7 The Federation of the Associations for the Defence of Public Health (FADSP) carried out a study as regards this,8 which is followed up by the excellent article published in this issue,9 and which confirms the results that demonstrate a clearer option for PHC in ACs governed by the Left.
Similar conclusions are reached even with other data.10 Thus, for example, if the health centres and specialist centres are added together, and divide by the health areas, the mean in Spain is 4.5. But there are enormous variations, up to 23 times, between 15.8 in Castile and Leon and 0.7 in Madrid, and the order is similar to that arrived at by the FADSP and the authors of the article commented on.8,9 In another example the order is almost similar, with the density of staff in PHC, much less professionals in ACs governed by the Right. If the order is reversed as regards the percentage of general doctors who still work with the 2.5 hours clinic model, then the list is headed by Galicia and the Balearic Islands, which confirms, in another way, the lack of interest in their PHC. That is to say, in general, the ACs that have been governed longer by the Right (Canary Islands, Balearic Islands, Community of Valencia, Galicia, Madrid, and Murcia), stand out as regards the lack of development in PHC. However, Castile and Leon is worth noting, with very good results, probably associated to its poverty and old age, although it may have been governed by the Right.
Conclusion
In research into services it is not easy to achieve irrefutable results. But, the study of trends and the hypotheses that "natural experiences" suggest as regards PHC in Spain, is very interesting. For example, although Spanish PHC reform in 1984 required an aggiorgamiento (bringing up to date), with more than one radical change, some of its components may serve as a suitable example to understand it in depth. In this sense, studies on the impact of political options on the development of PHC are fundamental. It would also be desirable to complete these studies with parallel ones on the impact on health. With these, the relationship between politics and health could be better understood.1 In any case, it seems that the political option of the Right is associated with less "interest" for PHC.
