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Rural Health System Resources


Political Determinants of Health: Healthcare Privatization and Population Health in Europe


Moise, Alexandru and Popic, Tamara


Healthcare reforms result in policy outputs that influence the provision of medical services, which have consequences for the health of the population. This paper looks at whether health policies actually lead to improvements in population health, using an original dataset of healthcare reforms passed in 36 European countries from 1989 to 2019. Focusing more specifically on legislative changes implying privatisation of healthcare delivery and finance, we ask the following question: What is the relationship between reforms that privatise healthcare provision and population health in terms of health outcomes and inequalities? We answer this question by relying on fixed effects time-series cross-section models. Health outcomes are operationalised using measures of subjective health status, unmet health needs and resulting health inequalities. Our results show that privatisation of healthcare is associated with higher rates of poor health and unmet health needs several years after the passing of reforms. These effects are stronger for individuals in the lower tiers of income and education, resulting in higher socio-economic inequalities. The article contributes to conceptualisation of the political determinants of health as health policy outputs and a better understanding of the relations between policy outputs and population health outcomes.

Why is this useful for rural and remote people?

Health policies are intended to result in an improvement in health outcomes for people. Policies can be direct, for example a policy to ban advertising to reduce smoking, or indirect for example a policy to increase the rural medical workforce to ensure rural people have good access to primary care. It is therefore important to understand whether health policies actually lead to improvements that contribute to better health in rural and remote communities. We know for example that rural medical workforce policies have failed to reverse the decline in the general practice workforce in rural areas, and have resulted in significant growth of doctors in cities, yet the policies remain largely unchallenged despite this failure. This paper looks specifically at the issue of privatisation of health services, which includes activities such as the outsourcing the operation of public hospitals to private operators. To the extent that privatisation policies were argued to be essential to improve the cost-effectiveness of the delivery of health care, and reduce health inequity, in Europe it is relevant to ask “did it work”. This study found that privatisation policies largely failed to improve health outcomes, address unmet need or reduce inequity. The report notes that there is a need to “understand the workings of the political process as pathways and mechanism through which power configurations cause illness and inequity (see Lynch 2023)”. In short, policy decisions such as the privatisation of health services are often represented by health systems as neutral decisions referencing economic theories or other rational justifications. Yet, the evidence suggests that these policies are innately political in nature, and that the political process provides opportunities for actors to lobby for their own interests behind the scenes. The authors argue that “health policy” decisions should therefore properly “be brought into the political arena and that policy interventions, especially controversial ones such as privatisation, [should be subject to] extensive [public] debates before they are implemented.” Rural and remote people are often told that policies are based on extensive research and evidence. What this study suggests is that the selection of evidence, or privileging of vested interests, can result in health policies that are poorly aligned to community need, and that thee decisions should therefore be part of the public political debate rather than decided behind closed doors. For rural and remote people, given the consistent failure of rural health policies to improve access to health care, or community health outcomes, it may mean that rural health policies should be decided by the public, and subject to more rigorous public debate before adoption.

Suggested Citation

Moise, Alexandru and Popic, Tamara (2024) Political Determinants of Health: Healthcare Privatization and Population Health in Europe , J Health Polit Policy Law 11257024


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