A recent read of Francis Fukayama’s Liberalism and its Discontents1 set me thinking. For someone who is not a social scientist despite being a short book of 174 pages, it is a tightly written, challenging but stimulating read, which I can recommend. I have in fact read the book twice and continue to delve into various chapters in the book.
Having in the past been taken to task for my application of the so-called neoliberal policies of budgetary austerity faced with a limited health budget2, the book made me think whether I am indeed a liberal with socialist leanings, which I had always considered myself to be, or whether over the length of my career as a senior government bureaucrat I have become the neoliberal apologist that my critics allege?
Neoliberalism is seen by some as a “pejorative synonym for capitalism” and the basis for policies implemented by politicians such as Margaret Thatcher and Ronald Reagan. Capitalism is characterised by private ownership and where the free market controls the production of goods and services for profit rather than the state.
Liberalism in its purest form limits the powers of government through laws creating institutions that protect the rights of individuals. Individual rights including property rights, civil liberties, democracy and free enterprise are the key tenets of a liberal society.
Socialism at times confused by some with communism, and I have in the past been accused of being both a communist and a socialist, is defined as the social ownership of the means of production, distribution and exchange promoting greater equality regulated by the government as elected by the people.
Communism, in contrast, is a system where all resources, both property and economic, are owned and controlled by the state in theory on behalf of the working classes or proletariat from which all citizens should benefit equally.
The criticism of liberal democracies is that despite their economic success the degree of inequality across the spectrum of their citizens is significant. Wealth becomes concentrated in the hands of a relative few. This occurs despite the individual freedoms and rights that a liberal democracy purports to ensure its citizens.
What interest then does this hold for one who has spent all of his professional life within the realm of health systems?
The United States of America, the country where I was born, as the leading free market liberal democracy in the world with great wealth has a health system, despite the reforms implemented by the Affordable Care Act of President Obama, largely located within the private sector. The country is characterised by great disparity in the access to health care services across its communities which is dependent on the ability of the individual to pay for the services provided.
In contrast as an example, Scandinavian countries have publicly financed comprehensive healthcare at a minimal or no direct cost to the patient. Implemented over 70 years ago the National Health System of the United Kingdom while existing in a liberal democracy is clearly a socialist institution in the manner in which it provides healthcare to the population of Britain. While not socialist democracies, these countries in terms of healthcare do reflect many of the tenets of socialism. Their healthcare systems promote equality of access but are dependent on the fiscal stability of their free market economies that support them.
Cuba, a poor communist country that I have visited, provides healthcare to all of its citizens without charge and has health indicators that indicate a more successful health system than its free market neighbour the United States. While the overall quality of the healthcare experience may not necessarily compare favourably with those in all other countries, there are no barriers for its citizens to entry into the system.
So are the criticisms of my actions as a health bureaucrat allegedly implementing the neoliberal policies of austerity valid?
Were any citizens prevented from accessing the health system which I managed as a result of an inability to pay for the services rendered?
The answer to this would be no. Entry at the primary level of care was without charge while entry to higher levels of care although requiring payment did not exclude those unable to make payment.
Was the standard of care provided in the health facilities for which I was responsible equal to that provided in the private sector or in higher income countries?
In terms of the standard of clinical care I would argue yes it was, but in terms of the quality of the experience as determined by factors such as the waiting times and the state of the facilities in which the services were provided, I would accept that it was not.
Was there a limit on the extent to which certain services were provided compared to that in the private sector?
Since the only limitation in the private health sector to the nature and extent of the services provided is the clinical judgement of the treating physician and the ability of the patient to pay, while comparatively in the public sector this is limited by both government policy and the ability of the state to fund the services, the answer would be yes.
Therefore in terms of the responses to the last two questions, it can be argued that there existed a degree of inequality and inequity in the healthcare provided to patients managed in the public health sector that I managed compared with those in the private sector. Measured against these criteria, there was and is not equity which does not meet the expectations of a socialist society. Given that the system reflects private choice and individual ownership, it appears that it nevertheless reflects some of the principles of a liberal society.
Given that South Africa is essentially a free market democracy based largely on liberal principles, such as individual rights, civil liberties, free enterprise and democratic principles, I would argue that my actions as a senior bureaucrat in this context fulfilled my beliefs as a liberal with socialist leanings. These were however tempered in time by the fiscal realities of a free market system and the simple philosophy that one cannot buy what one cannot afford.
I would be interested to hear the views of others!
