The history of a country plays an important part in shaping public policy. This essay will discuss the historical conditions that have affected the development of health policy in different states. The essay will begin by defining the term ‘state’. It will then discuss the origins of health policy in certain states. The essay will focus on the emergence of health policy in Germany and Britain. The essay will, finally, try to determine if there is a similarity in the development of health policy in these three countries.
Hague and Harrop (2001) define the term ‘state’ as “a political community formed by a territorially defined population which is subject to one government” (p 6). This is a good definition for the purpose of this essay because it is very clear and quite broad. There are a number of historical factors that can help influence the development of health policy in different states. In order to determine these factors it is important to discuss the origins of the policy within that state. This essay will focus on the development of health policy in Germany and Britain.
Germany is important to the understanding of health policy because they were the first country to introduce health care legislation. The most important piece of legislation to be introduced in Germany, with regards to health policy, was the Sickness Insurance Law of 1883. This legislation became the cornerstone of German healthcare policy and had an immense impact on the development of health policy in other European countries. The Sickness Insurance Law was the first of a number of healthcare policies to be introduced by chancellor Otto von Bismarck in the latter part of the nineteenth century.
The Sickness Insurance Law (1883) came into effect in December 1884. The underlying premise of the law was that the most vulnerable members of the population should, when ill, have access to medical assistance. The law also made provisions for dependants to receive income maintenance during periods of illness. Under the law the worker was entitled to four main types of benefits. These were medical, cash, maternity and funeral. The medical benefit provided free medical and dental treatment and allowed for free hospital treatment for up to twenty six weeks.
The maternity benefit entitled to free medical attention and a lump sum cash benefit. Finally, the law provided money for the family of a deceased worker for funeral costs. The Sickness Insurance Law provided for compulsory participation for all industrial wage earners and by 1886 had been changed to incorporate most of the wage earning population. The program was financed through joint contributions by both employees and employers. The state, contrary to Chancellor Bismarck’s original intention, made no contribution. (Leichter 1979)
The Sickness Law was the first major piece of healthcare legislation to be introduced in Germany and was closely followed by the introduction of accident insurance in 1884 and invalidity and old age insurance in 1889. However, the 1883 health insurance law did not take into consideration the relation between sickness funds and doctors. The funds had full authority to determine which doctors were allowed to participate in the program and to set the rules and regulations under which that were able to do so. These rules and conditions were set down in individual contracts between the funds and the doctor.
Many of the doctors, who had become dissatisfied with the contracts and their limited access to practicing medicine with the sickness funds, came together and set up an association in 1900 and even went on strike several times. By 1913, the sickness funds, along with the doctors, had established a system of collective bargaining to determine the way in which the licences and remuneration was distributed. (Germany: Development of the Healthcare System, 1996) There are two important factors that affected the development of health policies in Germany. Firstly, Germany was undergoing changes in their socio economic conditions at that time.
Germany’s industrial revolution developed somewhat later than their other European counterparts with their take off period of sustained economic growth being placed between 1850 and 1870. Inevitably, industrialisation was accompanied large demographic changes. The most important of these were the urbanisation and proletarianisation of the population. The working class increased from one fifth of the population in 1870 to one fourth in 1882. The urban population increased from twenty eight percent in 1858 to forty seven percent by 1890. (Leichter, 1979)
Secondly, it is important to assess Chancellor Bismarck’s political motivations behind his reforms. In 1878, there were two assassination attempts on Kaiser Wilhelm. Although neither of the assailants had any connection to the socialist movement, Bismarck used the attacks as a means of punishing the socialists. After the first attempt on the Kaiser’s life, Bismarck proposed an anti-socialist bill which was rejected by the Reichstag. However, when the second assailant was successful in injuring the emperor, Bismarck had the Reichstag dissolved and called for new elections, campaigning for his anti-socialist bill.
The newly elected parliament passed the Act Against the Aim of Social Democracy Dangerous to the Commonwealth. The Act came into effect in 1878 and prohibited the formation of socialist organisations. However, the anti-socialist law was reformed during the early 1880s as a means of controlling the socialist movement and the working class. These health policies remained relatively stable until the emergence of the Nazi regime during the 1930s. Under the Nazi regime, the healthcare system underwent a complete overhaul, with an emphasis placed on racial purification.
Doctors were advised to only treat individuals from the Arayan population. However, after the end of the Second World War, these reforms were disregarded for the more traditional ideas seen in Bismarck’s reforms. (Leichter, 1979) Healthcare policy developed in Britain much later than in Germany and it can be argued that many of the ideas behind British policy stems from those introduced by Bismarck in Germany. The first major legislation to be introduced in Britain was The National Health Insurance Act. This was one of a number of reforms to be introduced by the Liberal Government between 1906 and 1914.
It can be argued that these reforms, which included a school meal program, old age pensions, unemployment insurances as well as health insurance, were the beginning of Britain’s welfare state. (Leichter, 1979) The National Insurance Act was introduced in 1911 by David Lloyd George and consisted of two parts. The first part of the act introduced unemployment insurance and set up a Labour Exchange.
The second part of the act consisted of the health insurance scheme. The ideas behind the schemes were largely determined by a visit to Germany made by Lloyd George in 1908. Making Sense of the Red Book, 2003) There are a number of factors, besides Lloyd George’s visit to Germany that can be seen as extremely influential in the development of Britain’s health policy. Firstly, it is important to note that the first decade of the twentieth century saw an increase in concern for the health of the nation by the population and, importantly, the elitist members of society. This concern was fuelled by the Boer War (1899-1902). The Boer War was felt at the time to be a quick and easily won war.
However, this was not the case; the war took three years and cost over 250 million pounds. The dismal military performance was felt by many at the time to be a result of the poor condition of the working class army recruits and many felt that they demonstrated the unhealthiness of the working class. It was also felt that the dismal performance during the Boer War represented the decline of the British nation and that reforms were needed to improve the problem. By 1903, the conservative government, unable to ignore public opinion, introduced the Departmental Committee on Physical Deteriation.
The following year the department reported there was indeed a great amount of poverty, disease and malnutrition amongst the working class population. This report played a major role in the development of the notion that some form of state help was needed with regards to healthcare. When the Liberal government came into power in 1905, the factors played a large part in the development of their health policy. (Leichter, 1979) Although there were some minor changes to the policies, these provisions remained in place for the majority of the first half of the twentieth century.
However, in the years after the Second World War, the healthcare policy in Britain underwent a drastic upheaval. The system in place moved from an insurance program to a more state orientated program. This change came in the form of the National Health Service (NHS) which is the system still in place today. (Baggot, 1994) The National Health Service (NHS) was introduced in Britain in 1948, although the bill was passed by government in 1946. It was introduced by Aneurin Bevan. There were a number of factors which helped to develop the notion of the NHS.
Firstly, there were similar fears, as with the introduction of the National Health Insurance Act of 1911 that the country’s health had deteriorated after the First World War However, one of the pivotal moments in the development of the NHS was the Second World War. In 1938, the government concerned with the impact of the imminent war, on the British public created the Emergency Medical Service (EMS). The objective of the EMS was to organise the nation’s medical delivery during the war. The service was provided free for those injured by military action.
The EMS had a detrimental effect on shaping health policy after the war for two main reasons. Firstly, during the war the EMS were able to document the deficiencies in the delivery of the British healthcare system, and secondly after the provision of the temporary free healthcare system, the public felt there should be more state involvement in the delivery of healthcare. (Leichter, 1979) Another important factor which helped shape the NHS was the production of the Beverage Report in 1942. The report was base on three fundamental assumptions. Firstly, it emphasised a need for a free National Health Service.
Secondly, that there was a need to create some form of family allowance benefit, and finally, that and emphasis should be placed on the maintenance of employment. From this report, the Labour government of the late 1940s developed the idea of the NHS which would be funded through taxation and National Insurance Contributions, and would be free for all at the point of delivery. This is the system that we still have in place today. (Wall and Owen, 1999) In conclusion, there have been a number of ways in which historical conditions have shaped the development of health policy.
In Germany, the political ideas of Chancellor Otto von Bismarck have an important role along with a shift in socio economic conditions that were happening at that time. A similar pattern can also be seen in the development of health policy within Britain. British healthcare reforms were majorly influenced by the change in social conditions produced by Britain’s involvement in the Boer War and both world wars. However, it is possible that these reforms would have taken place eventually, if these conditions were not there.