Introduction

Typologies of health system expenditures tend to be based on their degree of publicness (Blank et al, 2018, p 73), or countries are compared on the basis of their total spend on healthcare (Kotlikoff and Hagist, 2005). However, there is still relatively little work which explores different categories of health expenditure and how these contribute to good or bad care, and whether that care, in turn, leads to better or worse health outcomes.

In terms of arguments around levels of expenditure, there is often a general assumption that greater healthcare expenditure allows the purchase of more health services, and that this should lead to better health outcomes. However, this clashes with critical work, perhaps best exemplified by Illich (1977b), suggesting that increased spending on healthcare may itself be detrimental (Blank et al, 2018, p 260), with medicine being portrayed as a ‘disabling profession’ (Illich, 1977a) that prevents us from trying to find our own sources of well-being. As well as the disabling profession critique, Illich argued that the toxic or dangerous effects of medicine (its ‘iatrogenetic’ dimension) were not being taken into account, and raised questions that more recent authors (O’Mahony, 2016) have used as a basis for questioning the legitimacy of many medical interventions, which they find fall short of the standards of evidence which medicine aspires to (Stegenga, 2018).

There have been significant debates on the implications of trying to shift expenditure between primary and secondary care, which has been explored both in terms of individual health systems, but also comparatively (Peckham and Exworthy, 2003). There is a general trend towards health systems becoming more ‘primary-care led’ and of care moving more away from high-cost hospitals into community settings where it can be delivered more responsively (and perhaps more cost-effectively), but conceptual and measurement problems abound of what qualifies as ‘primary care’ (OECD, 2019), and so, although this debate is an important one, it is not the main focus of this chapter.

When considering what health systems spend their funding on, there are significant challenges involved in trying to balance the acute health needs of people today with expenditure on those with long-term conditions, with changing demography leading to increasing numbers of people with conditions such as asthma or diabetes, which medicine currently often cannot cure, and so which potentially require life time support.