The market is coming. Despite the gross and widespread failure of markets to deliver on societies’ needs in recent years, the ironic consequence will be the reduced ability of governments to invest in public services. Governments are already spending public money in new ways, shoring up the banks and other parts of the private sector. This will lead to a claimed lack of ability to keep health services public, and the perfect opportunity for advocates of market forces and deregulation in health care to pounce. A gradual privatisation of health care has been taking place in some major economies of the world already. This is illustrated in Table 1.1. Although for 14 of 27 countries listed in the table the proportion of health care expenditures coming from the public purse has either been maintained or has increased over a period of almost 20 years, for the most advanced economies in this group, any increases are slight. As ever, the US is an exception, as its public sector contribution to health care funding continues to grow significantly. The point is that the pattern is not clear cut and in other advanced economies such as Canada and Sweden decreases in the share of spending coming from the public purse have been quite significant – and this has been during the good times. The opportunity is now here for more radical change in terms of pushing the agenda for greater private financing of health care. Some governments will be convinced, and make no mistake – if they could dispose of their obligations to health care financing on the basis that it could be more efficiently financed through other means, they would.

More than ever, therefore, it is important to make the case for public financing of our health services. However, we need to make that case on the same grounds as the market reformers – that of efficiency as well as equity. But, there is a quid pro quo. Strictly, in Latin, quid pro quo means ‘something for something’ or some sort of exchange of goods or services. This fits the language of economics nicely, whereby obtaining something that is worthwhile involves some sort of sacrifice, or a price to pay, even if that price is not determined in the marketplace.