Joan Benach is the director of the Health Inequalities Research Group-Employment Conditions Network (GREDS-EMCONET) at the Department of Political and Social Sciences at UPF and scientific co-director, together with Gemma Tarafa, of the book Com comercien amb la teva salut (How they treat your health like a commodity), a study on the privatization and commodification of healthcare in Catalonia published by Icaria.

- The introduction of the book collection says "Bad times in which the self-explanatory needs explaining...". Like what?

This refers to a question of great importance: the dominant, often conservative ideology or vision renders key social issues invisible or disguises them. Research must help to show and understand seemingly simple phenomena. For example, when measuring job insecurity in Catalonia, the percentage of temporary contracts (18%) is almost always used, and this approach underestimates the reality as our own studies show how job insecurity is more than double, and even higher in the Spanish State. The worst situations are endured by women, young people, immigrants and workers whose health is being seriously affected.

- How do they treat our health like a commodity?

You are referring to the latest book we published (Icaria, 2014). It is a synthesis in which we explain what we say in the subtitle, the "Privatization and commodification of healthcare in Catalonia". We review the concepts of public health such as the social determinants of health and equality; we compare public and private systems showing that the former provide better coverage, quality and efficiency; we contextualize the Catalan health system in history, showing its structure and functions, and the tendencies towards the privatization and commodification of a system that is too centred on hospital centres and medication; we explain the causes of a process where the reduction in resources is used to weaken the public health system and make a business out of health rather than a right. Finally, we review some of the social debates and actions of those who are fighting in defence of a public healthcare system that really is public, human, fair and participatory.

"The worst situations are endured by women, young people, immigrants and workers whose health is being seriously affected"

- What effect has the crisis had on the Catalan health system?

The economic recession has created a scenario that is conducive to neoliberal ideologies in favour of a commodified health system that transfers resources from the public to the private sector. The promotion of private healthcare impoverishes the public system. Let's not forget that health can be a huge business for major economic groups linked to the pharmaceutical, healthcare and technology industries. How do they want to profit from this? With "revolving doors", favours, irregular payments and awarding, as revealed by numerous pieces of journalism; with budgetary cuts in the public system, 14% since 2010, and a reduction of infrastructures and human resources.

These cutbacks affect the public sector far more and not not-for-profit private entities that maintain or improve their situation. With legal, media and management strategies that debilitate the public system. One example are the legal reforms like the "Omnibus Act" which encourages subcontracting, allowing organizations or private companies to manage or make use of public spaces.

- So we can say that the health of the Catalan population is decreasing unevenly, depending on their level of income?

Commodified healthcare is unfair, it breaks with the concept of citizenship and social solidarity, and opens the way to classism, discrimination and inequality. Unfortunately we do not have all of the data, information systems and analysis to properly ascertain the reality, but we know that the cutbacks have serious effects on health and inequalities. The weakening of access to and the quality of the health system translates into the closure of primary healthcare centres, ER units and operating rooms, longer waiting lists, redundancies in hospitals, a reduction in the number of healthcare professionals and worse working conditions. In Catalonia in recent years 77 thousand people have ceased to be insured, while the Catalan population has increased by 40 thousand. Moreover, the economic recession causes many other social and employment-related outcomes associated with increased poverty, housing problems, food insecurity, and social exclusion, all of which damage the health, especially among the weakest.

"Commodified healthcare is unfair, it breaks with the concept of citizenship and social solidarity, and opens the way to classism, discrimination and inequality"

- Privatization is often spoken about as being a tool to improve the efficiency of public services.

There is a highly ideological discourse that indicates that the privatization of management or the outsourcing of services mean that in this way the efficiency of public services will improve. There is no doubt about the need to improve public services. For example, by improving primary healthcare, controlling the abuse of technological interventions, or reducing pharmaceutical expenditure. Now, what we mustn't do is weaken the public system giving more power to a health system that by definition seeks profit. The scientific literature shows how public hospitals present better results than private hospitals provided they dispose of adequate funding. In Catalonia, a report analysed the differences in the quality of primary healthcare according to the provider pointing at the worst results in the healthcare activities of nursing staff at for-profit centres. Thus, the privatization and commodification of the healthcare system not only endanger access to healthcare, but also compromise the essential principle of equality.

- And measures such as co-payment, what is your assessment of this?

Although to some it may seem logical to implement such schemes, co-payments for public health services help commodify the system and are ineffective, unfair and inequitable. They don't contain health costs, they don't contribute to the sustainability of the health system and they don't increase efficiency but instead they generate problems and increase inequality. Co-payments reduce the use of healthcare services, whether they are effective or not, whether they are medical visits, prescriptions, admissions to hospital or preventive services. Moreover, they make the patient responsible for their healthcare consumption instead of the politicians, who have the responsibility and economic powers that promote consumption. Finally, co-payments make a "noise" that often masks or minimizes fundamental health issues such as the underfunding of public health (especially primary healthcare), the lack of efficiency of the system, or the commodification and privatization of health.

"The scientific literature shows how public hospitals present better results than private hospitals provided they dispose of adequate funding"

What solutions should be adopted to improve the effectiveness and efficiency of the system?

The Catalan health system is often described complacently and uncritically, without mentioning the problems of health and inequality. You cannot put economic or business interests before the health and welfare of the population. A society that doesn't look after the health and welfare of all its citizens is a 'sick society'. But it is possible to go in the direction of a different system where health is a right and not a privilege of those who can afford it, whether it might be general healthcare, dental healthcare or mental health services. It is possible to achieve a health system with a more controlled use of technologies and drugs that lead to unnecessary deaths and illness, and where the emphasis is on the human being, quality and equality. All of the past experiences tell us that this can only be achieved with truly public systems as regards their management and funding, that also maximize social participation.