Despite the prodigious growth in health-care spending over the past 40 years, there have long been nagging doubts over whether it provided value for money. Medical advances such as vaccines and antibiotics against infectious diseases have clearly done much to improve people's health, but these things are relatively cheap. What has all the rest of the spending achieved? A commonly used gauge of health status is life expectancy. This measure casts doubt on the effectiveness of heavy spending on health care in recent decades on two grounds. First, the biggest increase in life expectancy pre-dated the introduction of national health-care systems. In England and Wales, for example, life expectancy at birth rose by 20 years in the first half of the 20th century, but by only ten years in the second half. The most important reason for the early gain was the conquest of the infectious diseases that were taking such a heavy toll a century ago. But the biggest improvement occurred before the introduction of mass immunisation programmes and antibiotics. It is thought that medical care accounts for only about a fifth of the 20th-century gains in life expectancy in Britain and America. The rest came from improvements in nutrition, sanitation, hygiene and housing.
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