Designing a world class healthcare system
MATTER OF CONCERN
GOVERNMENT HAS AN ESSENTIAL ROLE TO PROVIDE BASIC HEALTHCARE TO UNDERSERVED AND DEPRIVED SECTIONS OF SOCIETY. HERE IS HOW WE CAN DO IT, WRITES DR SYED AMIN TABISH
Since the dawn of civilization health care has been a focus of public and government interest. As early as 1700 B.C.E., Hammurabi, ruler of Babylon, developed laws on health care matters that included access to services, payment for care, and quality control. Nations throughout the world are faced with growing demands on their health care systems, often accompanied by diminishing abilities to satisfy and pay for all the health care needs and wants of their citizens. The health care sector of the global economy is huge: Its issues are many and they are exceedingly complex. Arguments over trade-offs between social solidarity versus personal autonomy, public versus private health care financing, public versus private provision of health care services, and the need for high-quality medical care versus more basic levels characterize health care debates in virtually every nation. Yet, to move forward, we must understand these enormously complicated problems and find a path that moves us toward executable health care policies.
All modern, well-developed health care systems share a common goal for those who depend on their services: hope for full and healthy lives. The personal importance of this goal inevitably means that health care is much more than an ordinary economic good or service. Good health is a state of being that is necessary for each of us to have the opportunity to fully express our human selves and to be able to reach our human potential. Our health care system, whether public or private or mixed, is the social and economic expression of support for our individual good health. Health can be seen as a means, a foundation for achievement, as a first achievement itself, and a necessary premise for further achievement.
Ethos and Politics Shape a System's Potential
How medical care "wants," "needs," and personal expectations are fulfilled in a nation's health care system is driven by a number of non-medical considerations. Ethics and politics are two considerations that have profound effects on how a nation organizes the financing and provision of medical care for its citizens. The body politic of nations differs in their societal ethic. The distinction between social solidarity and personal autonomy is an important driver underlying a nation's choice between public and private health care systems. The United Kingdom adopted its public health care financing and delivery system as a "reward" to itself following the turmoil and pain of World War II. Social Insurance and Allied Services laid the foundation for creation in the United Kingdom of a National Health Insurance (NHI) program.
Goals for Health Care Systems
As means to an end of good health, those responsible for stewardship of health care systems adopt goals for their work. These goals (cost, quality, and access) are "ideals" that citizens and those who steward health care systems debate and strive to reach. Actual health care system performance quite often falls short of fulfilling these goals. One major reason for a performance gap is that assessing and measuring cost, quality, and access as well as their interrelationships and trade-offs are quite difficult.
Health Systems Structure
All health care systems must perform an array of functions designed to measure objectives, the ultimate objective of a health care system being health itself. To work effectively, a health care system must perform some high level functions. Delivering services is the most visible of these functions. However, in order to deliver services, a health system must first be effective at creating resources through investment and training. Funds for resource creation and service delivery are an essential lubricant; therefore, health systems must also arrange financing. Funds must be collected, pooled, and ultimately used to purchase needed goods and services. Government is ultimately responsible to its citizenry for the performance of its health care system through the nation's political system. Health care systems function to provide for population health needs. Fulfilling these needs is the system's objective. Health is clearly the most basic objective. WHO (2000) notes: ". . . while improving health is clearly the main objective of a health system, it is not the only one. The objective of good health itself is really two-fold: the best attainable average level-goodness-and the smallest feasible differences among individuals and groups-fairness. Goodness means a health system responding to what people expect of it; fairness means it responds equally well to everyone, without discrimination". Based on this notion of how health care systems perform, WHO adopts three fundamental objectives. These are: Improvement of the health of the population served, Responsiveness to citizen's expectations of their "needs" and "wants" and Financial fairness in providing protection against the costs of poor health.
Health Care Systems Performance
The world's healthiest overall population is Japan's, with 74.5 years DALE (Disability Adjusted Life Expectancy). Twenty-four nations have a DALE of 70.0 years, which can be considered as a "world-class" health outcome. The United States ranks No. 24 at 70.0 years, the United Kingdom ranks No. 14 at 71.7 years, and the 15 EU member nations average 71.4 years DALE. At the other extreme, the world's least healthy populations are found in Sub-Sahara Africa: Sierra Leone ranks No. 191 at 25.9 years and Niger ranks No. 190 at 29.1 years DALE. There are vast differences in DALE between the healthiest and least healthy nations of the world community. Most of the difference is explained by survival rates and not by years alive with disability. In the healthiest nations, disability-adjustments reduce life expectancy by about 10%. For example, life expectancy at birth in Japan is 80.0 years, compared to 74.5 years of DALE. In the least healthy nations, this adjustment amounts to 20% of life expectancy. Sierra Leone has 34.3 years life expectancy versus 25.9 DALE. The health profiles of populations in the healthiest nations also are very different from those of the least healthy nations. WHO measures this burden of disease using the number of disability-adjusted life years (DALYs) lost to various diseases. Developed nation's burden of disease is heavily caused by chronic diseases. Developing nations' burden of disease is heavily weighted toward infectious disease, diseases of childbirth, and accidents. There has been a great deal of thinking done about how to address this morbidity profile. Much of this disease burden is amenable to basic public health intervention. Clean water, sewage treatment, basic prenatal and postnatal care, accident prevention, and other simple interventions can greatly reduce these health problems.
Highly Effective Health Care Systems
Health care in the United States is delivered almost exclusively by private sector providers. Many hospitals are owned and operated by for-profit companies; others are not-for-profit or charitable institutions. Physicians and other health care workers are either independent practitioners or work for private-sector health care institutions. The U.S. mix of public and private sector responsibilities has its characteristic strengths and weaknesses. At 70.0 years DALE, the United States is one of the nations with "world-class" health outcomes. The other outstanding characteristic of the U.S. system is its responsiveness: It ranks No. 1 in the WHO survey. Health Attainment (DALE) captures the effectiveness of a national health care system in satisfying its population's health care "needs": Higher DALE is clearly associated with a healthier population. Responsiveness measures capture the intangible health care "wants" that arise from the importance of health care to individuals' sense of well- being: For a given level of health attainment (DALE), a health care system that is more client-oriented and patient-centered will rank higher in responsiveness. The U.K. health care system has world-class health outcomes, with little variation across its population, and high marks for financial fairness. There is, though, one large negative to this system: It receives relatively low marks for its responsiveness. Developed nations with world-class health outcomes (DALE > or = 70.0 years), which include both U.S. and U.K. health care systems, all spend "enough" on health care to satisfy their populations' health care "needs." Additional spending on health care tends to improve responsiveness (i.e., "wants") more than health outcomes (i.e., "needs"). Health is so essential and sensitive to individuals that even the best health care systems have difficulty managing their public's concerns and expectations.
An Ideal Health Care System
Designing a world-class health care system inevitably requires choosing between or mixing public and private approaches, most particularly in financing. Which choice or mix makes most sense depends in large part on the characteristics of public and private health care financing. Understanding the significant differences in the performance of public and private markets requires a digression into the economics of insurance markets. Health care systems need enlightened stewardship. The government stewardship of health care systems is necessary. The need for stewardship of public health care plans is clear. Stewardship is not, though, limited to public programs. Without enlightened regulation of health insurance (i.e., government stewardship), universal access to medical care is virtually unattainable. The base of an ideal system is a universal health care program providing for citizens' medical care "needs." Universal access is consistent with a social ethic of social solidarity in providing at least basic medical care services to all citizens. Having defined differences between health care "needs" and "wants," an ideal public universal health care system should cover population "needs" and leave funding for and coverage of population "wants" to an adequately regulated private-voluntary health insurance market. There needs to be a seamless, non duplicative interface between universal needs- based and voluntary wants-based parts of the health care system. Those charged with stewardship of the system need to design this interface carefully, which also is not an easy task. The health care system must have adequate medical care resources, and it must be flexible and able to adapt to new health care technologies and new medical care needs. As medical research continues to drive new technology, and as countries grow richer and their citizens value more and more medical care, so too will the boundary between "needs" and "wants" change. An artificial heart is an example of this dynamic. As artificial heart technology improves, will this extremely expensive medical intervention be made available and, as it becomes more effective and common, will it ultimately change from a "want" to a "need?" This single example should amply demonstrate the ethical, political, technical, medical, financial, and emotional issues that will continue to challenge health care systems.
Reorientation in Policy imperative
India spends only 17.3% on public health services as compared to UK that spends 95.6%, the US 44.1% and China 25%. An authoritative appraisal of health sector firmly blames the government for treating this sector shabbily. While the Union government budgetary allocation for health over the last decade has stood still at 1.3%, in the States it has dropped to 5.5% from 7%. Though Health is a state subject, there are many areas where the Centre has scope for intervention. It has a critical role to influence the health policies of the states, especially in disease prevention and health promotion. The poor are hard hit by ever-increasing price of drugs and lack of access to essential drugs. According to an estimate, India would require additional 7.5-lakh beds, from the current 15- lakh beds by 2012. These additional infrastructure facilities may require an estimated additional investment of anything around 10, 00,000 crore. A major part of this expenditure would have to be borne by the public sector as the low and middle income groups cannot afford to bear the cost of treatment in private health facilities. The government will have to promote the growth of private, social and community insurances to improve healthcare affordability for the people at large. Lessons can be learnt from Korea, Singapore and Brazil where insurance has become quite popular and helped the cause of healthcare. Indian pharmaceutical industry though quite big has not helped the poor people in getting adequate healthcare in rural areas. Government has an essential role to provide basic healthcare to underserved and deprived sections of society. Health is one of the most important assets a human being has. A higher awareness of the health of the people is necessary if sustainable growth is pursued. Factors like productivity and schooling are as important as health for the development of a country, where this last factor is sometimes not taken care of with the importance that it deserves. Health can affect not just the economic health of a person, but of an entire nation. It is important to include investment in health as a tool of macroeconomic policy, due to the fact that differences in economic growth rates between countries have been significantly explained by health differences, showing that investment in health improves economic growth and is one of the few feasible options to destroy poverty traps. If we don’t do it, who will?
[Professor Syed Amin Tabish FRCP, FAMS, FACP, MD (AIIMS) is Medical Superintendent, HoD Hospital Administration & Chairperson Accident & Emergency Department at Sher-i- Kashmir Institute of Medical Sciences, Srinagar]
Lastupdate on : Thu, 25 Nov 2010 21:30:00 Makkah time
Lastupdate on : Thu, 25 Nov 2010 18:30:00 GMT
Lastupdate on : Fri, 26 Nov 2010 00:00:00 IST
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