All health systems are a non-stop work in progress. We just have to go on improving across the system, from the bureaucratese to the technical. In other words, everybody’s responsibility
By Dr R Neerunjun Gopee
From the beginning of this year, the advent of the Covid-19 pandemic has brought awareness of and attention to health in a manner and on a scale never seen since nearly a century ago when the Spanish flu ravaged the world. Like everything precious, it is only when we lose it that we realise its value – and this has been the life changing experience of several people from all over the world who have had the good fortune of recovering their health and not falling victim to the coronavirus, which to date has affected nearly 35 million people worldwide and killed about 215 000. And with many countries in Europe recording steep increases in infection after initial lockdowns, facing the unwelcome prospect of very strict measures or even second lockdowns being imposed, no wonder apocalyptic scenarios are being feared as the year end approaches. Covid-19 is set to play spoiled sports for all major collective events that accompany end-of-year celebrations.
Health is indeed our true wealth, and while personal initiative (‘self-care’) is the starting point for enjoyment of good health, in the modern world where we face a double burden of disease – comprising infectious diseases and the NCDs or non-communicable diseases that result from a poor lifestyle – personal effort has to be supported by affordable and accessible healthcare when the need arises, and this can only be provided by a national health system. Because health has a multitude of dimensions as is evident from the World Health Organisation’s definition of health –‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.
In all US presidential elections, health has been a constant, central and contentious issue, and it is so again in the forthcoming one on November 4, 2020. The Democrats and the Republicans, which are two major voter categories, take almost diametrically opposite positions on what health system model America should have. The struggle to bring reforms has raged for decades, with President Obama succeeding in bringing the Affordable Care Act (ACA) during his second mandate. President Trump, predictably, has done everything to dismantle it.
One of the main objectives of the ACA was to extend coverage to the millions of Americans who did not have insurance, as the US has an insurance-based health system. In the pre-ACA era, nearly 45 million Americans were uninsured, and post-ACA this number was reduced by nearly 20 million, according to an intervention from a US doctor that I heard some days ago during a discussion on the subject in the context of the election. If the ACA were revoked, there would be a slide back to the status quo ante, perhaps even with an increase in the number of uninsured further to about 50 million. That is why, commented another participant in the debate, it was time that America considered health as a public good and, like many other advanced countries do, and shift to universal health coverage for all its citizens. Access would then be guaranteed, more affordable, and patients spared from catastrophic expenditure.
Economists tell us that a public good is a good that individuals cannot be excluded from use or could benefit from without paying for it, and where use by one individual does not reduce availability to others, or the good can be used simultaneously by more than one person. Further, a public good has ‘positive externalities’ in the sense that it is good for both the individual and society at large. This should be evident enough for health, as a healthy individual – especially one who comes as close as possible to WHO’s definition – would be a productive member of society and thus enhance economic prosperity as well as contributing to maintaining a peaceful and conducive environment in the country.
Healthcare in the US is very expensive. I learnt this from the experience of a Mauritian doctoral student at Cornell University, New York, where he was in the early 1990s. He suffered from an attack of migraine and had to be admitted to the university hospital, for investigations which included a CT scan of the brain, neurology consultation, and treatment. His bill for one night of stay? 9000 USD! His student insurance covered only half of that, and it took protracted negotiations to have the balance settled and that also meant an unexpected out of pocket expenditure for him.
It is to pre-empt such situations that the Affordable Care Act, also known as Obamacare, was signed into law in 2010, according to online source. It aimed to provide affordable health insurance coverage for all Americans, and was also designed to protect consumers from insurance company tactics that might drive up patient costs or restrict care.
Millions of Americans have benefited by receiving insurance coverage through the ACA. Many of these people were unemployed or had low-paying jobs. Some couldn’t work because of a disability or family obligations. Others couldn’t get decent health insurance because of a pre-existing medical condition, such as a chronic disease. However, the ACA has been highly controversial, despite the positive outcomes.
Conservatives objected to the tax increases and higher insurance premiums needed to pay for Obamacare. Some people in the healthcare industry are critical of the additional workload and costs placed on medical providers – this was confirmed to me by a paediatrician who practices in Los Angeles.They also think it may have negative effects on the quality of care. As a result, there are frequent calls for the ACA to be repealed or overhauled.
I recall that several years ago, at a global health meeting held in Mexico, it was agreed that the best health system for a country is mix of public and private health care, which is the case in our country. Our system of universal health coverage is based on the UK’s National Health Service, in which healthcare is funded by indirect income tax and is free of user cost at the point of delivery, that is, the patient does not have to pay anything for the services offered, everything including human resources being paid for out of public funds. Despite the limitations and criticisms, under such a system the patient is guaranteed of receiving essential emergency care, which is the critical component of the public good dimension of health and which many people fail to appreciate.
Unfortunately, the sheer volume of attendances and admissions in the public health system is such that it is not possible to provide for what are termed the ‘hotel aspects’: privacy, more individualized attention or the levels of cleanliness that would be desirable by the patient – which is the reason that many have resort to private nursing homes. Naturally there is a cost to all this, and that’s where insurance comes in, or if unavailable one has to pay out of one’s own pocket, what is technically known as ‘out of pocket expenditure’. But as far as the level of technical care is concerned, this is comparable in both sectors. It is of interest that according to our NHA (National Health Accounts – WHO), private healthcare expenditure has exceeded public healthcare expenditure. A separate exercise in itself would be needed to analyse why this is so.
The financing of a national health system is usually measured as a percentage of the country’s total expenditure on health and as a percentage of the country’s GDP. Every year the government budget for health has to be negotiated and increases have to be fought for very hard, and are not infrequently denied altogether by curtailing, for example, recruitment of additional human resources.
If there is a way to rein in expenditure especially in the public sector, given the ever-present budgetary constraints, it is by increasing the efficiency of the health system. Ajoy Nundoochan, Health Economist WHO Office Mauritius, has conducted a study on this subject: ‘Improving public hospital efficiency and fiscal space implications: the case of Mauritius’*, published in the International Journal for Equity in Health of September 4, 2020.
There is no perfect health system. Every country has to evolve its own. What is known is that even the richest country in the world, America, which spends more than any other on healthcare (about 16% of GDP), doesn’t have the best health indicators. All health systems, like any other service, are a non-stop work in progress. We just have to go on improving across the system, and doing so across all levels, from the bureaucratese to the technical. In other words, everybody’s responsibility. How many of us are prepared to undertake that?
*Ajoy Nundoochan’s study on public hospital efficiency is available at: hhttps://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01262-9
* Published in print edition on 13 October 2020