The Global Healthcare Lottery – how lucky are you?

Variety, they say, is the spice of life. But when it comes to healthcare systems – variety isn’t always a positive. Dr Sneh Khemka looks at why healthcare standards vary so much around the world

Introduction

Those of us who have a certain level of income or who come from the developed nations are bestowed a great privilege – we have access to the best doctors in the best hospitals in the world.  We are more or less guaranteed high quality treatments when we need them.

The development and industrialisation of a nation usually heralds the basic improvements in public health that can change the entire health of the nation – sanitisation, immunisations, safer childbirth and universal access to healthcare. But even in the most developed of nations, for those with access to the greatest resources, the standard of care can vary greatly dependent not only on where you are in the world, but which hospital or doctor you choose to visit.

Over the last three years, I have been inspecting hospitals around the world, and have come across some interesting surprises. Money does not necessarily mean quality; instead it may mean unnecessary over intervention, especially if practitioners are incentivised on pay-for-performance models. And if the quest for quality is not at the core of a healthcare system, no amount of cash can make for safe and efficient practice.

So, if you are interested in why healthcare standards vary so widely, read on for some of my observations.

How important is health to a country?

Individual countries have wide variations as to how much of their national resource they are willing to invest in healthcare. Healthcare is a huge industry, requiring vast sums of money to span preventive, primary and specialist care. Most developed nations spend at least 10% of their gross domestic product on healthcare, and this is rising every year. In the US the figure is now reckoned to be closer to 20%. And with a few exceptions, the more money there is, the better the healthcare system.
A study published in The Lancet last year highlights this. The researchers compared cancer survival rates across five continents. They found that people in high-income countries that spend more on healthcare live longer. And it’s well known that life expectancy in developing nations is frequently (but not always) lower than that of richer nations.

In short, you get what you pay for. When it comes to buying a car, most of us are happy to accept that cost equates to quality. When it comes to our health, the reality can be harder to swallow. This is especially true in richer nations, where people think that they’re entitled to good healthcare.

But it seems that the equation is not that simple. In the case of the United States, where there is the highest GDP expenditure on health, the events of New Orleans a few years ago unmasked a vast swathe of the population, almost 50 million individuals, who were uninsured and therefore effectively had no access to even basic care.
So the conundrum is complex. But putting money aside, what other factors influence our healthcare lottery?

The Hygiene Factor

One of the keys to good medical treatment is sanitisation. It was the industrial revolution of the 19th century and the introduction of sewers and basic hygiene, followed by the subsequent discovery of antibiotics, that allowed people to survive diseases and infections that would otherwise have killed.

It sounds easy on paper, but following general hygiene standards takes rigour and diligence. And the necessary ‘tools of the trade’ – sterilisation methods, disinfectants, antibiotics, even running water – aren’t always available in poorer countries. Inevitably, standards of care suffer.

Even for rich countries, however, hospital hygiene is a central issue. It is well known that one of the most pertinent signs of a quality institution is infection prevention and control. In the UK, the rise and rise of MRSA (Methicillin Resistant Staphylococcus) has exposed significant gaps in otherwise high standing centres. The prevention of surgical site infection has been a key focus of the World Health Organisation, and prevention of spread in the wake of pandemics is more important now than ever before.

Access to medicines

Even when a country has the requisite hygiene procedures, the drugs needed to treat patients aren’t always available. Poorer countries may simply be unable to afford them.
There’s a commonly held view that the pharmaceutical industry is a root cause of healthcare inequality. The real picture probably isn’t so simple. It might make it easier to label ‘big pharma’ as evil, but these companies are a by-product of global capitalism. For patients to have access to any drug, someone has to manufacture them. And that costs money.

Pharmaceutical companies defend their prices by citing the huge sums spent on research and development. This was estimated – by the industry itself it’s worth noting – to be around $58 billion a year in 2007. With new drugs taking 10 to 15 years to bring to market, they argue that losses need to be recuperated. Yet time and again the industry has faced accusations of inflating the figures to justify high prices and increased profit margins.
Wherever the truth lies, the pharmaceutical industry has – at least recently – offered more flexible pricing schemes, which mean poorer countries can buy more of the medicines they need. But many say more needs to be done to make sure that life saving medicines are made available to everyone who needs them.

Given the recent and very real challenge of widespread counterfeit medicines being produced and distributed widely in Asia, it is fair to predict that access to effective medicines will continue to flame the fires of our healthcare lottery.

Infrastructure and the political scene

‘Healthcare’ itself is a fluid concept. At its core, a nation’s healthcare system looks after the health needs of its residents. This can encompass many specialities. Interventions range from emergency care, to chronic disease management, to cancer therapy treatment. Dementia care, disability services and mental health strategies must all be accounted for too.

The scope is huge to say the least. Different countries have varying success in getting the necessary infrastructure in place to deal with the vast array of treatment modalities implicit with general healthcare.
Getting this infrastructure in place is far from easy. It requires political stability, with the necessary time and resources. Some poorer countries have never had the chance. Former colonial countries in Africa or Asia have been left in turmoil as their former invaders suddenly withdrew throughout the 20th century, leaving local factions to battle over resources and power. War-torn landscapes do not serve the healthcare ideal well.

Political instability and poverty breed another enemy of health too: corruption. Politicians and officials more concerned with lining their own pockets than establishing care for their citizens have held back the development of effective health care in many developing nations.

Too much for too few?

As touched upon earlier, it has to be admitted that healthcare systems in richer countries have plenty of problems too. As medical systems become more defined they reach further and further into society, and the risk of medical over intervention grows. A healthcare system may assume intervention is necessary when it isn’t.

There is a large body of evidence, originated by the Foundation for Informed Medical Decision Making, that shows that when incentivised in the wrong way, or in a system where supply is more than demand (such as in the world of private healthcare), more is often done than is needed.

The Dartmouth Health Atlas of North America showed unequivocally that certain surgical interventions were performed not dependent on actual need, but more on surgeon preference. That means that patients were having procedures they didn’t need and didn’t want.

Sadly, this overprovision continues to grow and exist, although the healthcare industry is at last seeing the greenshoots of the movement to combat this and ration healthcare more appropriately.

Are you winning the lottery?

Given the variations and differing drivers for the standards of care, the core message is in making sure you offer yourself the best chances of securing yourself an equitable and long-term coverage in case of ill health.
Staying knowledgeable, seeking wide information about your own condition, keeping healthy and ultimately knowing who to go to when you do need to access healthcare are the keys to winning our healthcare lottery.

Dr Sneh Khemka MBChB, MRCOphth
Medical Director
Bupa International