What Should a Country Spend on Health Care?

Contributor to the July/August 2012 edition of Health Affairs, William Savedoff, addressed in his publishing, What Should a Country Spend on Health Care?, four approaches that can assist in deciding the amount of money a country should be spending on health care. I purpose that his four factors are not only helpful in determining how much should be spent but they are also applicable in reasoning on what that amount should be spent on.

In 2012 State of the World Population Report, the United Nations declared that, along with good health, access to birth control is a human right. In this blog post, following the factors outlined in Savedoff’s publishing and in agreement with birth control being a human right, I have reasoned, with examples, why the US government should spend more on birth control.

Peer Approach: Is the United States’ spending on birth control more or less than countries with similar characteristics?

Sweden has one of the lowest rates of adolescent pregnancy, childbearing and STDs.

--Why you ask?

Well, in Sweden, sex education is started in the fifth grade in all public schools. As described in a 2006 article in the Washington Post, “without parental consent, teens can get free medical care, free condoms, prescriptions for inexpensive oral contraceptives, general advice at youth clinics, and free emergency “morning-after pills.” All of which, is mandated, supported, and put in place by the Swedish government. Investing in accessibility and education for birth control has proven to improve the sexual health of the population.

The US could easily follow Sweden’s lead in taking this step to improve upon it’s health care.

Political Economy Approach: Why is the United States spending less on birth control than it should?

During President Obama’s tenure, birth control has been an especially prevalent and reoccurring headliner in US media. In 2010, Obama signed into law the Affordable Care Act, which has influenced private companies to include birth control in their coverage. This past week birth control has been an extra hot topic in the news because the Supreme Court is trying to rule whether or not private companies can deny women from having access to birth control in their health insurance coverage due to religious reservations. “Some of the nearly 50 businesses that have sued over covering contraceptives object to paying for all forms of birth control.” The Supreme Court is expected to make a decision by late June.

In a country that is meant to have Church separated from State, equal rights for women, and affordable health care, the Supreme Courts decision should be clear.

Production Function Approach & Budget Approach:

·      What is the relationship between spending and the desire goal—that is, better health?

·      If we want the quality of life for the American people to go up, what do we need to spend on to improve it?

In the 2012 State of the World Population report, the United Nations made it clear that investing in birth control and family planning helps reduce poverty, improve health, promote gender equality, extend the number of years individuals spend in school, and increases labor force participation. Investing in birth control will ultimately have a multifaceted positive impact across health, economy, and education. Budgeting birth control will lead to a wide array of improvements for the US. This same concept is applicable across all nations.

Who needs a loan shark when you have a dentist

In October, the New York Times published an extensive article on a new form of health financing that literally involved financing. While most Americans’ health insurance (granted they have it) covers the basics—primary care such as ER visits, yearly check-ups, and some forms of PT or psychiatry—, dental is rarely covered. The Times explained that for people who cannot afford certain medical procedures, such as a root canal, dentures (or diverging from the dentists, hearing aids), without some form of alternative financing, just wouldn’t get the treatment. But, doctors to the rescue, there’s a solution: financing.

If you can’t afford the dentures now, just sign up for the dentist’s financial package, and after a quick credit check, you’re on the road to good teeth, and bad debt. In the Times article, 78 year old Ms. Gannon was charged 23 percent interest rates, with 33 percent penalties for late payments, resulting in 214 dollar payments each month for a 5700 dollar procedure. That was a third of her Social Security check each month.

This reminds me of the scam of an industry run by used car salespeople: This past summer I went to an auto mall in Queens where they tried to sell me a Sandy-soaked car for 10,000 dollars above my budget. When I told them it was out of my price range, they proposed an outrageous financial package of nearly 37 percent interest. It’s one thing to try to scam a college student looking for a car, but another to scam a senior citizen for medical care.

I am by no means filled with an antipathy towards capitalism; I believe a good profit is the best motive of all. However, I agree with the global tenet that health is a human right, if human rights are even a thing, and therefore find this to be some form of usury that even the venture capitalist in me can’t understand.

When paying for health we should look to more of a balance of payments, rather than a system of payment. What I mean is that there is something missing along the way, that doesn’t quite add up: we pay exorbitant amounts for health insurance, insurance companies pay exorbitant amounts to hospitals, who pay very cushy—but not entirely exorbitant—wages to doctors, and yet hospitals are going bankrupt. Paying for healthcare has become a higher and greater burden on the patient and the money doesn’t go to the doctors, it goes to the insurance providers…and now the bankers too.

Non-governmental actors and vertical programs in global health

In many cases, non-governmental actors recognize a gap human health relating to a disease or location, and then use funding to act on it.  While at one level this kind of work is necessary and important, it is also imperative to note that their efforts are usually specifically targeted and don’t address the broader determinants of health.  It raises the question, does this NGO Band-Aid approach of patching holes in global health detrimental to the formation of adequate health systems? Furthermore, how can aid approach health from the bottom-up while health emergencies prevail?     

There are vertical strategies of tackling public health issues (disease-focused), and horizontal strategies (more broad and health system-focused).  Non-governmental actors commonly take the vertical approach for several reasons.  Donor wishes or agendas and the measurability of having specific goals play a large part in this.  From a political economy standpoint, a problem with vertical programs is that they allow inefficiencies in health systems to persist.  NGOs have become an important branch of development aid, but are not meant to take over government roles for extended periods.  At the same time, how are developing countries supposed to develop solutions and systems to deal with public health problems if the problems are taken into the hands of outside influences?        

In developing countries where poor health is initiated by poverty and worsened by the lack of access to care, attempts to improve health starting from the source are extremely difficult.  Poverty reduction and health system construction take a lot of time, money, and planning.  Those kinds of goals are also more subjectively achieved.  More concrete goals, for example, the eradication of polio, are more concrete and have a greater sense of urgency.  Here we get back to the problem with donors and the agendas that determine public health priorities.  Solutions to this aren’t easy, but one idea is to develop better ways to combine horizontal and vertical approaches in order to address both immediate and long-term public health problems.

 

Global health governance: international, national, subnational

I think it is useful to discuss political economy of development in three broader contexts: subnational, national, and international. As Reimagining Global Health outlines, much of the policy-making and agenda-setting in global health starts at the top, the international sphere, with the IMF and the World Bank. It is worthwhile to consider how international institutions interact with not only national governments they donate to (i.e. the ‘developing’ world) but how their rules and agendas are set by powerful nations (namely the United States and, to a lesser extent, the United Kingdom in the Washington Consensus). The next bit is how national governments must adapt to these rules and agendas while juggling sometimes drastically different sub national realities.

Are both the IMF and the World Bank really at this agenda-setting “top?” One would think that multinational organizations which draw upon the standpoints and needs of all of its member states reflect a consensus, a World Consensus. This is debunked with the Washington Consensus and the driving need for the Western world (United States) to bring other nations in line with its own neoliberal system. As fun (or exhausting) as it may be to get into Marxist and Anti-Marxist critiques, there is truth that the IMF and World Bank reflect the Washington Consensus and 1980s neoliberal aspirations. Included here is the long road of privatization initiatives and other rules tied to loans which countries must implement, oftentimes including the commodification of health care. Nations which rely on types of care that differ from Western biomedicine have trouble introducing (Western) private-sector medicine to their citizens. In the end, many of these newly privatized markets end up benefitting mostly powerful nations making money investing rather than local populations outside of the new systems.

An integral part of the Washington Consensus is cost-effectiveness and the rise of certain initiatives because they are cheap and have a widespread and immediate effect. However, these initiatives are not necessarily a "fit" for different countries and more specifically, different parts of a country. In nations that are as large or diverse as Brazil and India, certain public health initiatives are simply either irrelevant or not as desperately needed as in other parts of the country. A great example is a disparity between different states in India in regards to institutional birthrates. Kerala, a southern Dravidian state, has a 100% hospital birth rate. The national average is about 41%, with some states in the 20s or even lower. In this example, funding going towards bringing women of childbearing age into hospitals is almost irrelevant in Kerala but desperately needed in other parts of the country. I am curious about how a nation as large as India handles these differing disparities and fund allocation. On the other hand, which health issues are ignored in favor of more cost-effective initiatives or ones which align more with international institutions’ goals?

Health Care Systems

There is an outbreak of measles in the Upper East Side of Manhattan.  I think it is safe to say that the Upper East Side has a relatively well designed and functioning healthcare system, particularly when compared to much of the world.  And yet even here in this comparatively well cared for part of the world there has been a significant outbreak of a completely preventable disease.  Measles can have very serious complications which include include swelling of the brain and death, among others, and it is spectacularly uncomfortable to suffer.  This is not even the only recent outbreak of measles in New York City, which suffered an outbreak of 58 cases in Brooklyn last year as well.  Most importantly several of the child victims of this most recent outbreak were children too young to have been vaccinated, the most vulnerable population and the most important to protect.

The fact that the United States’ health care system has not managed to adequately educate people about the critical importance of vaccination to build herd immunity and protect those who are too young to be vaccinated speaks to one of the greatest challenges of constructing a successful health care system.  While there has been controversy surrounding vaccination and speculation about its connection to autism and other “complications” none of this has been based in fact, and there is a wealth of medical evidence to the contrary.  However, people believe the thing that frightens them most, which is not often the most accurate information.  This is why it is critical that the people responsible for the United States health care system need to beef up the educational and outreach based parts of our process.  People need to fully understand that by not vaccinating their children they are endangering the lives of others too young to even have the option of protection.

The population who is currently failing to vaccinate their children against measles (and thus also mumps and rubella, as the vaccination is given at the same time for all three) is for the most part: English speaking, well educated, and middle to upper class.  This means that none of the primary broader social determinants of poor health in low and middle income countries is playing a part.  This is, in other words, a population that should know better.  It isn’t fair to be so judgmental, however.  Health care is complicated, and diseases are terrifying, particularly for parents.  It is the responsibility of the public health community to see these issues and find ways to deal with them.  Anything from public awareness campaigns to clinic hours in local community centers to school vaccination programs and requirements are options that can be built into the health care system itself.  

Health care systems need to be based on the populations they will be caring for, but more importantly they need to take into account the incredible complexity of health care.  Wellness is a conceptual moving target, and there is no way to deal with it if you aren’t creating a system that is as flexible and changeable as it is.  In the US you can see a need for increased educational campaigns about the critical importance of vaccination to protect those who are too young from falling ill.  In the Farmer reading the example of the catastrophic Haitian earthquake made the same point.  There was no way for the small, underfunded, and deeply rigid healthcare system in Haiti to adapt to the new needs of its target population.  Because of the quake a whole new set of health issues became the top priorities including cholera that was actually brought by the aid workers themselves.  These kinds of complications are inevitable, and must be a part of health system development.  It is clear that from the best funded to the worst, one of the greatest challenges for health care system designers is coming up with processes that people will understand and abide by.  This tendency not to listen, understand, and comply is a part of human nature, and one of the main issues that a well designed health care system can potentially alleviate.  

Cancer in the Developing World

5 million people die from cancer in low and middle-income countries every year, and incidence of cancer in these countries is on the rise. As the control of infectious disease improves, life expectancy increases, as does the risk for the development of non-communicable diseases. Yet, cancer in low and middle-income countries is not viewed as a high priority public health concern. In the face of more immediately pressing public health issues like malaria and HIV, cancer and cancer treatment has taken a back seat. The economic reality faced by these countries is incredibly prohibitive in regards to access to treatment and diagnostic testing. As a result five of the seven million deaths from cancer a year are people living in low and middle-income countries. 

It could be argued that cancer is really a disease of ‘wealth,’ as incidence is highest in high-income countries. Cancer is mostly seen in older populations, as the disease is thought mainly to be the result of genetic factors over time. In areas with low life expectancy people may simply not be living long enough to see cancers develop. This perception of cancer as an issue of ‘wealth’ may also simply be a result of access to diagnostic testing and equipment, as regions with greater access to these services may simply be able to diagnose cancer earlier and more readily. However cancer incidence is growing in low-income areas, especially cancers linked to infectious disease, alcohol and tobacco use rather than sedentary life style and high BMI’s. For example cervical cancer and liver cancer are the most prevalent in Sub-Saharan Africa and South America.

However, the prohibitive cost of cancer treatment contributes to the staggering number or deaths from cancer in low and middle-income countries. Cancer drugs are incredibly expensive, and protected by international intellectual property laws and trade agreements that prevent the manufacture and distribution of more affordable generics. Treatment can also be a very long and painful process that may simply not be an option available to people living in impoverished areas. Preventative measures are also not available in these countries; for example, cervical cancer is most prevalent in low and middle-income countries, specifically in northwest and southeast Africa (see this really cool interactive map of ‘cancer’s global footprint: http://globalcancermap.com/ ). This is likely due to the high correlation between STI’s and cervical cancer, and while vaccines and treatment for the STI’s (mostly HPV) that are most closely linked to these cancers exist they are not widely available outside of the United States and other western countries. Access to this kind of preventative treatment could potentially save millions of lives.

Access to the life saving preventative, diagnostic and therapeutic measures that are currently being developed specifically for cancer is critical to the health and well being of all populations regardless of socioeconomic status.  Cancer is the leading cause of death globally, and sixty percent of all new cancer diagnoses are from low and middle-income countries. Something must be done to prioritize the growing issue of cancer in these regions and to bridge the economic divide that prevents people from getting access to the medical care they so desperately need.