Health Care Around the World

The health care challenge: services for those with need

The World Health Organization (WHO) is the premier organization looking at health issues around the world. When looking at the pattern of health care around the world, the WHO World Health Report 2008 found some common contradictions (see p.xiv, Box 1):

Inverse care

People with the most means – whose needs for health care are often less – consume the most care, whereas those with the least means and greatest health problems consume the least. Public spending on health services most often benefits the rich more than the poor in high- and low-income countries alike.

Impoverishing care

Wherever people lack social protection and payment for care is largely out-of-pocket at the point of service, they can be confronted with catastrophic expenses. Over 100 million people annually fall into poverty because they have to pay for health care.

Fragmented and fragmenting care

The excessive specialization of health-care providers and the narrow focus of many disease control programs discourage a holistic approach to the individuals and the families they deal with and do not appreciate the need for continuity in care. Health services for poor and marginalized groups are often highly fragmented and severely under-resourced, while development aid often adds to the fragmentation.

Unsafe care

Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital-acquired infections, along with medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health.

Misdirected care

Resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden. At the same time, the health sector lacks the expertise to mitigate the adverse effects on health from other sectors and make the most of what these other sectors can contribute to health.

Health care provision is incredibly complex and many nations around the world spend considerable resources trying to provide it. Many other rights and issues are related to health, inequality being an important one, for example. Education, gender equality and various other issues are also closely related. Viewed from the spectrum of basic rights, the right to health seems core.

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Health as a human right

As noted by the Office of the United Nations High Commissioner for Human Rights (OHCHR) and the WHO,

The above fact-sheet also provides a useful breakdown of different aspects of rights to health, describing the relationship between health and

• Inclusive rights,
• Freedoms (from non-consensual medical treatment, from torture and other cruel or degrading treatments or punishments)
• Entitlements (to prevention, treatment and control of diseases; access to essential medicines; maternal, child and reproductive health; health-related education; participation; timely services)
• Non-discrimination
• Accessibility, acceptability and quality of services.

A wide range of factors, or determinants of health allow us to lead a healthy life, including

• Safe drinking water and adequate sanitation
• Safe food
• Adequate nutrition and housing
• Healthy working and environmental conditions
• Health-related education and information
• Gender equality.

Human rights in many of the above areas therefore also overlap with health-related human rights as also represented by this WHO diagram:

Based on these and related principles, most nations strive for universal health coverage.

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Universal Health Care

Universal health care is health coverage for all citizens of a nation.

Does provision of universal health infringe on individual human rights? Some argue that a universal system requires some level of transfer of wealth from those who have to support those who have not. Any such transfer infringes on the freedom of the individual being taxed.

Others argue that providing access to health enables one to enjoy freedom, and as a society it is a shared responsibility (much like sharing the burden of funding a military or providing education for all). As such, social equity and individual freedom do not necessarily have to conflict. (See also this site’s section on poverty and inequality for more about the effects of inequality on all of society.)

At some point the debate becomes ideological rather than practical, and most nations that attempt universal health care, while often supporting individual freedoms see value in a society generally being healthy.

There are numerous ways such a system is provided, for example:

• Government funded (tax paid) national systems
• Government funded but user fees to top up (often at point of use)
• Health insurance systems (funded by governments, citizens, or some mixture)
• Decentralized, private systems run for profit or not for profit

Different parts of the world have used different means for health care and generally, poorer nations have struggled to provide adequate health care.

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Structure of a health service

At a high level, health services fall into different categories of health care:

1. Primary health care
2. Secondary health care
3. Tertiary health care

(Some systems may also have additional levels of separation.)

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Health provision overview in numbers

Shown here are just a few health related statistics. (See sources for more data.)

Child mortality is a general indicator of health in rich and poor country alike. Life expectancy, while a useful indicator, can also include deaths caused by accidents and the like, so healthy life expectancy is also included:

• Life expectancy
• Child mortality
• Raw data

Life expectancy

Predictably, wealthier nations have better life expectancy:

Note, healthy life expectancy is an estimate of how many years they might live in good health.

Child mortality

Overtime, child mortality has generally improved around the world:

However, the gap is large between developing and wealthy nations:

Raw data

Life expectancy and child mortality figures from selected countries and country groups

Country/ group	Life expectancy	Healthy life expectancy	Infant mortality rate			Child mortality rate
	2008	2008	1990	2000	2008	1990	2000	2008
Source: World Health Statistics 2010 report, WHO Note, healthy life expectancy is an estimate of how many years they might live in good health.
Global	68	59	62	54	45	90	78	65
Low income	57	49	101	88	76	158	137	118
India	64	56	83	68	52	116	94	69
Lower middle income	67	61	64	55	44	91	78	63
Upper middle income	71	61	37	26	19	45	32	23
China	74	66	37	30	18	46	36	21
High income	80	70	10	7	6	12	8	7
Australia	82	74	8	5	4	9	6	5
Canada	81	73	7	5	5	8	6	6
France	81	73	7	4	3	9	5	4
Germany	80	73	7	4	4	9	5	4
Japan	83	76	5	3	3	6	5	3
Sweden	81	74	6	3	2	7	4	3
UK	80	72	8	6	5	10	6	6
USA	78	70	10	7	7	11	9	8

Spending figures show roughly how different regions fare:

• Costs per person
• Spending as % of GDP
• Spending sources
• Raw data

Costs per person

(Note that the costs are calculated in purchasing power parity (PPP) which is a method to provide equivalence between different countries, so that $1 spent in India, for example, would go as far as $1 spent in the US.)

Spending as % of GDP

Spending sources

Note that private sources include external resources such as foreign aid, social security expenditure, out of pocket expenditure, private prepaid plans.

For low income countries, external resources are a major source of funds, some 17%. As per the 2009 WHO report (p.107), some 85% of private spending comes out of pocket (i.e. at point of use), which for the poorer countries is an enormous cost for individuals and does not allow the pooling of risk and leads to a high probability of catastrophic payments that can result in poverty for the household.

Raw data

Health spending figures from selected countries and country groups, 2007

Country/ group	Total health spending as % of GDP	% of health paid by government	Health spending as % of total government spending	Health spending per person (PPP $)
Source: World Health Statistics 2010 report, WHO. (Note, some columns omitted to fit the available space. Please see source for full data.)
Global	8.7	59.6	15.4	863
Low income	5.3	41.9	8.7	67
India	4.1	26.2	3.7	109
Lower middle income	4.3	42.4	7.8	181
Upper middle income	6.4	55.2	9.4	757
China	4.3	44.7	9.9	233
High income	11.2	61.3	17.2	4,405
Australia	8.9	67.5	17.6	3,357
Canada	10.1	70.0	18.1	3,900
France	11.0	79.0	16.6	3,709
Germany	10.4	76.9	18.2	3,588
Japan	8.0	81.3	17.9	2,696
Sweden	9.1	81.7	14.1	3,323
UK	8.4	81.7	15.6	2,992
USA	15.7	45.5	19.5	7,285

The following trend is also interesting:

(This trend also applies if plotting life expectancy instead of healthy life expectancy. The former is a cruder measure but easier to estimate than healthy life expectancy.)

There are many, many more statistics at the WHO statistics web site. The above charts were created from data obtained in the World Health Statistics 2010 report.

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Health care in wealthy countries

All industrialized nations, with the exception of the United States, implement some form of universal health care.

Britain’s National Health Service

Britain has had a national health service (NHS) since the late 1940s. While tax-funded and government run, it provides access to all citizens and is mostly free at point of use.

The British system includes free primary care paying doctors and running hospitals through decentralized trusts. Side NoteIn fact, the NHS isn’t a centralized socialist bureaucracy that scare-mongering stories from the US right wing suggest; health authorities for different regions and local NHS primary care trusts allow local decision-making and accountability while the centralized NHS provides a framework and guidelines.

Almost all treatment is free. For working age citizens, prescriptions are obtained with a flat fee (with pharmacists often telling patients if the same drug is cheaper over the counter than through prescription). Dentist and optician visits typically have some fee associated with them, with dentistry having been increasingly privatized for many, many years.

There is a parallel private health option but is used by a small percentage of the population (usually the wealthy, by definition).

Over the years, the NHS has changed in various ways, but even the parties traditionally hostile to big government (the Conservative party) typically state (at least publicly) support for the institution.

There have been a number of problems within the NHS, which the right wing in the US are keen to expose (even if it includes exaggerating or bending the truth about NHS problems). Despite some on-going issues (as with all systems), the service provides universal care with generally low wait times, even as it faces budgetary constraints and changing social habits for which the health system wasn’t necessarily designed (just two examples being increasingly excessive alcohol consumption and obesity).

There are also concerns that under the guise of necessary reforms due to the effects of the global financial crisis, a privatization agenda is being pushed onto the NHS. SpinWatch, for example, claims that private healthcare companies have built a dense and largely opaque network of political contacts in the UK with one aim — to influence policy in their interests and get the reforms they want:

Using favorable terms such as freedom and choice, some of the reform plans have been intensely criticized, such as giving GPs (General Practitioners — also known as Family Doctors) more control over their budgets. At first glance this sounds ideal: localism and ground-up accountability. However, GPs themselves are worried about this because they have not been consulted on this plan as it would not just meant they have to also become accountants — without extra budgets to do this — but that they would end up having to ration limited resources and some people may not be able to get treatment as needed, while diluting the power of the NHS as a universal system throughout the country.

For an overview of health systems in various other countries, try the following:

• Universal Health Care, Wikipedia (last accessed August 30, 2009)
• Health care system, Wikipedia (last accessed August 30, 2009)

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Health care in developing countries

Many developing countries also strive to provide universal health care. However, most struggle to do so, due to lack of sufficient resources, or inappropriate use of existing funds. Health inequality, therefore, is quite common.

Poverty is a major problem. In some developing countries health facilities have improved considerably, creating a health divide where those who can afford it can receive good quality care. Health gaps typically mirror equality gaps. For the enormous numbers of people without access to health, there is a terrible paradox: poverty exacerbates poor health while poor health makes it harder to get out of poverty.

As detailed further on this site’s global health overview page, policies such as the IMF and World Bank’s Structural Adjustment Programs through the 1970s and 1980s have reduced the ability of many poor countries—many African nations in particular—to provide health services for their populations.

The same ideology encouraging those inappropriate health policies have continued to this day and privatization has often been preferred by these international financial institutions even if they have been shown over and over to be inappropriate for developing countries.

Corruption is an ever-present problem (sometimes in wealthy countries too). Corruption not only makes the problem worse, but some policies have encouraged corruption, too, as has the lack of health resources.

Another issue that plagues some poor countries is brain drain whereby the poor countries educate some of their population to key jobs such as in medical areas and other professions only to find that some rich countries try to attract them away. The prestigious journal, British Medical Journal (BMJ) sums this up in the title of an article: Developed world is robbing African countries of health staff. (Rebecca Coombes, BMJ, Volume 230, p.923, April 23, 2005.)

In many poorer countries, the number of health workers such as doctors and nurses in proportion to the population can be small and in many rural settings, it can be very difficult for people to access services.

The issue of user payment at point of use is perhaps more important in poorer countries than the wealthier ones. In wealthy ones, other than the US, universal health care works such that even where people have to pay at point of use, in many cases it is affordable.

Around the world, however, the problem can be worse as the WHO notes:

The way poverty and health costs are related, especially for the poor, cannot be understated. A WHO report on noncommunicable diseases (NCDs) — the leading causes of death worldwide — captures this very well.

This diagram summarizes the overall issues:

But their summary description is worth quoting at length:

The NCD epidemic strikes disproportionately among people of lower social positions. NCDs and poverty create a vicious cycle whereby poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty.

The rapidly growing burden of NCDs in low- and middle-income countries is accelerated by the negative effects of globalization, rapid unplanned urbanization and increasingly sedentary lives. People in developing countries are increasingly eating foods with higher levels of total energy and are being targeted by marketing for tobacco, alcohol and junk food, while availability of these products increases. Overwhelmed by the speed of growth, many governments are not keeping pace with ever-expanding needs for policies, legislation, services and infrastructure that could help protect their citizens from NCDs.

People of lower social and economic positions fare far worse. Vulnerable and socially disadvantaged people get sicker and die sooner as a result of NCDs than people of higher social positions … There is strong evidence for the correlation between a host of social determinants, especially education, and prevalent levels of NCDs and risk factors.

It is in this context that point-of-use health fees in poorer countries can be so catastrophic, as the WHO continues:

Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs creates significant strain on household budgets, particularly for lower-income families. Treatment for diabetes, cancer, cardiovascular diseases and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment. Household spending on NCDs, and on the behavioural risk factors that cause them, translates into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty – education. Each year, an estimated 100 million people are pushed into poverty because they have to pay directly for health services.

The costs to health-care systems from NCDs are high and projected to increase. Significant costs to individuals, families, businesses, governments and health systems add up to major macroeconomic impacts. Heart disease, stroke and diabetes cause billions of dollars in losses of national income each year in the world’s most populous nations. Economic analysis suggests that each 10% rise in NCDs is associated with 0.5% lower rates of annual economic growth.

As also noted earlier, in developing countries, especially the poorest ones, a large portion of health funded is dependent upon external or foreign aid. However, some spending programs may divert from general needs to specific needs, such as building hospitals (as opposed to strengthening primary care), or funding for specific diseases (which is usually treatment based with less visible effort on preventative care), etc.

Despite improvements over time, as the above charts show, the challenge remains enormous. The WHO and others have identified many areas where health provision can be far more cost effective than is currently provided, even with severe budget constraints. Perhaps that at least can be hope for a healthier future.

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