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Originally published on December 1, 2015

What Do Most Health Care Systems Have in Common?

by Emily Friedman

Societies, religions and cultures differ, but health care systems in most countries face remarkably similar challenges. Perhaps we can learn from each other to face them.

In the past few years, I have had the privilege of visiting several countries and learning about their health care systems. These have included Australia, Cambodia, Canada, Great Britain, Greece, the Netherlands and Singapore, among others. I have also been asked to participate in several international health care conferences, where I learned about many more systems, from China's to Italy's to France's to Pakistan's.

One lesson - which is not exactly rocket science - has been that no two health care systems are identical; indeed, variation from hospital to hospital, clinic to clinic, and medical practice to medical practice, is a given. Health care is provided in different ways in Minnesota and Boston, for that matter, not to mention Karachi and Capetown. But the most important lesson, to me, is that most health care systems face the same challenges.

The second lesson is that they all address these issues differently; but increasingly, in this age of the Internet, health care leaders around the world are influencing each other and, as a result, their respective systems. For example, China adopted a DRG-based payment system in 2009. Britain's National Health Service has embraced competition among hospitals. The tireless work of the U.S. Institute for Healthcare Improvement has influenced the quality of care in many countries.

This is not just an international trend. For many years, I have been involved with the National Academy for State Health Policy, which foments the interchange of information among state, municipal and territorial health officials throughout the United States. They share ideas, learn from each other and teach each other.

So the third lesson I would report from my recent ramblings in health care around the world is that many health care systems are beginning to look more and more similar. Sometimes this is a good thing; sometimes, not so much. But it is happening.

So, what are the shared trends?

Population Change

Although the details are specific to each situation, health care systems in many countries are confronted by four demographic issues: aging, youth, diversity and immigration.

In much of the developed world, the population is aging quickly. Overall, the median age of human beings on this planet is about 30, but that's an almost meaningless number. In more developed countries, such as the United States and Japan, as well as Scandinavia and much of Western Europe, the aging of the population and a low birth rate are creating older societies. The median age in most of Western Europe is in the low 40s; in the United States, it's about 38; in Canada, it's about 42.

On the other hand, in Afghanistan, Angola and many other countries in Africa and the Middle East, the median age is about 18. In Cambodia, the median age is 24. One reason for these lower numbers is civil conflict and violence, such as in Cambodia, where most of two generations were murdered between 1969 and 1989, and as a result, half the population is younger than 25. That makes for a potent workforce now - and a huge headache for its health care system in 40 years. In other countries, especially sub-Saharan Africa, AIDS has wiped out most of a generation. And in many places, marriage and childbearing at a very young age lead to a longer period of fertility.

All of the highest fertility rates are in Africa: The highest, currently, is Niger, at 7.6 children per family; if you don't know if you are going to live another day, you tend to have a lot of kids. The lowest fertility rates are in developed countries: Bosnia, South Korea, Portugal, Taiwan, Greece, Moldova, Poland, Romania, Singapore and Spain, which are all below 1.5 per woman. India is getting close to 2. The United States is at 1.9. That isn't even at the replacement rate for a couple. Although in rural Cambodia, families are still large, the birth rate for those in the emerging middle class is at or near replacement level. In China, the world's most populous country, the government has announced that the one-child-only policy is no longer in effect, which will have a profound effect on its population structure.

But because of growing diversity in so many societies, these numbers do not tell us enough. Non-Latino whites in the United States have a much lower birth rate than other groups. In many rural areas in most countries, families are much larger than in urban settings. It depends on circumstances, culture, religion, the rate of infant mortality, income and a variety of other factors.

And, as has been in the news lately, people are on the move. Folks are trying to get out of areas where civil conflict is ongoing, and are seeking a better life for themselves and their children. And despite the ambivalence of the developed countries about this influx - especially in light of the horrible attacks in Paris - immigrants are likely to be critically necessary, especially in health care, as our populations age and our older citizens want to stay in their homes, but will need many services.

There will be a pile of challenges - generational, cultural and logistical. But all of our health care systems must be aware of the demographics of their societies, of incoming immigrants and of what the health care needs of the future will be.

Chronic Disease

That leads to the obvious second trend, which is the growing presence of chronic disease. This is not confined to older people. Diabetes, for example, is a plague in South and Southeast Asia, and if other countries were more honest in their reporting, we would find that it has become the same in other countries.

It's not just diabetes. AIDS is now a chronic disease. I suspect, given the air quality and rampant use of tobacco, that chronic obstructive pulmonary disease is an issue in China. Tuberculosis is still a threat in some societies, including the United States. Alzheimer's and other forms of dementia are becoming more common. And there are many others.

Our health care systems originally were structured to treat acute disease, because when they were formed, few people lived long enough to develop chronic conditions. But that has changed.

Life expectancy has skyrocketed in the last 100 years. Right now, in Japan, Spain, Switzerland, Italy and France, it is older than 80; there are 26 countries in which it is also at or near 80. The United States, at 79, is sneaking up there.

Chronic disease treatment and gerontology have been the stepchildren of most of our health care systems since dirt. We need to get over it. And we need our funding sources to get over it.

Infectious Disease

At the other end of the spectrum is the increase in antibiotic-resistant infectious disease, including recent outbreaks of Ebola fever, Middle East respiratory syndrome and other plagues. Methicillin-resistant Staphylococcus aureus (MRSA) is a constant danger in many hospitals - I have lost two friends to it, one in Wisconsin and one in England. In an article on www.vox.com in 2014, Julia Belluz and Steven Hoffman quoted British researchers who predicted that drug-resistant disease will soon cause the deaths of more people than cancer.

We should have seen this one coming. In 1928, Sir Alexander Fleming accidentally discovered penicillin. He later wrote that we should be very careful in how we use it, because S. aureus and other bugs can mutate and develop resistance. Instead of heeding his words, we did everything from prescribing antibiotics for viral infections (which does no good) to feeding them to cattle. And then we freak out when antibiotic-resistant infections start appearing. Duh.

This is most definitely a worldwide issue, and one that the health care systems of the world will have to address together. With so much international travel and the emergence of new threats on a regular basis, it is a problem for all of us.

The Cost of Care

Aging populations, more populous societies, and the growing presence of chronic and infectious disease present another challenge: the cost of health care and how we are going to pay for it. When most patients are young and healthy and providers are mostly involved with preventive care and delivering babies, that's one thing; when most patients are old and have several comorbidities and are likely on government coverage - if they have coverage at all - that's a different matter.

The true cost of health care in the United States is a mystery, because our accounting systems are directly out of Harry Potter. There are all the complaints about $10 aspirins and so forth, but I think most health care accounting is done with smoke and mirrors. Much of the time, it's not conscious fraud or anything like it; it's just that no one knows how to properly track the costs of care, and government requirements make it nearly impossible to even attempt to do so.

My general impression is that the cost of care is just as mysterious worldwide as it is in my country. And everyone blames everyone else. It's the wrong diagnosis. It's unnecessary care. It's fraud. It's fancy new hospitals. It's for-profit health care. It's malpractice litigation. It's this. It's that.

Well, we haven't figured it out yet, but an aging population, the constant influx of technology and the cost of pharmaceuticals might have something to do with it.

Most countries regulate the price of pharmaceuticals. The U.S. policy has long been that the market should decide, which earlier this year led a 32-year-old entrepreneur to purchase rights to a long-used drug and raise its price by more than 5,000 percent. And why shouldn't he? It's legal. There have been other such situations. The market does not always decide wisely.

In any case, the pharmaceutical market in the United States is absolutely out of control. But as we move toward genetic-specific and personalized drugs, I don't think this issue will be confined to the United States.

I have no problem with new and more effective pharmaceuticals (although I do have a problem with me-too drugs and fancy diuretics and laxatives that probably aren't any better than over-the-counter products). Nor do I object to the advent of better health care technologies, if they really are better. After all, the increase in life expectancy wasn't delivered by the tooth fairy. Health care systems, when they aren't being destroyed by civil conflict or government corruption, have done an incredible job of increasing preventive care, promoting public health and trying to serve patients better. But the issue of how to pay for it all is a worry around the world.

Improving Quality

This brings us to quality improvement efforts. Most people who work in health care, wherever they are, want to do the best job they can, and want to protect their patients. But that takes expertise, appropriate funding - and common sense. There are too many things that can go wrong in health care for anything to be taken for granted.

And although the United States system has long boasted that it is the best in the world, there is little evidence of that. A study issued in July, based on data from the World Health Organization and The Economist's Intelligence Unit, reported that although per capita spending on health care in the United States is the highest in the world, we rank only 33rd in terms of outcomes. We use more technology and consume more pharmaceuticals than most societies, but it doesn't seem to be helping much.

In case you were wondering, the top five in outcomes are Japan, Singapore, Switzerland, Italy and Australia. One can attribute some of the success in Japan and Singapore (although the latter has a really amazing health care system) to homogeneous racial and ethnic populations, but Switzerland's society is somewhat diverse, and the populations of Italy and especially Australia are very much so. I suspect that if we drilled down into these data, we would find significant racial and ethnic disparities in health status and longevity.

And it's difficult to maintain high quality - it is an all-consuming job. A report by Michael Reich and Kenji Shibuya, M.D., in the Nov. 5, 2015, New England Journal of Medicine conceded that Japan's health care system - which includes universal coverage - is struggling with a rapidly aging population, a low birth rate and an economy that has been in the tank for years.

All health care systems could do better, whether in convincing all health care workers to wash their hands, reducing infections, limiting wait times or adopting electronic health records. Some are trying harder than others, and some don't have a chance, given civil conflict, lack of resources and government indifference.

System Structure

One of the most striking ways in which world health care systems are similar and are becoming more so is in the reconfiguration of the structure of providers. In the United States, of course, we are seeing massive consolidation of providers, insurers and even pharmaceutical firms.

Some systems always have been integrated, as in Britain. Others, like ours, are hybrids, as is also true of Australia, which has both public and private insurance, and most hospitals are private. At one point in the rather odd history of Australian health care, the government was selling private insurance to avoid a government monopoly.

There are many variations on the theme, but the three main questions are whether a system should be public or private (and the answer to that varies enormously) or a hybrid, how integrated the system should be, and how much competition should be allowed to flourish.

Competition in health care has been one of the main American exports to other countries, and there is nothing wrong with that. As a very wise man told me once, without competition, everyone is secure and has no reason to innovate or improve. I have seen that in health care operations overseas.

But anyone who ever made it as far as Economics 101 knows that the ultimate goal of competition is monopoly. Bill Gates knows that. Steve Jobs knew that. Establish a monopoly and you get all the money. So it's a balancing act.

Another insight was recently provided by Austin Frakt, Ph.D., in a July 8 article on JAMA, when he pointed out that "competition" does not necessarily mean "private." He used the British National Health Service as an example, saying that the introduction of competition among Britain's public hospitals (any patient must be given a choice of at least five hospitals for treatment) has improved quality and empowered patients. Mortality rates have decreased, as has length of stay.

Competition need not be tied to unfettered markets. It can be a valuable and effective asset in a variety of health care settings.

Access to Care

All systems struggle with adequate access to care. In a disastrous situation like Syria, if it were not for humanitarian groups such as Doctors Without Borders and the International Committee of the Red Cross, no care would be available. When these organizations must withdraw from areas of civil conflict, people have no access whatsoever. In many other countries, these humanitarian services are the lifeline for thousands of people.

In some situations, it depends on how much money you have and what resources are available. In some of the more nationalized systems, waiting times are a given, except for emergencies. (This has been overplayed in terms of critics of the Canadian and British systems - people generally don't die on waiting lists, but foes of single-payer systems will use any excuse to condemn them.) In a long-ago article in Health Affairs, Canadian physician David Naylor argued - in what I considered an unintentionally amusing concept - that having to wait for care gave the patient the chance to reconsider treatment and to put his or her affairs in order. Uh, OK. But then, U.S. hospitals are required to ask any incoming patient if he or she wants to donate an organ, which may be a little scary if you are just having a hernia repaired.

The challenges of access to decent care are many. In rural areas, it is a problem in most countries. The roads may be unusable in hard weather. Shortages of providers are commonplace. There may be threats from civil conflict, bandits or what have you. In urban areas, if it's a cash-on-the-barrelhead system, if you can't pay, you can't get care. And in the many places where health care is being privatized, you need insurance or cash. Subsidies are often available to the very poor, but many people are left wondering whether they should buy food for dinner or inoculate their kids.

And despite the Affordable Care Act and the good work of our hospitals, community health centers and other providers, at least one out of 10 residents of the United States is still uninsured and, therefore, at risk of lack of access. For those who can afford it but choose not to buy insurance or pay for their care, I have no sympathy. But there are many others who really do not have the money.

I'm one of those bleeding hearts who believes that access to care is a human right. In many health care systems, that sentiment is not shared.

Workforce Adequacy and Distribution

Health care systems all over the globe are rife with workforce silos, turf wars, maldistribution and scope-of-practice issues. These may be more extreme in the United States, but they are not unique to our country. Tsung-Mei Cheng wrote a report for the Brookings Institution in May that found significant shortages of nurses and practitioners in certain specialties in Taiwan, which has an otherwise successful health care system. I recently spent some time with Professor He Jingwei, who works in Hong Kong and studies patient unrest in China. He has found that one of the main reasons for such dissatisfaction is that physicians are often required to see 60 patients a day, which means that few patients, if any, get appropriate care.

Also, as the United States learned long ago, providers are not evenly distributed. Rural areas are a problem. Low-income urban neighborhoods are a problem. The massive growth in medical groups and salaried physicians - both of which I support - means that there are often fewer practitioners in disadvantaged settings, and it is much more difficult to find a physician who will accept a Medicaid patient.

The report on Taiwan found that one reason for a shortage of OB-GYNs is that the birth rate is so low that there is not as much demand as there once was. On the other hand, expect a boom in that specialty in China now that the one-child-only policy is toast.

The basic issue is that clinicians, like anyone else, want to have good quality of life, an acceptable income and a comfortable practice environment. The sometimes dreadful rural health centers in Cambodia are not going to float that boat.

There are all kinds of schemes being tested: Work in a rural area for a while and your medical school debt will be obviated; we'll pay you more if you work here; or, in some situations, here's where you are going to work, period.

But there is another issue here, which is that many health care professions have established certification and licensure and scope-of-practice requirements that are not necessary. Walgreens and CVS and Wal-Mart did not get into the primary care game by hiring physicians; they hire nurse practitioners. Pharmacists and techs give flu shots.

Many nonphysician clinicians can diagnose a cold. So can your mom. Most countries are reconfiguring their health care workforces to ease the burden on the physicians they do have.

There are things that only physicians can do - I don't want a lab tech performing surgery on me. But the international trend is to broaden the scope of practice of health care workers and, in most cases, it works out fine.

Information Technology

And one of the most valuable tools at our disposal, in dealing with workforce issues, rural health care and quality improvement, is health care information technology.

Telehealth makes it possible for a physician in Bangladesh to seek a consultation with a physician from the Mayo Clinic. It also makes it possible for a patient with diabetes or heart disease to send A1C or blood pressure data electronically. The day of the prescription scrawled by a busy physician in indecipherable handwriting is ending, as e-prescribing becomes the norm. The integrated electronic health record is becoming the preferred means of keeping and sharing patient information, especially in Singapore, which is so far ahead of the United States in this regard that I was almost embarrassed when I visited there.

Are there issues? Well, yeah. Providers in the United States are still protesting about having to adopt ICD-10 when many countries are preparing to adopt ICD-12. Some physicians are still relying on paper records, and I think it may take a nuclear weapon to get them to change.

And privacy of personal health information is an issue everywhere. I learned that in Singapore, despite total transparency and availability of health records to patients, people cannot gain access to their records at home over the Internet, because the system is wireless and therefore can be hacked. However, any patient can gain access through hospitals and clinics, many of which have do-it-yourself kiosks. A friend of mine told me, "Oh, only the old people actually use the keyboards on the kiosks. The young people just wave their cellphones at it." Okey-dokey.

If a health care system does not discriminate against the sick - as ours still does, through insurer manipulation of formularies, provider practices and other subtleties - then perhaps privacy of personal health information is not so important. But for me, it's my business, not yours. As health care attorney and ethicist Lori Andrews wrote years ago, "My body, my property."

The Rise of Consumerism

I refuse to refer to patients as "consumers." Most patient participation in health care is involuntary, and most of us would avoid it if we could. Few people look forward to a colonoscopy or pelvic examination. If they did, I would worry about them.

However, around the world, patients are demanding more of a say in how they are treated. Professor He told me about a phenomenon in China that has produced a new job description: "medical harassers." For a fee, these folks will demonstrate outside hospitals in protest of poor care. Sometimes it is just an angry family. Sometimes it is a way to extract money from the facility. But given the tightly run Chinese society, this is akin to a revolution.

People expect more from their health care systems now. They want transparency. They want to know what they are buying. They want access to their records. They want to participate in their care and not have decisions made for them unilaterally.

Historically, at least in the United States, there were two main drivers of patient consumerism: the rights of female patients, and the rights of the terminally ill. As these movements spread around the globe, forgive me if I celebrate.

And that includes the tricky issue of end-of-life care. A scathing report was recently released about care for the terminally ill in Britain, and it wasn't pretty. To quote an article about the report that appeared in The Times, "hundreds of thousands of people endure a painful, undignified or lonely death because of 'appalling' end-of-life care right across the health service." That is hardly unique; some friends of mine reported that an Australian friend, hours away from death from multiple myeloma, was still being pursued by a physician who wanted him to participate in a clinical trial.

As most of my readers know, I oppose physician-assisted suicide because I don't think anyone should have impunity when it comes to ending the lives of others. That doesn't mean that I think allowing people to suffer when their time is coming is a good idea. We know how to provide palliative care. We know how to provide hospice care. Increasingly - it took us long enough - we know how to control pain, once we get over the ridiculous fear that someone who has a week to live is going to become addicted to narcotics. What if she does? So what?

On the other hand, in those cultures with aging populations and low birth rates, euthanasia - by which I mean causing the deaths of people simply because they are old and sick - troubles me deeply. As of October, human euthanasia was legal only in Belgium, Colombia, Luxembourg and the Netherlands. Physician-assisted suicide is legal in Albania, Germany, Japan, Switzerland, Germany and four U.S. states. It has been deemed illegal in Mexico, the Northern Territory of Australia and Thailand. And no, I don't know why these countries made these decisions. I just work here.

I do think that better care at the end of life, consideration of the impact of euthanasia (which does not have a pleasant history, dating back to the Nazis and probably before) and monitoring of any death caused by a clinician are going to be global issues.

Violence Against Health Care Providers

I have written about this issue extensively [see the report, "Warning from a Mass Grave: Hospitals Under Attack" — Updated (without footbotes), which is available at no cost], so I won't dwell on it here. But perhaps the most disturbing international trend is attacks on hospitals and providers. I recently talked with a Pakistani health official who told me that polio inoculators - known charmingly as "lady health workers" - are being murdered on a regular basis by Taliban thugs.

Anyone who is not living in a cave knows that United States forces - for whatever reason - attacked a Doctors Without Borders hospital in Afghanistan and killed 30 patients and staff members; six ICU patients burned to death in their beds. The Syrian government seems bent on destroying its own health care system, despite the fact that its president is a Western-trained ophthalmologist. And the latest piece of gross hypocrisy is Vladimir Putin, the Russian president, condemning the attacks on civilians in Paris, despite the fact that a hospital administrator in the Crimea was kidnapped during the Russian takeover and hasn't been seen since, and at least one patient was dragged out of a hospital, beaten and left to freeze to death, which he did.

Enough is enough.

We Are All Different, We Are All the Same

Our health care systems differ. Our societies differ. Our religions differ. But we are members of a very special community, a community of caring. And we need to stand with our health care brothers and sisters.

An attack on any hospital is an attack on all hospitals. An attack on any physician, nurse or other caregiver is an attack on all caregivers. An attack on any patient is an attack on all patients. We are an international community of healing, and an attack on any of us is an attack on all of us.

All of our health care systems face similar challenges, and we formulate different solutions for dealing with them. It is my hope that we can learn from each other, implement what works, and discard what doesn't, but above all, stand together in trying to protect and improve the health of all people, wherever they are.

This column is based on a presentation by the author at WorldConnex2015, sponsored by Connexall, in Santa Rosa, Calif., Oct. 20, 2015.


Copyright 2015 by Emily Friedman.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. Her website is EmilyFriedman.com.

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