"How sick are the world's healthcare systems" is deserving of a journalism award.
In the best of health? Photograph: Getty/Guardian
China - long lines; access to care is bureaucratic. A soaring demand for quality medical care by Jonathan Kaiman
In Lewis Carroll’s Through the Looking Glass, Alice finds herself facing a difficult conundrum. She’s running towards a distant hill; yet no matter how quickly she runs, her surroundings move with her, effectively stranding her. She meets the enigmatic Red Queen. “Now, here, you see, it takes all the running you can do, to keep in the same place,” the Queen explains. “If you want to get somewhere else, you must run at least twice as fast as that!”
China’s healthcare system suffers from the same problem – despite running at full speed over the past few decades, it can’t possibly move fast enough to keep up with the country’s social and economic changes. China’s per capita GDP grew more than 25-fold from 1980 to 2011; its life expectancy rose by nine years; its infant mortality rate quartered. Yet as Chinese citizens grow older and wealthier, they are also burdened by a rise in pollution, smoking, obesity and other public-health hazards, creating a soaring demand for quality medical care.
During the Mao era, in the 1940s through to the mid-70s, the country’s healthcare system was rudimentary but egalitarian, entirely supported by the state. Yet in the 80s, reformer Deng Xiaoping dismantled the system, leaving hospitals suddenly responsible for their own economic wellbeing. The result has been rampant profit-seeking: overprescription of medications, excessive testing and shocking efforts to cut corners. Many Chinese hospitals don’t keep soap in their public bathrooms. Physicians are so underpaid that they often must supplement their salaries with kickbacks from drug companies and patient bribes.
The system is also deeply stratified. A typical villager, upon falling ill, will first visit a local clinic – usually a concrete-floored, one- to two-room facility, equipped with little more than intravenous drips and a small pharmacy. If his malady requires further attention, he will be forced to ascend through a hierarchy of institutions – to a county hospital, then a provincial hospital, then a specialised clinic in a metropolis such as Beijing or Shanghai. Major institutions, inundated with patients from afar, suffer from chronic overcrowding. It is common to see families sleeping overnight on hospital lawns to avoid early-morning queues.
With the stakes so high, tempers run hot when treatments fail. Patient-on-doctor violence has become startlingly common – stabbings and mob-style attacks have risen 23% a year on average since 2002, according to the China Hospital Management Association. A typical hospital suffers one such incident every two weeks.
The Chinese government has poured billions of pounds into healthcare reform in recent years, and the system has improved accordingly. At present, 99% of the rural population gets some kind of insurance, up from 21% a decade ago; the country plans to roll out universal coverage by 2020. Yet the price of basic medical services has also risen, and many insured patients are paying as much as they once were. As of last year, the government gives each rural resident 280 yuan (£28.34) in annual healthcare subsidies. Yet elaborate procedures can cost many times that, and patients must pay the difference out of pocket. China has one of the highest savings rates in the world – about 50% – largely because families fear catastrophic healthcare costs.
Chinese authorities have been embracing other, more innovative ideas to improve the system: new technologies, private investment, new training regimens for doctors – in short, redoubling their speed just to keep up the pace.
South Africa: ‘Labouring under a two-tier system’ With the world’s biggest HIV caseload by David Smith
HIV with rampant tuberculosis (TB) and rising obesity, South Africa's healthcare is under strain.
The government spent more than 8.5% of GDP on healthcare in 2012, higher than the 5% recommended by the World Health Organisation (WHO) for a country of its socioeconomic status, yet performed worse than comparable nations.
The historical legacy of colonialism and apartheid is still manifest in one of the most unequal societies in the world. Health care is not exempt from this culture, so South Africa continues to labour under a two-tier system.
The private sector consumes 60% of total health spending yet caters to only about 15% of the population. The facilities are world class and less expensive than in Britain, the US or Australia – fertility treatment, for example, attracts foreigners at a fraction of the cost – but are beyond the financial means of most South Africans.
Public healthcare struggles to meet the needs of the other 85%, with often overcrowded facilities, poor equipment and shortages of drugs. Less than 30% of doctors, dentists, pharmacists, physiotherapists and psychologists, and just 40% of professional nurses, work in the public sector.
Some essential services are provided free by the state. TB treatment, for example, is not available in private clinics. After diagnosing a patient with TB, private doctors refer the patient to the public sector, where everyone receives TB medicine free of charge.
The most striking success in free provision is the antiretroviral treatment programme for people with HIV, initiated 10 years ago after the government, accused of “Aids denialism”, lost a landmark court case. Today, South Africa has the world’s biggest public-sector HIV programme, with 2.5 million people receiving treatment (!). The country’s life expectancy has consequently increased from 53 in 2002 to 60 in 2013.
But there are practical barriers. Patients’ first point of contact are primary healthcare clinics where, in serious cases, nurses and community health workers can refer them to hospital. These clinics are concentrated in cities and towns, often inaccessible to people in rural areas who cannot afford transport. Some 47% of children live in rural areas where only 12% of doctors and 19% of nurses work. Some villagers rely on an informal network of traditional healers and medicines.
Not everything in public hospitals is free, and only an estimated 17% of South Africans are part of a medical aid scheme to cover the costs. In addition, staff shortages translate into long waiting times. Critics say treatable conditions are not treated on time and preventable diseases are not prevented. The government has admitted the need for a “radical improvement” in the quality of services and “massive investment” in buildings and equipment, as well as fundamental changes in management.
The health minister, Dr Aaron Motsoaledi, has been known to roll up his sleeves and work a night shift at the Chris Hani Baragwanath hospital in Soweto, the biggest hospital in the southern hemisphere. He and his family use public hospitals and in 2011 he told the Mail & Guardian newspaper: “It’s a self-defeating prophecy to keep on saying we don’t have the means. There are good services in countries with fewer facilities and staff than us.” Nevertheless, Motsoaledi has a big plan for healthcare reform: a national health insurance scheme. The aim is to provide essential healthcare for all, irrespective of employment status and ability to pay, as enshrined in the post-apartheid constitution. Anyone earning above a certain income will be required to contribute to the NHI Fund.
The plan has met resistance from the private sector. But the government insists: “It will actually make the sector more sustainable by making it levy reasonable fees. The intention of NHI is rather to make sure that citizens are able to use both the public and private sectors in such a way that they complement each other rather than one undermining the other. At the moment, private healthcare is only for the rich. NHI is trying to blend the two in a more sustainable manner that benefits the population.”
India: ‘Public or private, India’s health care system is largely unregulated’ by Anu Anand
When Ria, 12, an illiterate maid’s daughter, suddenly developed a giant lump in her abdomen, her mother knew better than to trust India’s publicly run hospital system. Mazes of dingy corridors, outdated equipment and filthy wards where linens are absent and rats run freely greet the desperately poor and sick patients seeking care.
India spends just 1.3% of GDP on healthcare, one of the lowest in the world. Every day, patients from around the country, some who have travelled for days, can be seen queueing outside India’s biggest public teaching hospital, the All India Institute of Medical Sciences (AIIMS) in New Delhi. Hundreds jostle to see erratically available specialists. Others push their way to the counters of crowded roadside medical shops to purchase not just bandages and surgical equipment, but even life-saving drugs and the pints of blood patients are often expected to provide. At night, dozens of patients and their relatives sleep under the bright lights of the closest bus shelter, unable to afford accommodation.
The other option, equally inaccessible for poor Indians, lies a few miles away. In the lobby of one of New Delhi’s swanky corporate hospitals, wealthy patients from around the world sip lattes as they wait for doctors in brightly lit waiting rooms, complete with cleaners, attendants and stacks of glossy magazines.
Here, by global standards, the best diagnostic tests and procedures can be had for a fraction of western prices, a fact that fuels medical tourism to the tune of an estimated $78.6bn in India. But public or private, India’s health care system is largely unregulated.
In May, David Berger, a visiting Australian doctor writing in the British Medical Journal of his experiences in a small Indian hospital, blew the lid off the widespread practice of doctors receiving kickbacks for referring patients for medical tests, scans and even surgery. Subsequently, a group of doctors at AIIMS formed the Society for Less Investigative Medicine to counter corruption, which is deemed widespread by many.
India’s new health minister has also vowed to clean up corruption. And the new prime minister, Narendra Modi, has further spoken of his vision for universal healthcare. Partially inspired by Obamacare, it would potentially be the largest scheme in the world and tackle such daunting silent epidemics as tuberculosis, which claims 300,000 Indian lives annually.
But critics argue that such a private sector-led scheme will further marginalise the state system and leave India’s poorest citizens increasingly vulnerable to exploitation and substandard treatment, especially in rural areas.
Ria successfully had a grapefruit-sized tumour removed from her ovary. Her mother’s employer led the search for credible doctors, interpreting their advice and helping to cover the roughly £600 in diagnostic and surgical costs. Thankfully, her tumour was benign.
Brazil ‘A huge gap between standards of private and public care’ by John Watts
When more than a million protesters took to the Brazil streets last year, the woeful condition of the public healthcare system was high among their list of grievances.
Inequality and vast distances are the main problem. According to the World Bank, the country has 1.8 doctors for every 1,000 people – well below the 3.2 ratio in neighbouring Argentina, and significantly below those of Mexico, the US and the UK.
On paper, however, Brazil has one of the most comprehensive and generous public health networks in the world. The Unified Health System, or SUS as it is widely known, is universal and free for everyone. It has notched up impressive achievements. Since the turn of the century, life expectancy is up from 68.8 to 74.5, infant mortality is estimated to have fallen to 14.4 per 1,000 live births from 17.6, and the government says 95% of children are now fully vaccinated. Brazil’s healthcare spending was 9.3% of GDP in 2012.
But, reflecting this very unequal society, there is a huge gap between standards of private and public care. In state capitals, the one in four of the population who can afford private services benefits from almost double the doctor-patient ratio. For those in the SUS, there are insufficient beds, and waiting times for basic diagnosis and treatment are long.
Regional disparities are even more glaring. Residents Maranhão, the country's poorest state, have barely a quarter of the spend per head as the inhabitants of wealthy Rio de Janeiro.
To address this problem, President Dilma Rousseff last year launched a crash programme to fill the gap with thousands of primarily foreign medics. The “Mais Medicos” (More Doctors) programme offers incentives to those go to medical schools in remote and poor areas, such as the Amazon, so that in the long term they can train a new generation of professionals. So far, 4,199 doctors have been dispatched and the plan is to increase this to 11,500 doctors by the end of 2017.
The vast majority have come from Cuba. This is politically controversial because the Cuban government pockets about a quarter of their salaries. When they arrived, Brazilian doctors booed and chanted “slave” at the newcomers and accused them of lacking the necessary qualification and language skills needed to do a good job.
While it is true that the normal diploma requirement has been waived for the Cubans, the government says this is justified because they are only expected to provide primary care, not surgery. “Mais Medicos is a success because it is serving the public with quality and because it is greatly improving health indicators throughout Brazil,” says health minister Arthur Chioro. “Fifty million people who did not previously have primary care now have exactly what they need most of all.”
Egypt ‘A system that doesn’t know how to manage itself’ by Patrick Kinsley
A few weeks ago, a woman gave birth in a street outside of a public hospital in northern Egypt. Depending on who you believe, the hospital either didn’t have enough medics to tend to her – or they demanded money that she couldn’t pay.
Hers was an extreme example of the problems with Egypt’s public health service, particularly in provincial areas. Thanks to a decree issued earlier this year, all Egyptians should get free access to emergency hospital care for at least 48 hours. But in practice some state facilities, particularly in the countryside, either cannot provide instant healthcare – or have to charge for it. Due to a shortfall in government funding, they have no other way of paying their staff.
And the problem goes beyond A&E. A state-run insurance scheme nominally provides subsidised non-emergency healthcare to children, government workers and the families of those workers – a group that the government says totals 54% of the population. But by the government’s own count, only 8% of those covered by the scheme actually use state facilities. “This in itself denounces the problem,” says Ayman Sabae, a doctor and campaigner for healthcare reform at the Egyptian Initiative for Personal Rights, a prominent watchdog. “Both the service quality and access to the services are so limited that only 8% use them.”
A government clinic that Sabae visited in rural Qena province last month exemplifies the problem. Like about half of Egypt’s 4,000 state clinics, this one is well-equipped, and newly refurbished. But according to Sabae, there has not been a doctor here for the past four years. Clinicians assigned here might only earn around 1,200 Egyptian pounds a month – about £100, or little more than Egypt’s average monthly wage – whereas they can earn around five times as much in the private sector. So they opt for the latter.
“There’s a couple of finance employees, maybe a nurse,” says Sabae of the clinic. “But no doctors. And that’s very typical – you have a system that doesn’t know how to manage itself. You have the money to renovate the clinic, but not the human resources to manage it.”
As a result, the half of the population who are eligible for free healthcare are often no better off than the half who aren’t. Most end up paying for their care themselves – in fact, 71.8% of healthcare spending in Egypt comes from people’s pockets. NGOs, charities and religious groups pick up some of the slack (the now-banned Muslim Brotherhood part-built their influence on their network of clinics).
Those who aren’t covered by the state healthcare plan can apply for another of state-paid treatment – the Program for Treatment at the Expense of the State. But this is only for those with life-threatening diseases who can show they are incapable of paying through other means.
As a last resort, any patient can get free treatment at university training clinics and hospitals. On the plus side, the doctors here are often the best in the country. On the downside, students observe every operation, the facilities are often unhygienic, and the cost of basic supplies is frequently covered by the patients or the doctors themselves.
“When I worked there as a doctor, I was paid 200 Egyptian pounds [about £20] a month, and I would spend more per month from my own pocket to buy blood from other hospitals,” says Sally Toma, another doctor who campaigns for healthcare reform. “Otherwise, I was told, I would have to choose who should get blood, and who should not.”
Italy ‘A persistent complaint is unfairness’ by John Hooper
Italians by and large regard health as a priority. And it shows up in one of the highest life expectancies in the world. In 2012, according to the World Bank, the average newborn Italian could expect to live to the age of 83 – the same as in Switzerland or Japan.
But, like many things in a country of contrasts and disparities, the provision of health services varies widely from one part of Italy to another. Last year, a report was published by the parliamentary committee that scrutinises what Italians callmalasanita (literally “bad health”): cases of extreme negligence on the part of doctors or hospital staff. Out of 400 deaths attributable to malasanita between April 2009 and December 2012, more than 40% occurred in just two of Italy’s 20 regions, Calabria and Sicily.
Italy’s Servizio Sanitario Nazionale was founded in 1978 and modelled in large part on the NHS. But right from the outset it was only to a limited extent national.
The central government fixes the overall budget, determines minimum levels of care and, for example, negotiates drug prices with the big pharmaceutical companies. But it is the regional governments that administer the system, and there are huge discrepancies between them in levels of efficiency and integrity.
In parts of northern Italy, patients receive attention as good as anywhere in Europe. “Customer satisfaction”, however, falls off rapidly in the southern half of the country. And the drop goes hand in hand with a fall in measures of efficiency.
In Sicily, for example, there are roughly 10 hospital doctors for every hospital bed. In the north-eastern region of Friuli-Venezia Giulia, the ratio is half that.
Discernible in the statistics are variations in the degree of corruption and the use of public services to distribute jobs and patronage. Last year’s parliamentary commission report noted that in Campania, the region around Naples, 383 health officials had been taken on to the payroll without having to go through the bother of a selection process.
A persistent complaint among patients is of unfairness. In the southern half of Italy especially, they often move up waiting lists, not according to the date on which their names were first entered, nor by virtue of the seriousness of their condition, but according to whether they can secure a raccomandazione(reference) from someone with influence over the relevant surgeon.
By and large, the state has been open-handed in allocating resources to health. In 2012, Italy spent 7.2% of its gross domestic product on the public health system. That was less than was spent by the UK, Germany or France. But then Italy’s economy has scarcely grown since the turn of the century and is under growing pressure from European institutions to trim its spending.
Cuts have been made in recent years. But the overall budget for this year, of almost €111bn (£88bn), was still almost 4% higher than it had been in 2011.
The United States ‘More than 13% of Americans still have no health insurance’ by Nicki Woolf
When he announced the news that a doctor returning from Guinea to Harlem, in New York, had been diagnosed with Ebola in October, mayor Bill de Blasio said that New York’s had the “world’s strongest healthcare system”.
But the fact that he referred to the city’s system, rather than the nation’s, is telling. In fact, while the US can boast some of the best doctors and most advanced medical technology in the world, it doesn’t really have a coherent healthcare system at all. Healthcare in the US is private insurance-based and decentralised, with most care providers owned locally by private companies, and local and state governments controlling access to federal programs.
The private and public systems that overlap in some areas, and leave gaps in others, make the US the country that spends the most per capita and as a percentage of GDP of any country in the world, but paradoxically consistently last among comparable nations in measures of quality of coverage such as infant mortality.
Because their cost is decided by private companies, individual procedures can be extraordinarily expensive. A single MRI scan in some parts of the country can cost as much as $2,871 (£1,780); an appendectomy as much as $29,426 (£18,000), and a caesarean-section delivery as much as $26,305 (£16,000), according to a report by the International Federation of Health Plans. Some procedures can be as much as eight times the price of the equivalent operation in the UK, and a 2013 study by NerdWallet Health showed that medical bills are the biggest cause of bankruptcy in the US.
Some of the gaps are filled by government operations. One of these is Medicare, which guarantees health insurance for the elderly. Another is Medicaid, a low-income program which the Obama administration has recently expanded – but state governments, especially those controlled by rightwing Republican governors, have consistently rejected the expansion, leaving many poor residents without healthcare. Yet another is the Veterans Health Administration, which was hit by scandal in April 2014 when it was revealed that at least 40 US military veterans had died while waiting for medical care.
Perhaps the core struggle of Barack Obama’s presidency has been to pass his Affordable Care Act (ACA), which would aim to use state online insurance exchanges to reduce the number of people without coverage. But the bill has become a political football for the far-right Tea Party, who see any attempt to close the gaping holes in coverage as unacceptable government overreach.
The result has been that as of the beginning of 2014, more than 13% of Americans still have no health insurance coverage at all.
Germany ‘It gives patients a lot of choice’ by Philip Oltermann
Germany’s healthcare system is best understood as a middle option between the British state-run and the American market-led model. In principle, healthcare cover is universal, as in Britain: treatment of the unemployed is covered by the state, and ordinary patients rarely get presented with a bill after seeing a doctor.
Unlike in Britain, however, this universal care is not funded by a centrally collected tax, but by so-called Krankenkassen or sickness funds – a system that goes back all the way to Otto von Bismarck’s health insurance bill of 1883. Signing up with a sickness fund is compulsory for every German citizen. Once you have joined, you pay a premium calculated according to your income: half of it is paid by you, the other half by your employer. If you make less money, you pay less.
If you are lucky enough to have a career that makes you a lot of money – and this is where Germany veers towards the US model – you can choose to ignore one of the 131 public, non-profit sickness funds, and go with a private insurer instead. One advantage in comparison with the British system is that you don’t end up having to pay double – say, for Bupa and the NHS. In Germany, about 89% of the population is covered by public sickness funds, the remaining 11% are private.
One of the big plus points of the German system is that it gives patients a lot of choice: you are not restricted to the nearest general practitioner in your postcode but can sign up with any GP you like. GPs also have less of a gatekeeper function: if you know you have a back problem, you can go straight to see an osteopath.
Because the system is less centralised, doctors and nurses don’t have to stick to behavioural guidelines: for foreigners, some German doctors can come across as shockingly informal. “Practitioners enjoy a lot of freedom in Germany,” says Stefan Etgeton, a senior expert of the Bertelsmann Foundation. “But therein can also lie a problem: forcing through new medical standards can be arduous, because some doctors are convinced that their way of doing things is still best.”
In Germany, the healthcare system does not attract the same unholy combination of vitriol and affection that the NHS does – it just about works so that both the left and the free-marketeers can see in the system what they want. But that’s not to say that there aren’t problems eating away at the system.
For a start, the per-capita cost of healthcare has been much higher in Germany than in Britain for years. Most recent figures, from 2012, show the country spending 11.3% of its GDP on healthcare – 2% above the OECD average. “As a whole, the German system encourages overspending,” says Edzard Ernst, Exeter University’s German-born professor of complementary medicine. Doctors, who get charged per item, are incentivised to oversubscribe, and patients are incentivised to use the system more than in other countries.
There are also concerns about the long-term effects of the dual private-public system. One of the problems is that it provides an incentive for the best doctors to move to urban areas where there are more high earners who can afford private sickness funds. As a result, rural regions struggle. A public survey in 2012 showed 58% of the population supports scrapping private health insurance altogether.
In the best of health? Photograph: Getty/Guardian
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