(Problematic) Health Systems

Written by: Berkehan Erkılıç

A problem is never solved until it is addressed as such and separate from customs and traditions. When it comes to a topic founded on many obstinate beliefs – surrounding health, suffering, and disease – we can be sure that we are dealing with fundamental problems. Food for thought: can our definition of being healthy be the problem itself? Can we redefine health as a more integrative concept?

When it comes to public health, institutions are pivotal. To find the sweet spot of successful disease management, a well-balanced harmony is needed between institutions’ three elements: policymakers, executors, and the affected.  Researchers, as a subset of executors, and policymakers must be mobilized to ensure that actions are informed by evidence and that any policy changes are assessed for generalizable insight. Similarly, the affected (the population) must be given space to express their health needs through inclusion in government policymaking, budgeting, and planning processes. It is important to remember that health systems are a prerequisite for successful disease control rather than a result of increased investment. As the definition of health has swerved away from simply being disease-free, so should policies and social categorizations distance themselves from the idea of a binary system of ‘’healthy-diseased’’ or ‘’less investment-more investment’, classifications which reinforce ideas of undeserved poverty and fatalism. 

A health system is only one contributor to good health. Other major contributors are inherently the social determinants of health (education, wealth, employment, and social protection)  and cross-sectoral public health actions (tobacco taxation, improved food and water, and road and occupational safety regulations). Although seemingly separate, all of these fall under the scope of the aforementioned system. 

A strong public health system is comprehensive. Hence the ways to build it come in different forms where one cannot survive without the other.  The European Observatory on Health Systems and Policies’ document “Strengthening Health System Governance: Better Policies, Stronger Performance” discusses how both simple and complex policies have failed in systems for reasons not relating to money or political will, but rather stemming from governance troubles [1]. 

In low-income countries, the need for such innovative and affordable health financing systems is much more important due to the simple fact that resources there are more scarce [2]. A particularly important example is Rwanda, a low-income country that made a tremendous comeback after the bloody genocide of 1994 that shook the country with a death toll of up to one million people. A peak in healthcare outcomes was consistently demonstrated by data from various health domains: from infectious diseases that haunt the continent like malaria and vaccine-preventable diseases, to non-communicable diseases and other ailments that continue to negatively affect people worldwide. Rwanda, which adopts community-based health insurance, showcased that health outcomes do not necessarily correlate with the quantity of money spent on the healthcare system: out-of-pocket spending for health has decreased by 83 percent since 2000 to only 12 USD [3], achievable because of determined and solution-oriented governance. 

Countries such as China, Costa Rica, Cuba, Sri Lanka, and India have shown that dramatic improvements in health can occur without high or rapidly growing economies. Similarly, Europe in the late 19th and early 20th century witnessed great improvements in health conditions without prior or concomitant increases in income [4]. And yet, during the COVID-19 pandemic the world has observed many breakdowns from countries believed to be the most resistant to healthcare crises. Countries such as Germany, France, the United Kingdom, Spain, and Italy have undergone the most damage, inevitably raising questions about the strength and resilience of  these healthcare systems [5]. For example, in November 2020 it was reported that 1 in 4 deaths in France were associated with COVID-19 [6]. The statistics keep evolving as we speak, but one thing is for sure; this global pandemic has revealed many previously hidden shortcomings and perhaps most importantly that wealth is not necessarily correlated with disease control.

Public health success lies in public health measures. Public health measures lie within individual actions. Individual actions lie within quality public health education and awareness. Thus, the main target of a decision-making body should be rendering the information available and digestible for the target population of, above all, healthcare personnel. 

Moreover, a focus should be upon direct and indirect advocacy to the power holders, a plan requiring an agenda and strong plan of action.  The primary focus of long term advocacy should be for health systems to be judged primarily on their impacts, particularly better health and its equitable distribution. This impact will ultimately be evaluated through the capacity to measure and use data to learn. In fact, a guide from the London School of Hygiene & Tropical Medicine states the factors contributing to good health as follows: political and historical commitment to health as a social goal, strong societal values of equity, political participation and community involvement in health, high-level investment in primary health care, and widespread education including that of women and intersectional linkages for health [7]. High-quality health systems should rest on four key values: equity, resilience, efficiency, and a focus on the people.

The most important goal of an aspirational society should be an inclusive healthcare system where no one is left behind, ensuring a maximum of financial risk reduction and minimal out-of-pocket spending with the maximum number of services provided.  People-centred health systems are not only cheaper but also more manageable and always more favorable than competing systems. Most importantly, such systems result in happy and productive people who have the resources to put something on the table for their society. 

References

^[1] “Strengthening Health System Governance – WHO/Europe.” https://www.euro.who.int/__data/assets/pdf_file/0004/307939/Strengthening-health-system-governance-better-policies-stronger-performance.pdf. Accessed 3 Dec. 2020.

^[2] “The Impact of Community Based Health Insurance Schemes ….” 22 Feb. 2019, https://www.imf.org/en/Publications/WP/Issues/2019/02/23/The-Impact-of-Community-Based-Health-Insurance-Schemes-on-Out-of-Pocket-Healthcare-Spending-46587. Accessed 3 Dec. 2020.

^[3] “The Impact of Community Based Health Insurance Schemes ….” 22 Feb. 2019, https://www.imf.org/en/Publications/WP/Issues/2019/02/23/The-Impact-of-Community-Based-Health-Insurance-Schemes-on-Out-of-Pocket-Healthcare-Spending-46587. Accessed 3 Dec. 2020.

^[4] “Investing in Health – Disease Control Priorities in Developing ….” https://www.ncbi.nlm.nih.gov/books/NBK11754/. Accessed 3 Dec. 2020.

^[5] “Europe’s coronavirus second wave: What went wrong – CNN.” 20 Sep. 2020, https://www.cnn.com/2020/09/19/europe/europe-second-wave-coronavirus-intl/index.html. Accessed 3 Dec. 2020.

^[6] “Coronavirus deaths cast a pall over France, two weeks into a ….” 13 Nov. 2020, https://www.washingtonpost.com/world/europe/france-coronavirus-deaths/2020/11/13/265a1ade-2461-11eb-9c4a-0dc6242c4814_story.html. Accessed 3 Dec. 2020.

^[7] “Good Health at Low Cost – LSHTM.” https://ghlc.lshtm.ac.uk/files/2011/10/GHLC-book.pdf. Accessed 3 Dec. 2020.