Contemporary Health Systems

Contemporary Health Systems Context

At the beginning of the 21st-century health systems are entering into a new context – over the past two decades, the field of global health has become a complex network. Across the world – in developed and developing economies – there is a growing gap between demand for healthcare, which is rising, and the resources needed to fulfill that demand. In 2018 the health industry is 8 trillion dollars across the globe and projected to grow to 18 trillion dollars by 2040 and yet for all this money spent we appear not to be getting the outcomes we desire – the word “broken” or “crisis” are often used when talking about health systems. Today there is an overarching transition taking place in the whole context or environment within which health systems exist. Humans are shifting from a predominantly natural context to a predominantly designed context and this is changing the very foundations upon which health systems reside.

As humanity makes this major transformation from a predominantly natural environment prior to the 1950s – when the urban population was 746 million – to a predominantly engineered environment after 2050 – with over 6 billion urban dwellers – the nature of health threats is shifting from deriving from natural origins to those that derive from how we design and manage the systems that make up our engineered environments and the behaviour choices we make as individuals. The shift of health challenges is a shift from what are often called “natural diseases” to “diseases of civilization.”

We have transitioned from a natural world that was given to us to a world that we have designed and developed ourselves. That transition has removed many of the health challenges of the past but it has also created new ones due to the structure and nature of the cultural, social, economic and technological systems we have built. While we have found cures for many natural diseases, we have at the same time created many new threats deriving from the world we have built. This is illustrated by the reports of the World Health Organization where experts claim that there is a multitude of factors that impact the health of the world’s inhabitants today, which include increased levels of stress, deterioration of the environment, hormones and chemical components used in products, crowded living conditions, worsening nutrition situation more processed food, pollutions, traffic accidents, while 8 out of 10 cities globally fail to meet WHO guidelines for air pollution with 3 million people dying every year from air-related diseases – 40 of the 56 million annual deaths globally now occur from chronic conditions.

The health systems we inherit were designed and evolve in the context of the industrial age to respond to the challenges of that time. The challenges of a mass industrializing society are providing basic services for the mass of people – that means largely dealing with the diseases of nature and communicable disease. But the challenges of today have change and become greatly more complex and subtle.

Changes In Diseases

The changes in living condition, environment and mentality of people has altered the nature of disease in just the past decades. Right now globally there’s a massive shift – called the epidemiologic shift – from communicable diseases to non-communicable diseases. These health issues are termed “lifestyle diseases” or “diseases of civilization” because the majority of these are preventable. The most prevalent causes for non-communicable diseases (NCD) include poor diets, tobacco smoking, alcohol abuse and physical inactivity, all of which are environmental and behavioral. NCDs are caused by environmental factors or inherited. 40 of the 56 million deaths that occurred in 2012 were from essentially four major conditions, cancer, heart disease, stroke and respiratory conditions – these weren’t even in the top five just 100 years ago. The number of people being diagnosed with cancer is expected to rise by 70% over the next twenty years. Tobacco alone accounts for 7.2 million deaths every year and this is projected to increase over the coming years.1

Diabetes is one of the fastest-growing health crises of our time, in Britain the National Health Service spends 10 billion pounds per year treating it, that is almost 10 percent of the entire national health budget. By 2040 it’s estimated that one in ten people around the world will have the disease.2 A great degree of the resources of the WHO now goes into helping countries to manage these slow epidemics of major diseases. Previously, chronic NCDs were considered a problem limited mostly to high-income countries, while infectious diseases seemed to affect low-income countries but almost 80% of deaths due to chronic NCDs worldwide now occur in low and middle-income countries.3 According to Chinese National Health and Nutrition Surveys, average weekly physical activity levels among Chinese adults declined by 32% between the years 1991 and 2006.11 This was mainly because of decreases in occupational activities as a result of urbanization. Due to increasing urbanization and affluence in India and China –  leading to overnutrition and reduced activity levels – these countries now account for almost half of all type 2 diabetes.

Clearly, the best way to deal with a non-communicable disease is to prevent it, but the causes are complex. Our built environments, for example, have a huge impact on obesity, our access to good food has a huge impact on our basic health, on diabetes, on obesity and osteoarthritis, our approach to clean air has a huge impact on cardiovascular disease on chronic obstructive pulmonary disease and so on. In the Netherlands alone there are 5.3 million chronic patients, over half a million people over 75 using more than 5 medications at the same time.4 Patients require ongoing treatment for chronic conditions so it’s not as simple as just giving an antibiotic and walking away, prevention is difficult and prevention requires lifestyle changes, in low resource settings managing chronic disease requires self-management and education and this has proved difficult even in rich countries. When it comes to acute health we are great, we intervene, we diagnose, we cure, we try to prevent, chronic health is though a different dynamic that we are certainly far from being able to deal with effectively.

Coupled with this is the demographic transformation of aging, particularly a growing demand from an increasingly aging middle class of developing nations which will fuel an added pressure on health systems going forward. In China, in 2012, there were around 180 million people over the age of 60 that figure is expect to reach 487 million in 2053 which will be 35% of the population according to UN figures. If you look at the demographics of every country, both emerging as well as developed, it becomes apparent that we do not have enough doctors and nurses nor do we have the capabilities to produce enough doctors and nurses to deliver healthcare in the same mode that we’ve done in the past.

Likewise, add to changes in diseases and aging, antibiotic resistance is set to be another major challenge to the current disease prevention model. A challenge that is pressing in the medium to long term is the re-emergence of infectious diseases, even in high-income countries, this is driven by increasing antimicrobial resistance and secondly the increasing emergence of novel zoonotic infections. Increasingly we’re seeing infectious diseases that are difficult and in some cases impossible to treat with antibiotics and other antimicrobials. Microbes have evolved over millions of years to be very good at adapting to changes in their chemical environment, there’s this ongoing race between humans trying to develop new drugs to treat infectious disease and microbes developing new resistant strategies. In 2016 we saw nearly half a million new cases of multi drug-resistant tuberculosis we seeing resistance emerging to HIV treatment, to malaria treatment, we’re seeing increased incidence of Methicillin-resistant Staphylococcus aureus (MRSA). A World Health Organization (WHO) report released April 2014 stated, “this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country. Antibiotic resistance—when bacteria change so antibiotics no longer work in people who need them to treat infections—is now a major threat to public health.”

Governance

In the age of globalization, the nature and structure of health systems is evolving. Globalization refers to an increase in global interconnections that results in the formation of new forms of global networked organizations which traverse the traditional divides and boundaries of the industrial age systems of organization. The health systems that evolved over the past century are largely organized around a centralized model of the nation-state, but it is becoming clear that this model will not scale to meet the needs of a global population of up to 9 billion. The formal national healthcare systems we developed in the past may have worked for a small minority of the global population but due to their design and current resource constraints that same model will not scale to deal with the needs of a globalized world.

Emerging economies now have significant health needs, different industry regulation than their more developed counterparts and a receptive environment for experimental products. Simply trying to scale up existing models would become overwhelmingly costly. The building of new medical facilities presents a significant challenge across the globe. The health of the individuals within society affects everyone, healthy population leads to better chances of economic development for everyone. This is to a large extent why we developed our existing health framework, as the nation-state formed people became interconnected and interdependent within that society and started to see the benefits of having a health system to support all. Today we are becoming interconnected globally and the imbalances, inefficiencies and inequalities on the global level are becoming ever more apparent to us.

Today there are huge imbalances between and within health systems, both in any given system and around the world – which largely map onto unequal distributions of wealth. For example, in India urban centers that account for some 30% of the population have approximately 70% of the doctors. Today in many regions of the world there is an acute shortage of qualified health personnel. 25% of conditions of bad health in the world are in Africa while only 3% of the health funds are spent in Africa and only 1% of health employees are in Africa.4

As the borders to nations become more porous and we start to find our selves living in a single global economy the need for some form of health system that is global, rather than just national, is becoming more apparent but remains significantly lacking. While there have historically been huge achievements in cooperation internationally, it would be difficult to say that the development of that is matching the pace of change given ongoing processes of globalization. There is no such thing as a real global health system, there are many national systems, many NGOs and a very thing global organization of the WHO – the WHO has an operating budget of some 4 billion dollars a budget smaller than that of many multinational corporations – to try and manage global health.5

We have essentially gone from one agency on the field, the WHO, to an explosion of many new players – for example there have been 6000 new NGOs created within a very short period of time to deal with HIV alone – that assert leadership claims and the right to dictate the policy’s, the right to decide the whole direction and priorities of global health within a certain sphere. It’s become so complicated that almost no one can really keep track of who’s deciding what agendas and who is in charge.6

There is a huge amount of value and opportunity being left on the table in terms of our capacities for coordinated efforts on a global level. The issue of how we can more effectively coordinate the use of resources by greater cooperation between all those actors who are in the global healthcare field is a huge leverage point, that as of yet has not been effectively utilized. If we were to do that then with the same amount of resources we could achieve many times more in the global health field, but the complexity of that is at often times overwhelming. As such global health can be said now to be not so much a technical issue as an issue of coordination and governance in a world that largely lack sufficient global institutions and resources to enable coordinated action; to effectively focus on issues that matter; deal with the scale of issues at hand.

Interconnectivity

Globalization means an increase in global interconnectivity between people, this increase in interconnectivity means many more channels for diseases to spread. We are increasingly living in an interdependent world where the health of anyone is the health of everyone. With mass urbanization, changes in land usage, deforestation and increase international travel, new infectious diseases – like multidrug-resistant tuberculosis – can rapidly spread from a rural area to a city or from one continent to another in the time span of a long haul flight.

In just the last few decades we’ve witnessed the result of this increased connectivity, with the spread of HIV, in the last 20 years we’ve seen SARS in 2003, swine flu in 2009, MERS curvey in 2012, Ebola virus in 2013, Zika virus in 2015 and we’ve seen many new zoonotic diseases travel from animal hosts to humans and then spread across country borders. Given existing and increasing population density and the fact that in any one year more than a billion people move from one place to another we’re likely to see more and more of these novels zoonotic diseases and other infections spread across country borders and threaten global health security.

Likewise, we can note that bioterrorism is becoming a greater threat, with the changes in the cost and availability of things like gene editing technology the chances of there being a bioweapon developed and deployed are increasing as the technology matures. Added to this we now have climate change that is increasingly being recognized as a major health threat. Climate change affects social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter. For example, very high air temperatures lead directly to mortalities from cardiovascular and respiratory disease. In the heat wave of summer 2003 in Europe, more than 70,000 deaths were recorded.21 Climate change is just one more element in a nexus of factors working to create an ever more dynamic and complex health context going forward.

Incentives and Financing

Our health systems have evolved over the 20th century to become hugely complicated with major issues surrounding misalignment of incentive structures and financing. WHO estimates that 150 million people around the world every year face catastrophic health expenses. In nations with high out of pocket expenditure, high health costs push many entire families into poverty, all because one family member got sick. Industrial societies have evolved to become hugely stratified in their health by income – what is called the social gradient in health. Those at the lowest income with the least education find themselves in environments that are very unhealthy – poor diets, cramped living conditions, poor air – while at the same time they are the least well economically equipped to deal with the resulting financial burdens.

How to finance both national and global health systems is still a major open, contentious and complex issue. Health financing requires a lot of interrelated decisions unless you get it right in all of these it can be difficult to get closer to achieving better overall outcomes – simply pushing the problem from one place to another. The decision involves, who should pay? how much each should pay? when they should pay? what happens to the funds that are then collected in the sense of what services are available? and then who benefits from those? Each one of those decisions is part of what we call health financing. Everyone should pay according to their needs but some will not be able to pay and will need subsidizing meaning a role for public financing.

Today health systems around the world face huge pressures to reduce costs and focus on value. The WHO estimates that between 20-40% of all health spending is wasted through inefficiencies due to irrational use of medicine, overuse of diagnostics services and medical equipment, inappropriate hospital admission and lengthy stays.18 Misaligned incentive structures prevent much-needed usage of the system, while overselling things that aren’t needed. In the US it is estimated that 30% of all test and treatments done are unnecessary, it is much more profitable to sell drugs and procedures than it is to talk about prevention. The result of this is huge financial burdens on governments. In the developed economies the cost of health is very large as a percentage of GDP and still growing rapidly – in the US cost have gone from 15% in 2005 to 25% in 2030 to a projected 37% in 2050.8 As a consequence of misaligned incentives – and the development of a very complicated system that lacks visibility or intelligibility – there is a growing lack of trust in the system on many sides.9

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References






1. https://goo.gl/HP6Qup

2. https://goo.gl/QNsRsC

3. https://goo.gl/6XWZAx

4. https://goo.gl/HP6Qup

5. https://goo.gl/ZTcQ4W

6. https://goo.gl/cnUpYx

7. https://goo.gl/zs76mH


8. https://goo.gl/5ULprW

9. https://goo.gl/CGyUx8

10. https://goo.gl/kHyFmL

11. https://goo.gl/UW224H

12. https://goo.gl/RaxUbj

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