HSS4331A – International Health

1. HSS4331A – International Health March 8, 2010 – The Brain Drain and Health Care Systems Around The World

2. But first! • Your policy papers are now due: • Monday March 22 at 11:59pm (see how nice I am?)

3. Tomorrow’s talk by Kevin Pottie has been cancelled • Wednesday, Climate Justice “teach-in” at Colonel By B012, 7-8pm

4. Coming Up • March 15 – guest lecture by Arif • March 22 – me & course evaluation • March 29 – guest lecture by Arif • April 5 – no class • April 12 – wrap-up & exam review

5. Today we’ll look at health care around the world

6. What Are The World’s Best Health Care Systems? • In 2000, The World Health Organization has carried out the first ever analysis of the world’s health systems • Using five performance indicators to measure health systems in 191 member states

7. Indicators Used to Make Rankings The following were employed by WHO in their 2000 rankings • overall level of population health • health inequalities (or disparities) within the population • overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts) • distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system) • the distribution of the health system’s financial burden within the population (who pays the costs).

8. Why Country Topped the List? • France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan

9. 1 France 2 Italy 3 San Marino 4 Andorra 5 Malta 6 Singapore 7 Spain 8 Oman 9 Austria 10 Japan 11 Norway 12 Portugal 13 Monaco 14 Greece 15 Iceland 16 Luxembourg 17 Netherlands 18 United Kingdom 19 Ireland 20 Switzerland 21 Belgium 22 Colombia 23 Sweden 24 Cyprus 25 Germany 51 Dominican Republic 52 Tunisia 53 Jamaica 54 Venezuela 55 Albania 56 Seychelles 57 Paraguay 58 South Korea 59 Senegal 60 Philippines 61 Mexico 62 Slovakia 63 Egypt 64 Kazakhstan 65 Uruguay 66 Hungary 67 Trinidad and Tobago 68 Saint Lucia 69 Belize 70 Turkey 71 Nicaragua 72 Belarus 73 Lithuania 74 Saint Vincent and the Grenadines 75 Argentina 26 Saudi Arabia 27 United Arab Emirates 28 Israel 29 Morocco 30 Canada 31 Finland 32 Australia 33 Chile 34 Denmark 35 Dominica 36 Costa Rica 37 United States of America 38 Slovenia 39 Cuba 40 Brunei 41 New Zealand 42 Bahrain 43 Croatia 44 Qatar 45 Kuwait 46 Barbados 47 Thailand 48 Czech Republic 49 Malaysia 50 Poland

10. What Is “Universal Health Care”? • the law says that everyone must have access to health care

11. What Is “Single Payer System”? • characterized by one provider being able to create a market power that would buy all goods and services in the healthcare market

12. Canada • Single payer system, provincially run, funded through general government revenues • ~10% of GDP expended on health care • 100% of citizens are insured • Most physicians are paid fee-for-service • There are only 2.1 physicians per 1,000 people (less than OECD average of 3.0 physicians per 1,000) • No copayments • Lengthy waiting lists • Fraser Institute estimates that “800,000 Canadians are waiting for treatment at any given time”

14. The Human Cost of Illness in the USA • 45.6% of all bankruptcies involve a medical reason or large medical debt • 326,441 families identified illness/injury as the main reason for bankruptcy in 1999 • An additional 269,757 had large medical debts at time of bankruptcy • 7 per 1000 single women, and 5 per 1000 men suffered medical-related bankruptcy in 1999 Source: Norton's Bankruptcy Advisor, May, 2000

15. If you want to see Obama’s planned reform… • Go here: • http://www.healthreform.gov/ • History here: • http://en.wikipedia.org/wiki/Health_care_reform_in_the_United_States

16. France • Often seen by political liberals as an ideal system (according to The Economist) • Universal health care with few waiting lists • highest level of satisfaction with their health care among all European countries • The “General National Health Insurance Scheme” covers 83% of French workers • other occupational specific (e.g.: for agricultural workers, for the self employed, for miners, etc.) cover the remainder

17. France • Copayment rates for most services are 10%-40% • About 92% of French residents have complementary private health insurance • unlike true single-payer systems, it employs market forces • France is the third most expensive health care system (~11% of GDP) in the world • in 2005 the health care system ran a €11.6 billion deficit and in 2006 the health care system had a €10.3 billion deficit

18. France • Most of the funding is from a 13.55% payroll tax (employers pay 12.8%, individuals pay 0.75%). There is a 5.25% general social contribution tax on income as well • Private health insurances makes up 12.7% of French health care spending. • French doctors are paid by the national health insurance system based on a centrally planned fee schedule, but doctors can charge whatever price they want • The average French doctor earns only €40,000, although medical school is free for them and the French legal system is fairly tort-averse • “To sum up: the French health care system clearly works better than most national health care systems. Despite some problems, France has generally avoided the rationing inherent in other systems. However, the program is threatened by increasing costs and may be forced to resort to rationing in the future.” –the Economist

19. Italy • While France may have the highest rated health care system in the world, Italy is second according to the WHO • Despite the high rankings by the WHO, Italians are dissatisfied with the quality of their care • Health care spending rose by 68% between 1995 and 2003. • Funding is based on a regressive payroll tax. The tax starts at 10.6% of income for the first €20,660 and drops to 4.6% of income between €20,51 and €77,480. The rest of the funding comes from federal and regional general taxation

20. Italy • Physicians are paid via capitation • Italians have limited choice of their physician but more than in the UK or in Spain. They must register with a general practitioner (GP) in their area • Inpatient and primary care are free. For tests, diagnostic procedures and prescription drugs, copayments are as high as 30%. However, 40% of the population (e.g.: the elderly, pregnant women, kids) are exempt from these copayments. • Waiting times are fairly long for diagnostic tests

21. Spain • The Spanish have one of the most centralized health care systems in the world. • Spain ranks #7 on the WHO health care rankings and the Spanish are the second-most satisfied with the quality of their health care in Europe (behind France). • 98.7% of the population is insured • About 12% of the population has private health insurance • Most physicians are quasi-civil servants and are paid a salary based on seniority and credentials • Spain has fewer doctors and nurses per capital than most OECD countries

22. Spain • There are few copayments except for prescription drugs. • Waiting lists are a significant barrier to care in Spain. The average wait to see a specialist in Spain is 65 days • Rehabilitation and convalescence are not covered. Those with terminal illnesses are generally the responsibility of the patient’s relatives.

23. Japan • Japan has universal health insurance based around a mandatory, employment-based insurance. • Japan has very generous health insurance benefits, significant provider choice, and high quality medical technology, but costs are not as high in the U.S. • One reason for this is a significant level of cost sharing. The average Japanese household spends $2300 per year on out-of-pocket health care expenses • Another reason for lower costs is that the Japanese government sets a reimbursement fee schedule for all physician services. This has resulted in “assembly line medicine” where “two-thirds of patients spend less than 10 minutes with their doctor; 18 percent spend less than 3 minutes.”

24. Japan • The health insurance plans are funded by an 8.5% (for large business) or an 8.2% (for small-businesses) payroll tax • Those who are self-employed or retired must pay a self-employment tax • Very few Japanese use private, supplemental insurance. Private supplemental insurance pays for less than 1% of health care costs

25. Japan • There are no restrictions on physician or hospital choice and no referral requirements. • Copayments are 10% to 30%, but generally closer to 30%. Copayments are capped at $677 per month for the average family. • Waiting times are a significant problem at the best hospitals. Since the best hospitals can not charge higher prices there will be a queue. Many hospitals have been known to accept “under the table” payment to see patients quicker.

26. Norway • All Norwegians are insured by the National Insurance Scheme. This is a universal, tax-funded, single-payer health system. Compared to France, Italy, Spain and Japan, Norway has the most centralized system. • 100% of Norwegian citizens and residents are covered. • Funded by taxes

27. Norway • Norwegians can opt out of the the government system and pay out-of-pocket. Many pay out-of-pocket and travel to a foreign country for medical care when waiting lists are long. • Doctors receive a salary • Patients choose general practitioners (GPs) from a government list. These GPs then act as gatekeepers for specialist services. Patients can only switch GPs twice per year and only if there is no waiting list for the requested GP.

28. Norway • There are no copayments for hospitals stays or drugs. There are small copayments for outpatient treatment. • There are significant waiting times for many procedures. Many Norwegians often go abroad for medical treatments. The average weight for a hip replacement is more than 4 months • Generous system that has been known to pay for spa treatments

29. U.K. • Centralized, single payer system (National Health System – NHS) • Health care spending is fairly low (7.5% of GDP) • 100% of citizens are insured • In 2006, system had a £700 million deficit despite the fact that health care spending increased by £43 billion over five years. • 10% of Britons have private health insurance. Private health insurance replicates the coverage provided by the NHS, but gives patients access to higher quality care, and reduced waiting times.

30. U.K. • most physicians and nurses are mostly government employees • In 2004, the NHS negotiated lower salaries for doctors in exchange for reduced work hours • Few physicians are available at night or on weekends • because of low compensation, there is a significant shortage of specialists

31. U.K. • Patients have very little physician choice • There are no deductibles and almost no copayments except for small copayments for prescription drugs, as well as for optical and dental care. • Waiting lists are a huge problem in Great Britain • 750,000 are on waiting lists for hospital admission • 40% of cancer patients are never able to see an oncologist • there is explicit rationing for services such as kidney dialysis, open heart surgery and care for the terminally ill

32. Case Study: Tony Wilson • Famous founder of Factory Records (see movie, 24 Hour Party People) • Died 2008 of cancer, after being denied expensive cancer drugs by NHS • "I've never paid for private healthcare because I'm a socialist. Now I find you can get tummy tucks and cosmetic surgery on the NHS but not the drugs I need to stay alive. It is a scandal.“

33. Switzerland • of all the countries with universal health care, Switzerland’s is the most market-oriented • Spends 11.6% of GDP on health care, yet the government pays for very little of this funding • Still the 2nd most expensive system in the world • 99.5% of citizens are insured • Insurance is purchased by individuals.  Individuals generally must pay the full cost of premiums, but the government helps to finance insurance purchases for the poor. • Idea is that no individual pays more than 10% of income on health

34. Switzerland • Physician compensation is negotiated between the insurance companies and doctors • Switzerland has strong regulation with respect to non-physician health care professionals (e.g., nurses, PAs, NPs,) and thus patients are often compelled to use expensive physicians even when this may not be medically necessary • According to WHO, Switzerland ranks second only to the U.S. in terms of the ability of patients to choose their provider • Short waiting times

35. Germany • All Germans with incomes under €46,300 are required to enroll in a “sickness funds”; wealthier people can opt out • There are 200 of these funds, private and non-profit • Funded by payroll taxes (~15%) • 99.6% of citizens are insured • Approximated 9% of Germans have supplemental insurance • Physician reimbursement is set through negotiation with the “sickness funds” • Short waiting lines

36. Germany • A family doctor in Germany makes about two-thirds as much as he or she would in America • German doctors pay much less for malpractice insurance, and many attend medical school for free • Germany also lets the richest 10 percent opt out of the sickness funds in favor of U.S.-style for-profit insurance • These patients are generally seen more quickly by doctors, because the for-profit insurers pay doctors more than do the sickness funds

37. Thoughts • Health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment. • Rising health care costs are not a uniquely North American phenomenon. Although many other countries spend considerably less than both Canada and the USA on health care, both as a percentage of GDP and per capita, costs are rising almost everywhere, leading to budget deficits, tax increases, and benefit reductions. • In countries weighted heavily toward government control, people are most likely to face waiting lists, rationing, restrictions on physician choice, and other obstacles to care. Source: “The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World“ by Tanner, CATO Institute

38. Additional Reading • http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/ • “Sick Around The World: Five Capitalist Democracies and How They Do it” • http://www.cato.org/pub_display.php?pub_id=9272 • “The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World”

39. What Does All This Mean? • There are many ways to put together a national health system in a modern, Western democracy • Canada’s is not necessarily the best • There are pros and cons to all the models

40. What Then Are The Challenges for Developing a HC System for the Global South? • Many of the OECD examples are barely solvent, consuming 10% or more of GDP • Developing nations are heavily focused on primary care, with insufficient prevention infrastructure • Brain drain

43. Does more money mean better health?

45. Is Having Enough Doctors Important?

47. Brain Drain • What is the “brain drain”? Movement of trained people from a population where they’re needed to a place with greater resources Re: health care The draining of health professionals from one country or place to another. Drain can be between countries or within a country.

48. Why Do HCW Move? • Remuneration • Living conditions / security • Opportunity for family • Intellectual “wastage”

49. Recommendations from the Romanow Report • Recommendation 18 – The Health Council of Canada should develop a comprehensive plan for addressing issues related to the supply, distribution, education and training, remuneration, skills and patterns of practice for Canada’s health workforce. • Recommendation 47 – Provincial, territorial and federal governments and health organizations should reduce their reliance on recruiting health care professionals from developing countries.