Medicine in other countries

From Ganfyd

Jump to: navigation, search
The USA healthcare system is economically inefficient while that in Japan appears much more effective.

Medicine in other countries If you are a doctor wanting to know about working abroad this article will only deal in fundamental organisational and broad comparison issues essentially common to all Western health care systems. Please see comparison of health systems for some data on English speaking countries and the external link below for data on most first world countries.


Health systems

There are four models with most societies having a pick and choose approach as none has proved satisfactory on its own:

  1. Social insurance
    1. Pros
      1. Likely to have active market
      2. Allows infrastructure separate to state funding cycles
      3. Can offer effective primary care
    2. Cons
      1. Has to be regulated to avoid cherry picking
      2. Unable to meet every need so rationed
      3. May need public subsidy (to avoid cherry picking)
      4. Higher administration costs than if publicly funded
      5. Depends upon social cohesion
      6. Harder to ensure most appropriate access
  2. Publicly funded
    1. Pros
      1. Access easier to deliver according need
      2. Most efficient if no corruption
      3. Likely to regulate cost (monopoly supplier)
      4. Best at prevention and public health medicine
      5. Can offer effective primary care
    2. Cons
      1. Most open to political distortion
      2. Corruption easy if not funded or regulated
      3. Unable to meet every need so rationed
      4. Slows down innovation
      5. Unlikely to offer luxury, indeed infrastructure and resource neglect is common
      6. Depends upon social cohesion
  3. Private insurance
    1. Pros
      1. Likely to offer individual choice for a price
      2. Likely to offer convenience
      3. Does not need social cohesion
      4. Can offer effective primary care but only in managed care bundle
    2. Cons
      1. Cherry picking and managed plans
      2. Only usually available to those with (historic) employment or their immediate dependents
      3. Bureaucracy
      4. Limited cost regulation
      5. Most open to political lobbying
      6. Potential for inappropriate access
  4. Out of pocket funded
    1. Pros
      1. Individual choice if a true market exists
      2. Individual choice (if competency)
      3. Can pay for extras
      4. Only rationed by cost, ease of access and availability
      5. Individual responsibility
      6. Promotes innovation where this profitable
      7. Convenience
    2. Cons
      1. Unpredictable costs
      2. Less likely to be effectively regulated
      3. Discriminates against chronic disease
      4. Discriminates against those most likely to need healthcare
      5. Tends to be available to only most affluent subpopulation
      6. Difficult to regulate
      7. Leads to powerful guilds
      8. Patient comes to healthcare worker
      9. Primary care access unpredictable
      10. Unreasonable expectations
      11. Stifles innovation where unprofitable
      12. Tends to meet demand not need
      13. Inefficiencies due to shopping around
      14. Potential for inappropriate access

see Percentage of health expenditure by source of financing, OECD countries, 2004

Health system evolution

Changes in OECD life expectancy at birth since 1960
  • To a degree this is illustrated by recent changes in life expectancy.
  • Most OECD economies have evolved towards a 80% odd publicly funded health system.
  • The USA has increased its public sector contribution from less than 25% in 1960 to more than 40% so its absolute level of public funding per head of population makes it about the 4th largest in the OECD.
  • Publicly funded health system have prioritised control of secondary care capacity but increasingly ambulatory care capacity has had controls or incentives introduced. Planning of social care capacity has similarly had controls or incentives introduced.
  • The politics of funding and organising publicly funded health systems has remained controversial, mainly due to the resource implications, as health technology and demographics conspire to require ever greater proportionate resources

Health finance

OECD public spends on health corrected to common buying power against life expectancy at birth 2003

Health system finance is extremely complex but certain generalisations are possible.

  • There is over 3 fold variation in bang for buck by simple measures which raises important issues in health system design.
Proportion of GNP spent on health care -OECD data 2006
  • Almost all OECD countries have increased their proportion of gross national product spent on health since 1990:see Percentage of health expenditure by source of financing, OECD countries, 2004. This is due to:
    • Demographic change
    • Health care inflation
  • The absolute amount spent on health in a society can be related to life expectancy at birth. Such a graph is highly suggestive that net health gain for the population is more efficiently attained in some societies than others. There is little doubt that organisation of the gross spend for the public good may be a factor and that some public sectors seem to get more bang for their buck.

It can be easily demonstrated in insurance based systems that the variance in health care spend in an organisation follows an exponential pattern, being almost 4 fold higher for small organisations compared to ones that serve over 2 million population. It seems likely that smaller organisations tend to cherry pick and have issues with spreading risk[1].


See health productivity and health-care productivity.


OECD data on change in doctors numbers since 1960
  • Nations have different densities of physicians[2]
    • Remember numbers of nurses in some health systems has been shown to better correlate with real outcomes (and this varies markedly by health system, as do the tasks the different health professional groups routinely do)
    • Reflects:
      • Morbidity
      • Mortality
      • Health expenditure
      • Health systems
      • Overt and covert restrictions on entry to medical school
    • ↑ numbers (of approprately trained doctors[3] !) can improve outcomes
      • Intensive care[4]
      • Hospital mortality[5]
    • But may result in poor outcomes
  • Controlling numbers of physicians
    • Can help cost-containment
    • At cost of outcomes and responsiveness
    • With tendency for training programmes to experience cycles of boom and bust
  • Concern about shortages of doctors in many OECD countries
    • International migration of doctors increases flexibility of the labour market
      • International equity concerns
    • Policies that improve retention of physicians
      • ↑ job flexibility
      • Defer retirement
    • Attraction and retention doctors rural and deprived urban areas
      • Educational policies promoting admission of students with rural background to medical school
      • Regulatory policies restricting practice location
      • Financial policies
        • Mixed success with scholarships in return for a commitment to practice in an area for a minimum period
        • Some success:
          • Support occupational opportunities for spouse/partner
          • Education of children
          • Accommodation.
  • Increasing specialisation in medicine
    • Incentives for primary care training
      • Regular work schedules
      • More leisure time
  • Physician productivity can be challenging
    • Fee-for-service methods of payment raise activity
    • Salaried or capitated methods of payment less activity
    • Quality of care poorly correlates with activity however
      • Attempts to renumerate by quality
        • Constrained by difficulties in measuring and monitoring quality of care

External Links