The United States spends twice as much per person as Canada on healthcare and yet the average Canadian has a higher life expectancy than the average American. France spends less per person than Canada and yet has more hospital beds and doctors per inhabitant than either of the other two. And French women have one of the highest life expectancies of all. For one thing, this shows the importance of using the right indicators for measuring healthcare performance. Life expectancy may be a useful measure of our well-being, but it depends on many factors apart from healthcare, such as standards of living, diet and physical activity.
Still, more people are living longer. This poses a daunting challenge, for elderly care is where most health spending is concentrated. The increase in pressure on healthcare systems that ageing will bring cannot be met without managing scarce public resources wisely. Consumers demand value for money. But as several writers in our healthcare pages point out, they do not want their health services to be pared down to the bone. Naturally, they want health services that deliver results. They want policymakers to be more patient-oriented, to find out whether more operations have been successful, to ensure that clients get real satisfaction.
It may be that, in some cases, public spending on health has to rise to achieve efficiency. Performance indicators help to establish this, and Sheila Leatherman of the US-based Center for Health Care Policy and Evaluation, shows the pitfalls and potential of using different measures. Coming up with the right indicators requires considerable analysis, particularly in the increasingly difficult area of long-term care, as Keio University’s Naoki Ikegami explains. For Mr Ikegami and all our writers, consumers, not just accountants, will judge whether improvements are being made.
Healthcare performance is also about responsibility. Who do we blame when the service goes wrong? Legend has it that Chinese emperors used to pay their doctors only when they were well, since if the emperors were ill the doctors were clearly not doing their job properly. Many centuries later there is still an interest in paying doctors by results, provided these can be reliably identified. Again, this underlines the importance of measurement. As leading surgeon David Khayat passionately holds, it may also mean that a new ethics culture is called for, to help guide doctors in their changing and highly pressurised professional roles.
Malpractice in the medical profession is a cause of public alarm in several countries and consumers are becoming “impatient”, as Janne Graham, a patients’ spokesperson and witness, tells us. Also, the rise of biotechnology and genomics raises ethical questions that health professionals alone cannot answer. Elettra Ronchi and Anne Carblanc from the OECD warn that genetic coding and DNA information might have to be better protected by policymakers if public confidence in these potentially beneficial technologies is to be won. How can medical services cope with all these pressures and still achieve improvements? To judge by the candid contributions of five health ministers to our roundtable – from Canada, Finland, Mexico, New Zealand and the United States – policymakers are rising to the challenge. A difficult road awaits them, but it is clear that more evidence and record of experiences are needed to help them build policies that work. For, as fertility expert Kajsa Sundström describes in the case of Sweden, policies that do not take full account of the behaviour and desires of the people they are aimed at may simply fail.
Information is also crucial. As Tim Kelsey from the Dr Foster company explains, better information leads to more pressure for accountability and this in turn should lead to better health system performance. Education too is important, whether in improving professional training or health education for all, including children. Such action can start now, but the effects will be long-term. There is a risk that education will increase pressure on health services, as better informed patients become even more demanding. But education is also key to successful preventive care, and governments can do more to encourage lifestyle improvements that not only lengthen life expectancy, but can reduce some of the burden on healthcare systems. Yet even this is not so simple. Today’s consumerism pulls in the opposite direction, with modern problems, like obesity from too much junk food or lack of exercise, having to be overcome.
Finance will always be a tricky question. As the OECD’s Nicole Tapay reminds us, more work has to be done to find out how public and private insurance might work together to help strengthen our health systems. Getting the regulatory framework right is vital. Different rules can work against each other, making it hard to achieve a fully integrated health system, as Niek Klazinga from Amsterdam University explains in connection with the Dutch health model.
Most people in OECD countries enjoy good access to health services; yet, some do not. And for millions outside the OECD area, health is still a luxury item. All these challenges are compounded by uncertainties. Health services can be stretched in emergencies, and, as we have recently been painfully reminded, whole systems can be tested by biochemical and other types of terrorism. Such events may be few and may not affect overall long-term spending costs, but they raise management questions, about surveillance, responsiveness and confidence. We all want good value, but how do we put a price on human safety?
Fuelling uncertainty is the fact that health, especially in relation to infectious diseases, is a global public good. Some infectious diseases like TB are staging a comeback and new ones are emerging. Many of them migrate across borders. Solutions have to be cross-border, too. As Brett Parris from World Vision International argues, an OECD strategy for improving healthcare performance would be compromised (even ineffective) if it did not take worldwide performance into account. The World Health Organization’s work described by the director-general, Gro Harlem Brundtland, in our leader column should ensure that the global dimension plays a central role.
Many of the contributors to this spotlight on healthcare are participants at the high-level OECD conference in Ottawa on 5-7 November, Measuring Up: Improving Health Systems Performance in OECD Countries, hosted by the government of Canada. Measuring health performance is a vital part of the job ahead, but it is only the first step towards better healthcare. Investment in time and resources will be needed. It will be worth it, because our wealth does indeed depend on our health.
* This article was originally written as an introduction to a series of articles on healthcare, all of which can be found on http://www.oecdobserver.org/healthcare
©OECD Observer No 229, November 2001