Good health care is driven by a number of people, services, products, finances, policies and information working together and staying together even in times of crisis. Good health systems do not just treat people when they are ailing, they help to promote quality of life through healthy living and prevent the population from falling ill. We in Trinidad and Tobago (T&T) are quite fortunate to have free health care. What is the benefit of having good health care for all, and how does this affect our population?
A healthy population translates into an increase in the nation’s Gross Domestic Product (GDP) and this on its own can justify the investment in healthcare to treat an unhealthy society. According to the World Health Organization (WHO), statistics show that about 31 percent of our population in T&T are overweight and 21.41 percent of total deaths are due to Coronary Heart Disease. Investigating health care as an investment and measuring its sustainability to many may seem to be unethical, but may be an appropriate issue to address in commemorating World Health Day celebrated on Sunday 7th April.
The theme for World Health Day this year was ‘Universal Health Coverage’(UHC), which is a good place to start. When we think of UHC we ask the question, “What do you need to get to be and stay healthy?” To answer this question, we must consider the availability of well-trained health workers, safe and effective treatment, medication and health products as well as financing, policies to ensure the continued availability of these services and the accurate information about the whole system available to government so they can make the right decisions to have everything work the way it should. These are key elements that need to be present to ensure our investment in health care reaps the returns that we may project.
UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right. It clearly puts health within the context of a right rather than a privilege or luxury. This declaration calls for all governments, regardless of politics and conflicts, to work together toward global health. This declaration still stands today as an outline for international health goals and urges all governments under the WHO, like T&T, to strive to achieve it. However, as in most nations, health care and achieving UHC remains one of the most sensitive issue in politics. To understand health care in our context and to make sense of it, we must understand how it applies to T&T. Our country, like the National Health Service (NHS) of the United Kingdom (UK), actually follows the policies of the UHC. It is financed through taxes and national insurance contributions and is guided by the principle that health care is free to all. This system achieves the goal of the declaration as it upholds the right of everyone to adequate medical care and confers a level of protection from the threat of sickness. If we compare the UK’s NHS, that operates on UHC, to the United States (US), that runs on managed care, which is health insurance-based, we see that the UK’s health bill comparatively comes up to half that of the US. So, if its cheaper and everyone gets coverage, why are most nations not adopting this pattern of health care? If we take a closer look at the current state of the NHS, it is in fact under quite a strain. A recent report by the Organization for Economic Co-operation and Development (OECD), found that the current quality of care within the NHS is uneven and continues to struggle to keep pace with many other countries. This in fact, mirrors the problem in T&T as we have a similar system. Many analysts think it needs more funding, a policy that involve raising taxes, something most governments tend to avoid. It drives us to ask the burning question, is UHC really sustainable?
In some ways we are a product our own success. The fundamental issue is that people are living longer. The fact that the cost of our national insurance plan and the retirement age is going up is a telltale sign of this. The median life expectancy in T&T for males is 68.2 and females are 71.8 and climbing. One may think that is great, but there is a ceiling to how long a human can live biologically. Data puts this figure at 115 years old. Like everything in the mortal world, we have an expiration date.
We need to ask ourselves, “Can we continue to sustain a UHC or look for another alternative?” The answer should not be from a political perspective, but one based on real economics and centred around the population’s health.
To find our answer, we must look at the basic avenues of health care provision which can be viewed as two extremes. On one end, we already looked at UHC where the government funds health for everyone, and on the other end is a private system, where each person pays individually for the health care needed, either directly or through insurance (much like the US). There are pros and cons of each; UHC tends to be compassionate and treats everyone equally whether young or old; rich or poor. As mentioned above, like most large government institutions, it tends to be inefficient, very slow in adapting the change and lacks innovation. The private system, on the other hand, is run like a business in that it is efficient, high volume and revenue generating but in my opinion, can also be quite brutal.
With an ageing population, either extreme becomes less efficient. The truth is, a hybrid system which leverages the advantages of both, is probably the best option and the answer to our health care problem going into the future.
On looking more closely at the compassionate aspect of UHC the question might be asked: “Is it moral or ethical to think about cost when treating a patient?” If we say no; the more medical costs go up. There will be a threshold point that is reached as the cost of health care becomes more unaffordable, when cost will become more and more a question that is given priority in the mind of the health care provider during delivery of care. It will also come to the point where health care providers see the need to explain to patients how much things cost and why, and patients will need to start listening and stop equating price with quality. In fact, discussing cost may seem more ethical when we consider there are quite a number of areas where we waste health care resources on things that do not impact on health.
The final point may be the most difficult to achieve and this involves quality over quantity. If we believe that it is better to have lived a few years happily rather than decades in sadness, we may better understand this point. As a society we need to start prioritising quality of life over quantity. Does it make sense prolonging the life of a loved one if they are not actually able to live life? Many may have differing opinions on this topic and everyone is entitled to their own. No one is right or wrong, it is all based on what you believe. It is a topic that will never make much sense to any of us and a difficult position to be put in.
Therefore, it would make more sense to focus on health policy and creating a healthier society. This means that our cultural perceptions of life, death and disability need to change. More and more, patients need to be given adequate and accurate information regarding treatment options so they make informed decisions about extending their lives and if it is worth it to them. One should not be pressured into treatments that a health care provider may assume will benefit and ensure a patient’s survival, but will later affect his/her value as a person.
Taking all discussed thus far into consideration, can we still define health care as a right or luxury? If something is a right, but as a society we can no longer afford to pay for it, can it now be seen as a luxury? If we are looking at a sustainable healthcare system, maybe it would help to shift the focus from defining health care, to our readiness as a society to make the right choices with food, exercise and lifestyle. This way, our focus shifts from preventing the different medical issues and diseases as opposed to treating them.