Country Choice Final

CHAPTER 16

16.1 INTRODUCTION The World Health Organization (WHO) (2001) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. A society is known for where it stands globally in regard to the health and wealth of its people. It is also known for where it fits in regard to the rest of the world in other measures of significance. A brief review of selected global comparisons is provided in order to lay the foundation for the discussion of 11 countries presented in Chapters 4 – 14 .

16.2 DETERMINING A COUNTRY’S HEALTH STATUS As the learner begins assessing health outcomes of specific countries, it is important to consider how the country covers the cost of health. Table 16-1 presents the total health expenditures for selective high income countries. Also important is the information provided on population density. Population density is often reported along with other statistics when discussing healthcare accomplishments and challenges experienced by countries. Population density represents the number of people per square mile, or square kilometer (km) derived by dividing the total population per land area by square miles or square km. For example, Canada’s population is 33 million divided by its land area of 3,559,294 square miles yielding a population density of 9.27

people per square mile. It is important to note, however, that because some areas are more densely populated than others, population density is a raw, rather than absolute estimate.

Infant mortality is widely considered one of the most important indicators of a nation’s health status because it reflects such things as maternal health, quality of, and access to, medical care, socioeconomic conditions, and public health practices (MacDorman & Mathews, 2008). It is often one of the first considerations given when evaluating a country’s overall health outcomes.

Table 16-1 Total healthcare expenditure in 2007 for selective high income countries.

Country Percentage of GDP

United States 16.0

France 11.0

Germany 10.4

Canada 10.1

Italy 8.7

United Kingdom 8.4

Japan 8.1*

Data From: Gauthier-Villars, David. France Fights Universal Health Care’s High Cost . The Wall Street Journal, April 7, 2009. http://online.wsj.com/article/SB124958049241511735.html . OECD Health Data 2008. *2006 data reported for Japan

In a report on social determinants of health, Marmot (n.d.) indicates that:

In general, the poor suffer much higher child mortality than the better-off. For example, in India, Indonesia, the Philippines and Vietnam, the under-five mortality rate among the poorest quintile of the population is three times higher compared to the richest quintile. Rural populations usually have worse access to clean water and sanitation facilities, greater risk of malnutrition, and lack educational opportunities. Urban populations however, are plagued with major sanitation problems, overcrowded, unsanitary housing, polluted air, slum and shantytown settlements, that are prevalent throughout the developing world (p. 12).

Clearly health is predicated on so many complex factors that good health outcomes become difficult, if not impossible for many countries to achieve. Further, says Marmot:

Health is a universal human aspiration and a basic human need. The development of society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill-health. Health equity is central to this premise. Strengthening health equity—globally and within countries—means going beyond contemporary concentration on the immediate causes of diseases to the ‘causes of the causes’—the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age. The time for action is now, not just because better health makes economic sense, but because it is right and just (p. 174).

From a global perspective there is great system emphasis on funding acute care initiatives and supporting highly technological infrastructures that seek to cure problems. On the other hand, there is relatively little emphasis on maintaining health and preventing disease. Funding healthcare initiatives in developing and developed countries vary greatly. Decentralization, a term used to describe government control over fiscal and political healthcare decisions at the lowest levels, is often viewed as a positive way to improve service delivery, equity, and quality (WHO, 2008).

However, this is not always the case, as is evidenced by the United State’s federaly funded, state mandated Medicare and Medicaid programs and a current trend toward health reform globally.

16.3 GENERAL TRENDS, SIMILARITIES, AND DIFFERENCES Healthcare systems everywhere, whether they are centralized or decentralized, should be equitable, that is fair, just, and impartial in the treatment of those in need of services. Throughout the industrialized world, health care is universally government provided and controlled. Four examples of this are Canada, Italy, Japan, and the United Kingdom. Each has government provided, fully funded single payer systems that, with the exception of co-pays and or coinsurance, covers the care for all residents. Consequently, the playing field is leveled between the impoverished and the affluent.

A striking healthcare similarity globally is seen in how countries provide for individuals in need of behavioral/mental health care. The WHO has two programs geared toward achieving better outcomes in mental health care. These are the Mental Health Gap Action Program (mhGAP) and the Mental Health Policy and Service Guidance Package. Countries that utilize these tools are likely to improve their behavioral health and mental health outcomes.

The mhGAP Program aims to scale up services for mental, neurological, and substance use disorders for countries with low and middle incomes. This is a comprehensive program that includes the treatment of psychiatric and mental health problems. The intent is that, when adopted and implemented, tens of millions can be treated for depression, schizophrenia, and epilepsy, prevented from suicide and can begin to lead normal lives—even where resources are scarce (WHO, 2010, p.11). The combined Mental Health Policy and Service Guidance Package is a compilation of 14 user friendly modules with full instructions on how to use them. This package is designed to assist policymakers and planners to accomplish four things: 1) to develop policies and comprehensive strategies for improving the mental health of populations; 2) use existing resources to achieve the greatest possible benefits; 3) provide effective services to those in need, and 4) to assist with the reintegration of persons with mental disorders into all aspects of community life. It is believed that if this is accomplished, the individual’s overall quality of life will be improved (WHO, 2003, p. 1).

Although disease incidence and prevalence varies widely from nation to nation and coast to coast, there are also similarities among countries in that the top ten diseases plaguing countries are usually preventable. In addition, these diseases are costly to treat, recovery is generally slow, there are many years of life lost, and millions of dollars are lost in earned income and productivity (Life

Science, Intelligence, n.d.). The United States outranks other industrialized countries in potential years of life lost due to circulatory problems (773/100,000) and diabetes (99/100,000). Interestingly, for Cuba and the United States, the top three causes of death are identical (see Table 16-2 ). For many countries, industrialized and developing, similar patterns exist. When a person becomes ill in the industrialized world (developed countries), the responses by the more affluent among them might be to simply seek the assistance of a physician or visit the closest hospital, get the appropriate care needed to recover, then proceed with business as usual. For people in the developing world (non-industrialized countries), the situation is not so automatic or simple. Nor is it automatic for many in the industrialized world who are living in poverty, sometimes within the same geographic reach of the affluent, yet far removed from their radar screens.

Although the United States leads the industrialized world in pharmaceutical spending, and healthcare spending per capita, its health outcomes are anything but astounding. In 2006 the United States spent $843 per capita on pharmaceuticals, Canada spent $639, France $564, Germany $500, and all other industrialized countries spent well under $500. The United States’ per capita spending on health care was $6,714 as compared to Canada’s $3,678, France’s $3,449, and the United Kingdom’s $2,760 (OECD, 2008). Healthcare spending in the United States increased from $1.3 trillion in 2000 to $2.4 trillion in 2008. Projections suggest that by 2017, the cost of health care in the United States will reach $4.3 trillion and consume 20% of the GDP (National Coalition on Health Care, 2009). However, despite the disparity in healthcare spending, the United States has poorer outcomes. The World Health Organization’s ratings of healthcare performance among 191 member nations, published in 2000, ranked Canada 30th, and the United States 37th, and the overall health of Canadians 35th and Americans 72nd.

Table 16-2 Health indicators: a comparison between Cuba and the United States.

Indicator Cuba United States

Life Expectancy 77.6 77.8

Physicians per 10,000 population 62.7 26.3

Nurses per 10,000 population 78.9 79.5

Percent Births attended by a skilled health professional

99.9 99.0

Infant Mortality Rate 5.3 6.8

Maternal Mortality Rate 49.4 13.1

Percent of 1 year Immunization to DPT3

99 96

HIV Prevalence Among Adults

15+/100,000 population 52 508

Top Three Cases of Death Heart Disease Malignant Tumors CVA

Heart Disease Malignant Tumors CVA

Sources: Cuban Annual Health Indicators of Health. US, 2006. National Statistics Bureau, Havana

United States Statistics Yearbook, 2006. National Center for Health Statistics, Hyattsville, MD. WHOSIS

The United States leads the world in the number of persons receiving dialysis, total knee replacements, and Percutaneous Transluminal Coronary Angioplasty (PTCA). It also experiences the most deaths from respiratory diseases such as bronchitis, asthma, and emphysema; and it has

the highest incidence of adult obesity (defined as individuals with BMI >30) (OECD, 2008). Table 16-3 presents the international obesity comparisons for eight countries of which the United States is highest. Mexico, not reflected in the table, ranks second highest and the United Kingdom ranks third highest. Japan is among the lowest obesity ranked countries in the world at 3.2 which is equivalent with Korea, a country also not represented on the table.

Years of life lost, as calculated by the number of deaths multiplied by a standard life expectancy at the age at which death occurs, is also used for determining years of life lost due to disability. For example, the younger the individual at the time of death, the greater the number of life lost in years. This calculation is used sometimes to settle litigated financial settlements. In comparing the years of life lost due to communicable diseases as opposed to non-communicable diseases, the percentages of deaths are more than eight times higher for low income countries. Although the trend in some countries appears to be reversing to non-communicable diseases as the top ranked cause of death, worldwide infection still leads the world as the number one cause of death. One death in three is from an infectious or communicable disease, such as HIV/AIDS, and almost all the diseases and deaths occur in developing (non-industrialized) countries. Table 16-4 highlights years of life lost to communicable and non-communicable diseases.

Table 16-3 Percent of adult obesity by country (weighted averages).

Country Percent Ranking

United States 30.6 #1

United Kingdom 23.0 #3

Canada 14.3 #11

Germany 12.9 #14

Netherlands 10.0 #20

France 9.4 #23

Italy 8.5 #25

Japan 3.2 #28

Data from: OECD Health Data, 2005 Retrieved from: www.nationmaster.com/graph/hea_obe-health-obesity

People worldwide are dying from infections that have all but been eradicated in industrialized countries. They are also dying from highly treatable infections because some countries do not have access to appropriate antibiotics to treat those in need. For example, pneumonia slightly outranks diarrheal illnesses as a deadly killer of children under 5 years old, worldwide. In the words of Rudan and colleagues “it is the forgotten pandemic, killing more children than any other illness—more than AIDS, malaria, and measles combined—more than 2 million children die from pneumonia in developing countries each year, accounting for almost 1 in 5 deaths of children under five worldwide. Yet, little attention is paid to the disease” (Rudan, Tomaskovic, Boschi-Pinto, & Campbell, 2004, p. 895).

Table 16-4 Distribution of years of life lost by cause, 2004.

Data From: World Health Organization. World Health Statistics 2009, Table 2, “Cause-specific mortality and morbidity.” http://www.who.int/whosis/whostat/EN_WHS09_Full.pdf

In contrast, while many developing countries lack the necessary antibiotics to treat infections, health providers in the United States have for years overprescribed antibiotics to the extent that today, many infections have become resistant to antibiotic treatment. Topical triple antibiotics can also be purchased over the counter by anyone wishing to purchase them, including teens. Infectious and parasitic diseases remain the major killers of children in the developing world, partly as a result of the HIV/AIDS epidemic (WHO, 2003). Infectious diseases disproportionately affect children and consequently childhood death rates. A baby girl born in Sub-Saharan Africa faces a 22% risk of death before age 15. Whereas, in China the risk is less than 5%, and in industrialized countries the risk is much lower, just 1.1%. The vast majority of these deaths are preventable with the right interventions (UC Atlas of Global Inequality, 2000).

Once a disease exceeds epidemic levels and reaches pandemic proportions, affecting an exceptional number of the population like malaria has in many tropical countries, it is so widespread that it becomes almost impossible to control. Notably, health–illness trending patterns in Japan are shifting. Although still considerably lower than the United States and the rest of the western world, the prevalence of coronary disease is increasing in Japan. In fact, the prevalence of lipid risk factors in younger Japanese people is now similar to that in the U.S. population. There is also some evidence of a continuous increase in the frequency of diabetes in Japan (Kita, 2002). Although, India and China have made some progress in the declining numbers of child deaths by approximately 30 percent over a twelve year span, the cause-of-death pattern has remained fairly stable, with the exception of perinatal conditions whose proportions have notably increased (WHO, 2003).

Persons living in high mortality countries die of communicable diseases, while those in low-mortality countries die of non-communicable diseases (UC Atlas of Global Inequality, 2000) such as heart disease and stroke. Table 16-5 presents selected causes of death as percentages of all causes of death in high income countries for 2004. Table 16-6 lists ranked changes in death rate for diseases and injuries in developing countries for 2004 with baseline projections for 2030. It is predicted that, “if these projections are realized, lower respiratory infections and HIV will be the only infectious diseases remaining among the top ten causes of death two decades from now” (Nugent and Feigl, 2010 p.3).

Table 16-5 Selected causes of death as percentage of all causes of death in selective high income countries, 2004.

Note: The UK statistics includes only England and Wales

Source: Anderson, GF, Frogner, BK and Reinhardt, UE. Health spending in OECD countries in 2004: An update. Health Affairs. (2007, September/October26 (5) 1481 – 89. http://www.commonwealthfund.org/Publications/In-the-Literature/2008/Jul/Health-Spending-in-O ECD-Countries-in-2004--An-Update.aspx

Table 16-6 Ranked causes of mortality in developing countries in 2004 and 2030 baseline projections.

Source: (WHO, 2008a), In Nugent, RA and Feigl, AB. Where have all the donors gone? Scarce donor funding for non-communicable diseases. Working paper 228, November 2010. Retrived from: www.cdev.org/files/1424546_file_Nugent_Feigl_NCD_final.pdf .

Crude death rate is the number of deaths that occur in a particular population during a given period of time, such as from April through March. Crude death rates below ten per 1,000 persons in the population are considered low and over 20 per 1,000 are considered high (Rosenberg, n.d.). In July 2011, the crude death rate per 1,000 persons in the population worldwide was estimated to be 8.78. The U.S. fell slightly below, at 8.39 per 1,000 (CIA World Fact Book, 2011). Crude death rates below ten are considered low and over 20 per 1,000 are considered high (Rosenberg, n.d.). The July 2011 crude death rate was 17.23 per 1,000 persons in the population for South Africa, 16.03 for the Russian Federation, 11.49 for Sierra Leone, 8.57 for Ghana, and 6.38 for Brazil. In contrast, the crude death rate was 9.93 for Italy, 9.15 for Japan, 8.85 for France, and Canada 8.09

per 1,000 persons in the population (CIA World Fact Book, 2011). Typically, crude death rates in developing countries are unusually high (Rosenberg, n.d.).

Many developing countries, such as India and Ghana, are severely challenged by depressed economies and poor infrastructures, leaving them defenseless against such conditions as poor sanitation, cross contamination of crops from inadequate sewage systems, unstable electricity, contaminated drinking water, environmental noise, and a multiplicity of other problems threatening public health and decreasing their quality of life. While in developed countries, much focus is placed on protecting the ozone layer and cleaning up the environment by “going green,” recycling, finding new and cleaner natural sources of fuel and energy, and installing barriers along highways protecting residents in neighboring communities from disruptive traffic noise.

16.4 GLOBAL INEQUITIES IN HEALTH Global inequalities in health, within and among countries worldwide, send a serious message to consumers. Social determinants of health, defined by the WHO as “the social and economic conditions under which people live that determines their health” (p. 9) are major factors in health inequities. The conditions under which people are born, grow up, and work, and their cultural backgrounds, race, ethnicity, age, and gender, greatly influences their health-seeking behaviors. These things also determine how people define health/wellness and illness, and whether they are likely to self-treat or utilize the formal healthcare system when ill.

Another particular trend that results in a workforce disparity is candidly described by the WHO (2006), “health workers are migrating at unprecedented rates—increasingly from low-income countries with a low supply of health workers—to take up positions in the US and other affluent countries’ long-term care sectors, leaving in their wake workforce shortages and what some call a global ‘crisis in health.’ Abandoning positions in countries already experiencing major staffing shortages of especially physicians and nurses leaves a deleterious void in the home country.”

There is a major problem when documented evidence supports a widened gap in life expectancy and infant mortality among and within countries based on their wealth. Healthcare systems, irrespective of where they exist geographically, should be about the business of promoting health and preventing disease for all its residents. Some are better able to do this than others. The disparities seen in access to healthcare services, treatment options, life expectancy, infant mortality, and communicable diseases, vary among countries. Much can be learned if countries would embrace one another, drawing on unique strengths through interdisciplinary collaboration. Discussing strategies in this way might make a difference. The issues, trends, and influences of social determinants such as health literacy and illiteracy, living in poverty, culture, ethnicity/race

and even gender are critical challenges that 21st century health policymakers, administrators, and practitioners must be prepared to address.

Health research and development is essential in order for healthcare organizations to remain viable. However, there is underinvestment in health research relevant to the needs of low and middle income countries, with a mere 10% of the worldwide expenditure on health research and development devoted to the problems that affect 90% of the world population. This is referred to as the “10/90 Gap” (GlobalForumHealth, 2005).

SUMMARY There are a variety of differences among countries in the ability to finance and implement healthcare programs. Treatment priorities, availability of medicines, equipment and supplies, inequities in healthcare access and disparities are important considerations when determining overall health outcomes. Some countries are better able to address their health challenges than others. A careful review of the eight factors by country summarized in Table 16-7 , and the 11 healthcare systems discussed in Part II of this book should be helpful in assisting the learner to determine whether a country has true access.

Table 16-7 The Eight Factor Model for true access.