Emerging economies have the opportunity to rethink the provision of health services completely – and are doing so. Dare we learn from them?
Photo: Einar Nilsen
«We definitely study the organisation of health services in Northern Europe an thed USA,» Subramaniam Sathasivan told me. «We wish to learn – not least what we shouldn’t do.» Subramaniam is a dermatologist who was trained in Singapore, Wales and Ireland, and has been Minister of Health in Malaysia since 2013. He uttered this statement at a meeting organised by the World Economic Forum, where the topics included health services and health systems in emerging economies (1). These economies include countries such as South Africa, Turkey, Mexico, China, India, Indonesia and Malaysia, which are experiencing a powerful growth in their national economies, average incomes and life expectancies. This growth is accompanied by growing expectations in the population with regard to public and private institutions and services – for example health services. Subramaniam explained that Malaysia has a publicly funded health system that provides the population with good access to a network of public and private clinics at affordable prices. The challenge consists in fulfilling the rising expectations for higher quality, shorter waiting times and access to the latest treatment methods without exceeding budget spending and reducing accessibility.
These countries wish to reproduce the development seen in the Western world in order to obtain access to the same goods. With regard to health services, such an imitation is neither possible, nor desirable. They want to enjoy the same degree of medical progress, but can see that the way in which the Western countries have organised and funded their health services is not sustainable in the long run. It has become far too costly and there is little correspondence between the costs and key markers of health, such as life expectancy. The USA is now spending 18 % of its gross domestic product (GDP) on health services, or USD 8 000 per inhabitant, and has a life expectancy of a little less than 79 years. Singapore has a life expectancy of 82 years and is spending USD 2 500 per inhabitant, or 4.5 % of its GDP. Norway has a life expectancy nearly on a par with Singapore’s, is spending more than the USA in monetary terms per inhabitant, but only a little more than 9 % of its GDP. These figures can be estimated in various ways, but the main message is clear: even if economic growth continues in countries such as Mexico, Malaysia and China, they cannot possibly spend such amounts on health services as the USA and Norway do. An imitation of Western development is precluded not only by the monetary investments required – Nigeria will need 700 000 new doctors before 2030 in order to achieve the same GP density as an average OECD country. The costs of training alone – assuming it could be provided – would exceed current Nigerian health budgets by a factor of ten. If the training continues at the same pace as today, 300 years will be required to reach the current level of GP density in the OECD countries.
«Leapfrogging» means to speed up development by making use of new technology or procedures to bypass development stages that others have needed to go through. The classic example is the introduction of mobile telephones in remote areas of Africa. These areas obtained all the social and economic advantages of a modern telecommunications network without having to take the route of large investments in expensive infrastructure for landline telephones. The possibility to make such leaps in the health sector was discussed at the meeting I referred to above. Lagging behind in development can be turned into an advantage. One of the problems in our part of the world is that technologies, forms of cooperation and structures that were developed to meet the challenges of the past remain incorporated in the system even when the preconditions have changed and better methods have become available. The emerging economies can take a more unrestricted view of what is opportune, because they do not need to be concerned with prior investments and vested interests.
In contrast to the case of mobile telephones in Africa, there is no ideally organised health system that can simply be copied and implemented. The goal is therefore to make some really large and drastic frog leaps that bypass the solutions used by Western countries today and develop completely new alternatives that are adapted to the patients, technology and disease panoramas of the future – solutions that can reduce the cost of the services, thus making them accessible to a great many more people. And it is feasible! In some places in India, sophisticated services can now be provided at a fraction of the price of the same procedures in the Western world, with documentable and outstanding results. The main reason is untraditional and decentralised organisation of service provision, and not least other ways of making use of doctors and other health personnel (2). Others are experimenting with simplified training programmes and decentralised diagnostic technology. And not least, there are many who seek to ensure more efficient provision of health services to those who are chronically ill. The health services in many countries remain organised as though the encounters with patients are one-off episodes.
It is a major paradox that while medical research is at the cutting edge, the way in which we organise health services has changed very little. Subramaniam Sathasivan summarised it thus: «We don’t primarily need more clinical research, more equipment or more drugs. We need better logistics, different attitudes, more appropriate incentives and more involvement of patients and the population as a whole.» New ideas of how high-quality health services can be provided at a lower cost will naturally be relevant for us as well. It is threatening. The really big frog leap would be for us to take the chance of tearing free from ties to previous investments, ideologies and interests to liberate resources for the benefit of all those patients who fail to receive what they need – even in the richest country in the world.