Based on the country you have selected (Canada),?analyze its health system in terms of cost, quality, and access to care. Discuss how the country you chose is different from the

CHAPTER 17

17.1 INTRODUCTION AND EVALUATION OF THE EIGHT FACTOR MODEL

This discussion brings us to the end of our book journey. It summarizes the importance of the information included in the book and offers concluding remarks about what one country might learn from another. It also explores future leadership considerations that might prove beneficial in moving healthcare delivery toward a brighter future, worldwide. The Eight Factor Model was introduced for the first time in Chapter 3 to familiarize the reader with all aspects of it. The learner is encouraged to review it in greater detail. This table highlights a few of the most striking observations made about the countries included in Chapters 4 – 14 of the book. The observations may be useful in evaluating the extent to which true access is being provided. Healthcare delivery activities, positive and negative, are important considerations in determining true access. For example, although France and Italy are considered to be among the best systems in the world and they are progressively moving in the direction of providing full health care to all its citizens, one might conclude that neither is providing true access . Health care in both countries is costly, there is no consistent plan to care for non-citizens, and Italy has regional disparities. Similarly, countries such as Canada, Ghana, and India are challenged by a greater demand for services than can be provided because of a loss of physicians and nurses to other countries with better compensation packages. Planning and execution of interventions vary widely among countries as does

funding for health care. Both affect the extent to which patients get their healthcare needs met even if they experience no difficulty accessing care.

Table 17-1 Eight Factor Model for true access.

17.2 LESSONS LEARNED In regard to what lessons can be learned from the information discussed throughout the book, much can be said about embracing change with a new mindset. It is apparent that most healthcare systems would benefit from better collaboration and planning about how to maximize their current workforces. They would also benefit from planning new and creative ways to balance the supply of health professionals according to the demand for services. Another consideration is that a strengthbased approach to administering health care might prove beneficial. The obvious response from a larger, more powerful country might be, what can we learn from a developing country? However, by closely examining the strengths of even a relatively poor country, much can be learned. Replicating the country’s successful practices will likely result in better outcomes despite the size or characteristics of the country.

France, a developed nation, is admired as a healthcare leader. Yet, it is looking to other countries for answers in reducing their healthcare costs. In considering the success of France’s health system, lessons might be learned from the less costly United Kingdom system that achieves good outcomes without the extraordinarily higher expenditures.

Interestingly, the United States and Cuba demonstrate the same top three causes of death. A closer examination of the reasons for this might be helpful. The value of international collaboration on healthcare issues could provide insightful information on preventing future illness, and significantly improving health outcomes. Government officials must be transparent about the issues. They must also keep an open mind, and willingly negotiate for practice innovations that first and foremost address the needs of the people. Initiatives must include due diligence toward reforming what is clearly in need of changing in current systems, while retaining the best of what a system has to offer. It is also essential that there be more closely scrutinized bottom lines. That is, the sustainability of government financing of health care can only be made possible if there are serious efforts made to achieve system efficiency and effectiveness.

Another lesson learned is the importance of healthcare systems placing more attention on balancing health promotion, disease prevention, and interventions. Maximizing efforts at boosting preventive measures to keep people healthy, active, and more fully functioning while introducing interventions as early as possible to prevent complications, is essential. The ability to replicate the Cuban model where physician–nurse primary care partnerships are strategically entrenched in communities among the population masses could prove beneficial in that it assists people to remain in their homes and out of the hospitals. Joint crossdisciplinary efforts at improving true access is consistent with a major Healthy People 2010 goal. Providing access to quality services and service equality is of paramount importance in achieving the goal of eliminating healthcare disparities.

17.3 IMPLICATIONS FOR THE 21ST CENTURY LEADER If healthcare delivery systems are to be transformed, it will require an entrepreneurial type leadership that is unapologetically refreshing, risk-taking, motivating, cutting edge, embracing of new ideas and strategies for accomplishing goals, and pro inter-collaboration. The 21st century leader working in health care could emphasize the following seven strategic elements:

• The importance of planning for a stabilized workforce reflecting adequate numbers of well-educated health professionals at every level needed requires some level of risk-taking. We need to ask, are we inviting people who think differently? Are we creating learning organizations in which people feel comfortable expressing their ideas although different from others’? Do we reward people for thinking differently?

• Planning for creating and maintaining a retention oriented environment that thrives for high patient and staff satisfaction. Do we promote a fair and equitable distribution of the workload? Do we promote transparency in the data that are reported? Is the mission of the organization clearly communicated at every level of the organization?

• The need to identify and eliminate unnecessary costs. We need to determine the redundancy in our practices and ask what are the essential services to provide quality outcomes? We also need to ask, what strategies do we have to evaluate our efficiency and effectiveness?

• Ways in which opportunities for continuing education and training can be expanded. We need to ask how we can utilize research to enhance the quality of care through evidence based practice.

• Improving strategies to maximize efforts in providing true access to care. In what way do we continuously assess progress toward the achievement of organizational goals?

• Opportunities to engage in collaborative decision-making. Are industrialized countries open to best practices of developing and vice versa?

• Striving for improved standards. Are our ways of thinking outdated? Or do we look for new ways to improve the delivery of health care?

Each of these elements is important for the effective leader who is focused on moving the healthcare organization well into the 21st century. In the words of Patton (2001), “good practices are only as good as the evidence that supports them and their definition and applicability typically evolves in time and space” (p. ii12).

SUMMARY There is a strong argument in support of needing future healthcare leaders with vision. These leaders must be prepared to change environments. They must also establish better ways to improve effectiveness in approaches to preventing, diagnosing, and treating diseases. With increasing diversity more attention must be given to how we engage patients in their treatment and care. The effects of an aging society and the chronicity of illness and disability make strategic planning a priority. Heightened consumer expectations and demands, including their increased interest in using complementary/alternative medicine (CAM) require that providers be more sensitive to patient needs. Escalation in healthcare costs and budgetary pressures creates new challenges for providing coordinated high quality care.

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

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