Italy and Spain traditionally fall into the top five countries with the most effective health systems in the world. But these same countries are harder than others to suffer the coronavirus pandemic, like the United States – another country with a seemingly high level of medicine. Why did this happen and can ratings be trusted? About it writes the BBC.
In 2018, Bloomberg published rating of the effectiveness of health systems in the countries of the world. In this ranking, Russia took 53rd place, the United States – 54th. And among the leaders were Spain and Italy.
Moreover, in Spain there are already more than 200 thousand cases of Covid-19 and more than 20 thousand deaths, in Italy – 178 thousand infected and 23 thousand deaths. Things are worse only in the USA, where more than 850 thousand people were infected, more than 48 thousand died. Does this mean that the ratings are lying and that medicine in Russia is really better than American?
The simple answer to this question is: ratings do not lie. But it all depends on what indicators analysts look at when compiling their ratings. In addition, in a pandemic, even the most effective health care system may not perform well – and this is normal.
What are the ratings talking about?
In the case of the Bloomberg rating, analysts evaluated countries according to several parameters, primarily taking into account life expectancy and the availability of medicine.
The low position of the USA is explained by the fact that in this country the treatment will be very expensive – both in absolute terms and relative to the average income of citizens. And the expected life expectancy of Americans – approximately 79 years – is lower than in 25 other countries from the rating.
Other analysts are looking at equipping hospitals with equipment, the availability of medical personnel, the number of ventilators, and the number of beds in hospitals.
The disappointing news is that the numbers do not help to answer the question: will I receive effective medical care if my country is high in the ranking?
“Unfortunately, there is no single, 100% objective rating. Depending on what indicators you decide to rely on, you can expose your country in a wonderful light, ”says Aaron Carroll of Indiana University, a health systems research firm. – The United States, for example, has excellent survival rates for people with breast cancer. And if we take this as the main factor, we can lead the rating. But this figure is only one in a billion possible. ”
“Here’s the thing: in the case of high-income countries, it doesn’t matter how many beds, mechanical ventilation, or, say, how many nurses you have in your hospital. In such countries, as a rule, there is a sufficient level of equipment for hospitals, so there is no direct correlation between these things and the outcome of patient care. It all depends on how you use these resources, ”said Eric Schneider, MD, a public health research nongovernmental organization, Commonwealth Fund.
If there is no objective rating scale, how to determine where is better?
Before assessing the health systems of different countries, it is necessary to understand that these systems are everywhere arranged differently, depending on the role of the state in providing medical services to the population.
The USA is the only developed country in the world in which the private insurance model works, that is, the state does not guarantee its citizens free access to health services, and insurance is bought at their own expense or provided by the employer. The exception is elderly people over 65 and the poor, who may qualify for certain types of medical services as part of government programs. In other words, access to medical services directly depends on the money people have. Because of this, approximately 25% of Americans do not apply to see a doctor even in the event of a serious illness.
A completely different approach in Britain, where the health system is fully nationalized, and all residents can use NHS services. For citizens, this means that they – with rare exceptions – do not have to pay for medical services from their own pockets. In this case, we are talking about a simple visit to a doctor with influenza, and, for example, about the complex procedure of in vitro fertilization (IVF). True, in the second case, a woman (and not each, but only meeting certain criteria) receives a limited number of attempts, and in case of failure and if she wants to continue the process, she must turn to private clinics.
The Russian system is most similar to the so-called Bismarck model, which was invented and successfully used in Germany, as well as adapted, for example, in the Netherlands and Japan. This is a compulsory health insurance model.
In 2017, the non-governmental Commonwealth Fund from the United States published its rating of the effectiveness of health systems in eleven high-income countries (Russia is not among them). The United States took the last place in this ranking, and Britain – first.
“We are considering three aspects of the quality of health systems,” explains one of the authors of the rating, Eric Schneider. “The first is the structure (just the same mechanical ventilation, hospital beds, the number of professionals), the second is efficiency (how efficiently these resources are used to provide assistance), and the third is accessibility.”
What is the peculiarity of American medicine?
Schneider explains the low rating of the United States: despite the fact that the country takes one of the leading places in the world in terms of resources in the healthcare system, if people do not have access to medical care, all this is useless: “You can have all the mechanical ventilation of the world, but if the people who need them cannot use them, it’s better for no one. ”
In addition, in the fight against coronavirus, it is not enough to have a well-functioning healthcare system, the expert is sure. in a pandemic, other decision-making centres are involved, including political ones. But even if you do not focus on other aspects, the pandemic has largely demonstrated the disadvantages of the American model.
In the USA – and all experts interviewed by the BBC agree with this – high-tech medicine receives good funding, a lot of money is allocated for innovative research, including in the field of cancer, but primary medical care remains largely underfunded.
“In other words, we can take great care of people with serious illnesses in hospitals, but we are not very good at preventing and early diagnosing illnesses,” says Schneider. “Look at New York, where the system is overloaded right now.” People with Covid-19 need beds and mechanical ventilation. But those people who usually got access to high-tech help did not disappear. As a result, they lose access to equipment and die. According to our estimates, over the past month in the city, about three thousand people did not die. from coronavirus and due to him. ”
But in the West, an ambulance doesn’t come if the patient has symptoms of Covid-19?The former head of the British NHS does not recommend evaluating the health care system
Britain, which took first place in the Commonwealth Fund ranking, is probably not the best now, Eric Schneider admits. Firstly, several years have passed since the study, and secondly, experts often have to work with already outdated data if countries are slowly updating statistics.
The former head of the British NHS does not advise evaluating the healthcare system “through the prism of its ideology and views”
In Britain, the NHS – the National Health System – is often called a national treasure. Nevertheless, she is often criticized: for waiting in line at hospitals, for the refusal of ambulances to come to all calls, for refusing to use new expensive drugs, and a long wait for a doctor’s appointment.
Most difficult described former NHS director Chris Bourne: “People look at the healthcare system through the prism of their ideology and views when they try to find a solution to problems.”
This can be clearly demonstrated by the example of the work of an ambulance, which is arranged differently than, for example, in Russia. The British NHS recommends calling an ambulance only if someone’s life is in danger, or if a person has received a very serious injury.
Most often, we are talking about loss of consciousness, heart attack, stroke, unexplained seizures, chest pain, severe bleeding, severe allergic reactions, severe burns.
“If this is not a life-threatening situation, please consider other options before dialling 999 (an ambulance phone in the country),” the NHS asks. In most cases, the British dial another number – 111 – which they get advice on, or go to the hospital’s emergency department. This system, experts say, may not be ideal, but it allows ambulances to come to urgent calls – for example, cardiac arrest – within eight minutes.
With the advent of coronavirus in Britain, people began to call an ambulance more often. In addition, increased time for sanitizing machines after transporting patients with suspected Covid-19. This led to the fact that in March to the patients of the second category – that is, those whose life is in danger, but this is not about cardiac arrest and breathing – the ambulances travelled one hour, one minute and 22 seconds. Prior to this, the “anti-record” was recorded in December last year – then the ambulance could go 26 minutes, 42 seconds.
In Russia, the latest data on the reasons for calling the ambulance was published by the media in 2019. Then it was argued that the main cause of the call was “sudden illnesses and conditions”, followed by injury and poisoning in second place in frequency. At the same time, journalists did not explain what exactly falls into the first category.
An ambulance is the last resort in a pandemic. It should be triggered when you have truly life-threatening symptoms, such as an acute shortage of air. But this happens in a minority of patients with Covid-19, and most are much better off staying at home, ”said Julio Frank, MD.
The British system is not perfect, but effective for most people, says former NHS CEO Chris Bourne. Problems in such a system often arise in the field of innovative research and the use of expensive new drugs.
Imagine that the experts created a new innovative, but expensive medicine that prolongs the patient’s life for a couple of weeks. In the UK-based system, the NHS must evaluate this drug in terms of cost-effectiveness before it is available to all Britons. From this point of view, the American system, in which individual clinics can make independent decisions, will seem more effective. But – still expensive.
So why is the West coping poorly with the pandemic?
Julio Frank, MD, who used to be the former Minister of Health of Mexico and also worked for the World Health Organization, in 2000 became one of the compilers of the world’s most widely ranked health systems performance rating.
“In fact, it was a rating of countries in which people could count on a long life while maintaining their health. And Spain already showed good results. But, like all the ratings that appeared after, ours talked about the functioning of systems in ordinary times, and not in a pandemic, ”explains Frank.
He does not believe in the assertion that Western countries are not coping well with the pandemic, drawing attention to the experience of Germany, Norway and Denmark, which largely control the situation. Other countries have made mistakes in the fight against coronavirus, which, however, do not characterize their health care system, he said.
“In the US and some other countries, politicians initially argued with experts and scholars. They tried to downplay the threat. You know, populist leaders don’t really like to tell people bad news. This led to the fact that we lost valuable time, especially with regard to testing. I’m sure that the key US problem that led to the current situation is the lack of mass and effective testing. ”
Spain and Italy no luck?
What then is the mistake of Spain and Italy? Julio Frank is sure that the whole thing is not a mistake, but that a very large part of the population of these countries is elderly people, who, as you already know, are at high risk.
Spain and Italy could simply be unlucky, experts say: coronavirus initially spread among older people.
Eric Schneider, MD, agrees with him: “Do not underestimate the role of circumstances. Italy and Spain were not lucky: the virus originally spread among older people who returned from a vacation spent in China. And among older people, mortality from Covid-19 is very high. As a result, it turns out that the matter is not in the amount of mechanical ventilation, but in the way, the virus enters the country. ”
Aaron Carroll from Indiana University adds: as soon as the virus begins to spread, no matter how good your health care system is in your country. “A pandemic is prevented, not in hospitals, but at the primary care stage. If a country has underfunded this sector, such as in the USA, a pandemic begins to spread. The problem is that we are talking about a virus, and we do not have a cure for the virus. Even if we get tons of ventilators, this does not mean that people will live. All we can do is provide symptomatic treatment and hope that people themselves get better. ”
All experts agree that those countries that at the initial stages were able to provide a sufficient number of reliable test systems with a low probability of error, as well as deploy large-scale testing of people, are doing fine with the coronavirus.
“There are few tests in the US,” Carroll states. “If we tested more, the total number of infected would probably be much higher, which, incidentally, would proportionally reduce the mortality rate.”
Another important aspect of this problem is the need to limit people’s freedom, which is much easier to do in countries with authoritarian regimes, for example, in China. Some believe that the more power is in power, the easier it is for a country to cope with a pandemic. Julio Frank fundamentally disagrees with this: he points to the experience of South Korea and Germany – countries that were able to take the epidemic under control without violating civil liberties.
“As you know, my freedom ends where yours begins,” Frank says. – If I’m irresponsible, I don’t use protective equipment, walk the streets and meet other people, I put them at risk. That is why these norms are compatible with the rights and freedoms of democratic countries. But what really poses a danger to both democracies and health care is populism. Populists do not invest in science, and science is generally the only way to overcome the crisis. ”