Health Care Systems in Developing Countries in Asia

Christian Aspalter, Kenny Teguh Pribadi, Robin Gauld

• Publisher: Taylor & Francis
• Year: 2017
• Print ISBN: 9781472483416
• eBook ISBN: 9781317123125
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

For the last two decades, major Asian economies have successfully kept their economic growth momentum going. Now, as these economies are entering a new phase of economic growth, more attention is being paid to their respective states of social development, especially the provision and the expansion of social security and, in particular, health care. Academic study of the development of health care in developing countries has been for the most part neglected by the literature, and in-depth country case studies that are directly comparable on a one-to-one basis have not yet been conducted in a systematic manner. This book volume also proposes a new stance on health policy and the health care policy paradigm, one that focuses on "saving lives" from premature death, as well as illness, accidents, misery and poverty, based on the normative theory of developmental social policy (DSP).

This groundbreaking book will therefore serve as a valuable reference volume for health policy, social policy and public policy experts, social development experts, health and development economists, health sociologists, social workers, government administrators as well as other medical and health professionals and academics.

Part I

Introduction

1 Health care systems in developing countries in Asia

An introduction

Robin Gauld and Kenny Teguh Pribadi

“Health care systems” have become a topic of growing importance over the past couple of decades, especially so since the 2000 World Health Organization report (WHO, 2000). This report focused policy makers around the globe on different health care system functions and, particularly, on health care system performance for the fact that it ranked each member country. While there was no shortage of debate around how the rankings were done, and whether they were valid, the WHO report did bring attention to questions such as how equitable and efficient health care systems were and to the quality and accessibility of care delivered (Zelman et al., 2003; OECD, 2004; Ten Asbroek et al., 2004; Arah et al., 2006; Gauld et al., 2011). Since then, an international consensus has been building around what health care systems should aim for in terms of policy, structures and outcomes. This has been driven by not just the WHO but also other international agencies focused on health care, including the Organisation for Economic Co-operation and Development (OECD), think tanks, and a growing health care systems research community (OECD, 2004; Gauld, 2009; Leatherman et al., 2010).

Why the interest in health care systems?

The interest in health care systems is for a number of reasons, which are outlined in more detail in the sections that follow in this chapter and through subsequent chapters in this book.

Health care systems affect multiple players

First, and in brief, health care systems affect multiple players both within and between countries. Individual practitioners, such as primary care physicians working in solo practice and their individual patients, are inevitably a part of a broader system of care. The patient with a condition that the solo primary medical practitioner is unable to diagnose and treat will be referred on to a provider with a higher level of training, qualification and specialization. That provider may then require additional input from others, such as those with specific technology required to diagnose and to deliver effective treatment. Of course, prescribing pharmaceuticals is central to most patient consultations, and the drugs themselves are often dispensed by independent pharmacists to ensure there is a separation between prescribing and dispensing. Where such separation does not exist (as is the case in some Asian countries), this provides a potential incentive for the prescribing doctor to indicate medicines that generate a higher personal profit; it can also mean that patients do not necessarily obtain the expert advice and second opinion often provided by pharmacists. Many patients require hospitalization, either through referral from a primary care physician or due to an accident or emergency that requires treatment or ongoing observation. At any of these points, information on the patient is critical including medical history, current treatment regime and any test or other diagnostic results. For this reason alone, information systems are a fundamental foundation for health care systems.

This brief description implies complexity but also the necessity for organization and oversight. Those providing care demand regulation and training, there is a need to ensure that providers understand one another’s roles within the health care system, and patients need to know that the care provided is safe. Whoever is paying for care, whether it is the government, insurers or patients directly, the prices need to be fair and reasonable. Such challenges of regulation and organization of care are persistently at the forefront of the policy agenda in the high-income world. They are particularly prominent in each of the countries covered in this book, where the health care systems are, by nature, developing. They are exacerbated by the fact that each of the countries has particular geographic, infrastructural and socioeconomic challenges that do not necessarily figure to such a degree in many of the world’s high-income countries.

Numerous financing questions surround health care systems

A second reason for the growth in attention to health care systems is the cost of health care delivery and methods of funding. Globally, and in any chosen country, health care costs are a significant proportion of public and private expenditure. High-income countries, such as the OECD members, are naturally in a more advantageous position in terms of capacity to invest in health care and have a longer history of active investment. Indeed, the OECD average total expenditure on health care for 2013 was 8.9 percent of gross domestic product (GDP), and this was heavily weighted in favor of public expenditure (OECD, 2015). Only two countries, Chile and the United States, had less than 50 percent of expenditure from public sources. Turkey, at 5.1 percent, had the lowest GDP expenditure, while the United States, an international outlier, spent an extraordinary 16.4 percent of GDP on health, meaning this could be perceived as either a driver of its economy – with many employed in health care – or a potential cost.

In contrast with the OECD countries, the percentage of GDP attributed to health in the countries in this book is considerably less. At 5.1 percent, China compares with Turkey at the bottom end of the OECD ladder, while the remaining countries are 4 percent or below. At around 77 percent, Thailand is the only country in this book with a public percentage of total expenditure that is nearer the 2013 OECD average of 72.7 (OECD, 2015); three countries, China, Malaysia and Kazakhstan, sit around the 55 percent level, while in Indonesia and India only around a third of expenditure is public. With a global consensus today focused on universal health care coverage, the high proportions of private expenditure in these countries means the personal requirement to pay for health care can, for many, be prohibitive while also creating a significant development policy challenge (WHO, 2012b). The result is considerable suffering as care needs go unmet but also as individuals and families contribute substantially to meeting direct costs. As noted in Chapter 2, such costs and their impacts can be alleviated with a concerted and focused policy commitment to saving lives.

Global expenditure is placed in stark relief when distribution is considered. The residents of the 34 OECD countries receive 84 percent of global health care spending yet comprise only 18 percent of the world’s population. Average OECD expenditure per capita on health was USD4380 in 2012 in contrast with a global average of USD948 (WHO, 2012a). None of the countries featured in this book is an OECD member, and all fall well below the global average, including the world’s two largest populations: China receives less than half this global average per capita; and India around 15 percent of the average. Indonesia, the world’s fourth-most populous nation, sits at just over 10 percent of this average. Of course, these lower levels of expenditure need to be considered in the context of overall lower expenditure in the economy, including considerably lower wages, which are a substantial contributor to health care costs. However, many costs in developing countries are set in a global context, such as for pharmaceuticals, devices and consumables. The international mobility of health care professionals, and pull of much higher incomes and better quality of life in developed countries, poses a particular problem for workforce development and sustainability (Wismar et al., 2011; Zubaran, 2011; Nair and Webster, 2012). More broadly, the global context creates significant challenges for developing countries as they seek to extend health care, improve their systems and services, and provide the best available medicines and technology. This context has very real financial implications for domestic policy makers.

Patient behavior and expectations

A third reason is the growth of interest in how patients behave and what they expect from health care providers and systems. Less than a generation ago, medical and health care were professionally defined and driven, with decisions around patient needs and treatment protocols the result of a one-way process. This involved medical professionals providing a diagnosis based on the patient’s history and the clinician’s scientific knowledge and expertise. Diagnosis, within a biomedical paradigm, was focused on the specific condition that the patient presented with. Treatment plans were based on diagnosis and dictated to patients, usually involving prescription medicines. Indeed, medical care continues today in much of the world to be dominated by this approach (Freidson, 2001; Reiser and Banner, 2003).

However, the biomedical model of care has been in transition as a result of various factors. Principally, the need to change patient and community behaviors and to respond to calls for more involvement of patients and the public in health care planning, service design and delivery (Wait and Nolte, 2006; Hogg, 2007; Thompson, 2007). The rise of chronic diseases has played a key role in this as the world’s populations move from communicable to noncommunicable disease as the major health care threats (Quam et al., 2006). More and more, health care providers and communities are struggling with the burden of conditions such as diabetes, heart disease, respiratory conditions and diseases generally associated with “lifestyle” (Horton, 2005). These pose considerable economic and social costs as well as placing pressure on health care systems to the point that policy makers in many countries and internationally suggest that the situation is “unsustainable.”

The developing world is not immune from the rise in chronic diseases and its impact, as noted in several of the chapters in this book and elsewhere (Beaeglehole and Yach, 2003; WHO, 2005). What has been important in many higher-income countries is the response. This has been to focus on population (or public) health rather than to build more hospitals and health care facilities (although in the developing world, a major challenge is providing even an adequate level of basic services). The aim of population health is to better understand what drives behaviors and determinants of health, and work to change these, such as focusing on reducing smoking and improving nutrition and exercise, but also on developing better housing and other social services with the potential to affect health status. In turn, this has demanded that health care professionals consider more than just the specific condition a patient presents with, in order to address the health risks and determinants that the population faces. This requires that health care professionals work more closely with others in the health care system, especially those in health promotion and education, as well as those working in other health-influencing sectors (Hill et al., 2007).

Today, patient and public involvement in health care is a particularly strong theme in policy and service delivery (Gauld, 2009). The Internet has driven an information-demanding and savvy public, who seek health care having already searched and self-diagnosed their alleged conditions and how they should be treated. This has inevitably changed the doctor-patient relationship, putting patients in a stronger and more vocal position (Murray et al., 2003; Gauld and Williams, 2009). It has also led to patients demanding more involvement in decisions about their care. At the same time, professionals and researchers have spearheaded a movement toward care that is more “patient-centered” (Luxford et al., 2011). This means that services should be designed around and focused on the patient rather than the professional or provider organization. Patients may prefer certain services to be delivered by a nurse rather than a doctor or in a community rather than hospital setting. They may also want services to be connected up, with all providers working collaboratively rather than for the specific part of the system (e.g., a hospital specialty or primary care practice) they happen to work in. This is especially important in the context of chronic disease management, where patients have an ongoing relationship with a number of different professionals at different levels within the health care system. Ideally, they should have one lead provider (perhaps a nurse or a primary care doctor) who helps them manage their condition based on an agreed plan and coordinate interactions with other professionals in the system. This, of course, requires that professionals work together as an interprofessional and interrorganizational team with the patient (and perhaps the family), an integral member of this, and with close links to other community services. Patients, for their part, can be extremely effective when there is a commitment to “codesigning” services with them, in turn, improving patient compliance with treatment plans (Bate and Robert, 2006).

Patient safety and quality of care concerns have also propelled a focus on system improvement. Studies in high-income countries persistently show a percentage of patients are unintentionally harmed in the process of care (Wilson et al., 1995; Vincent et al., 2001; Davis et al., 2002; Landrigan et al., 2010). Many are permanently disabled or even die as a result. While an individual professional may be behind a mistake in patient care, such as wrong-site surgery or a medication error, usually the “system” is ultimately at fault (Institute of Medicine, 2000). This is because checks in the system were not in place to ensure that such errors could not occur. This has stimulated much work around patient safety and related system improvement, with initiatives such as the surgical checklist and various other suggestions known to improve safety (Haynes et al., 2009; Shekelle et al., 2013). It has also brought attention to issues such as how services are organized and regulated to ensure that each patient receives the same standard and level of care regardless of where and who they are treated by. Central to this is “clinical governance and leadership,” meaning that health professionals themselves are given responsibility for ensuring systems are clinically safe and of high quality (Scally and Donaldson, 1998; Gauld, 2014). Getting such policies and practices in place in the high-income world has proven challenging (Hogan et al., 2007; Gauld and Horsburgh, 2014); for the developing countries such as those in this book, there is a lack of even basic data around patient harms or such a shortage of health professionals that they simply do not have the time to get involved in system improvement efforts.

There has been growing international interest in involving the public in health care governance. While there are various methods for this, from open meetings and consultation sessions through to publicly elected board members, this movement has the potential for bringing a wider public voice into health care planning. Many public involvement projects have been implemented in developing countries, again with an aim of improving trust in and engagement with services but, as with such initiatives more broadly in the high-income world, tend to be fraught with difficulties of how to get the public to take an interest in governance questions and questions around whether such involvement makes a difference (Florin and Dixon, 2004; Laugesen and Gauld, 2012).

The need to reorient health care systems

A final reason for the interest in health care systems is the need to shift the foundations of care and focus of the system toward being a contributor to development and productivity. Health care systems are pivotal to development, especially where there is a commitment, as there is internationally, to the goals of the United Nations. These include the Millennium Development Goals and, as agreed to in 2015, the succeeding 2030 Agenda for Sustainable Development (UN, 2015). Health care systems have the capacity to reduce the diseases that reduce life expectancy, to contribute to reducing infant and maternal mortality and to deliver on immunization and other global goals (Figueras and McKee, 2012). Robust health systems also are a key contributor to delivery on many of the UN’s 17 Sustainable Development Goals (see Box 1.1). In practical terms, this means policy and investment in systems should be focused on primary health care, which multiple studies and policy reports indicate can deliver on goals of access to care, of equity, and of improving health, well-being and health ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• List of contributors
• Part I Introduction
• Part II Theory
• Part III Country case studies
• Part IV Conclusion
• Index