Global Healthcare Systems: Comparing Models and Outcomes

Health Transitions in a Globalizing World

Martens, Pim. (2002). "Health Transitions in a Globalising World: Towards More Disease or Sustained Health?" Futures, Vol. 34, Issue 7, p. 635+.

In this journal study, Pim Martens argues that the concept of "transitions" is useful for addressing and defining the current and future health status of the world as directly related to the process of globalization. Martens begins with a discussion of the current factors that affect human health and then examines the health transitions evident throughout history. He then focuses on trends and developments in health and disease among various populations of the world, measuring these trends according to three suppositions about future ages: the age of emerging infectious diseases, the age of medical technology, and the age of sustained health (Martens, 2002, p. 635).

More specifically, Martens attempts to define global and regional dynamics that might influence health and disease trends. He concludes that managing health variations and transitions effectively in the future will require "a micro and macro approach" that takes into consideration the social, cultural, and behavioral determinants of health (Martens, 2002, p. 635).

Martens claims that socioeconomic change, public health initiatives, and technology have contributed to a positive shift in health and disease outcomes. To support this premise, he points out that average life expectancy has doubled across the globe and that infant and maternal mortality rates have sharply declined.

However, Martens also identifies large health disparities that exist around the world. He suggests that the "pattern of infectious diseases" is less stable and that a trend toward anti-microbial resistance is evident worldwide. He also notes that in certain poor countries and in Sub-Saharan Africa, diseases such as HIV/AIDS are severely reducing life expectancy (Martens, 2002, p. 635).

Martens further points out that although life expectancy is generally rising, fertility rates are declining and health inequalities still exist between poor and wealthy populations (Martens, 2002). He suggests that the future health of individuals will depend on the process of globalization and environmental influences (Martens, 2002).

Martens poses the question: "given the current and anticipated socio-economic and environmental trends, will sustainable healthy life be possible in the future?" (Martens, 2002, p. 635). He then enters into a lengthy discourse about the forces that affect health, including trends in developing countries where health gains are occurring thanks to knowledge transfer regarding vaccination and sanitation. Increased literacy, family spacing, and improved nutrition are also cited as reasons for improved health conditions in developing countries. In Western populations, Martens proposes that health changes are more directly related to social and environmental factors as well as technological medical interventions (Martens, 2002).

Martens examines trends in health status against a background of economic, social, and cultural forces. He notes that access to sufficient quantities of food and water is critical to good health, and observes that individuals living in urban areas or poor countries still struggle with water and sanitation issues (Martens, 2002). He also notes that more than a third of the world's population lives in areas where the water supply is scarce, due in part to large population growth (Martens, 2002). Such inadequacies often impact health negatively. Malnutrition is also identified as a global risk factor for disease and a growing problem in the developing world (Martens, 2002).

Martens also suggests that social factors including literacy and education impact health, and that globally there is a consistent trend whereby people with more education generally receive better healthcare (Martens, 2002).

With regard to economics, Martens claims that rapid economic growth and wealth have globally enhanced life expectancy, which he attributes to improved income levels generally associated with lower mortality (Martens, 2002). After a certain economic level has been attained, however, Martens notices a trend in which health is determined by other factors, including poverty, which is present even in the wealthiest societies.

Martens proposes a conceptual framework for defining healthcare trends, which he calls the "health transition," suggesting that health trends can be defined by transitional stages. The first stage is characterized by mortality associated with "epidemics, pestilence and famine," usually resulting from a lack of economic means to provide adequate healthcare services. In this environment, infectious diseases are most common, causing high mortality rates (Martens, 2002). The next stage he describes as the age of "receding pandemics," where a fall in mortality rates is evidenced and life expectancy climbs alongside increased economic growth (Martens, 2002). During this stage, social factors become important and the introduction of modern healthcare techniques and technology becomes common.

Martens then proposes that a trend follows toward chronic diseases, where infectious diseases are virtually eliminated and chronic disease surfaces (Martens, 2002). He suggests that this stage occurs at different times in different nations and is driven primarily by economic and social factors (Martens, 2002). Most developed countries — including European nations, North America, and parts of Asia — are now in this stage, characterized by low fertility rates and chronic rather than infectious disease patterns (Martens, 2002).

The Canadian vs. U.S. Healthcare System

Martens also suggests that most developing countries are still in a state dominated by infectious disease, where the fertility rate remains high, and that most poor countries will likely remain in this state unless economic conditions shift favorably to allow for better care, access to supplies, and health information.

In summary, Martens's account reveals that healthcare trends vary significantly between developing and developed countries, and that even within those broad categories, considerable variation exists. He presents the idea that many factors contribute to healthcare outcomes — not simply the healthcare system itself.

Armstrong, Hugh; Armstrong, Pat; & Fegan, P. (1998). "The Best Solution: Questions and Answers on the Canadian Health Care System." Washington Monthly, Vol. 30, Issue 6, p. 8.

In this article, the authors compare the United States healthcare system to the Canadian healthcare system in an attempt to determine which works better and what improvements can be made to both. The article begins by pointing out that most consumers favor a plan like that in Canada, because it provides universal coverage to all citizens. The Canadian plan is also praised for its practical appeal to physicians because it offers patients freedom of choice of doctors — far more appealing to most than life under the direction of an HMO (Armstrong et al., 1998, p. 8).

The authors point out that while most physicians in Canada initially opposed universal coverage out of concern that it was too socialistic — a concern also voiced among American physicians — universal coverage actually worked quite well in practice and offers a better professional life and more choices for both physicians and patients. The primary message of the article is that many aspects of the Canadian system work well and should be considered for adoption by American policymakers.

The authors then analyze healthcare costs. In the United States, healthcare is privatized. They examine healthcare costs from multiple perspectives, including looking at the cost of healthcare goods and services as a percentage of all goods and services exchanged — i.e., the Gross Domestic Product (Armstrong et al., 1998, p. 8). They note that Canada spends approximately 10% of its GDP on health, whereas the United States allocates approximately 14%. In addition, Canadians are noted to spend just over $2,000 per person — roughly half of what Americans spend per person on healthcare.

The authors suggest that the optimal way to view the Canadian system is by focusing on public costs and the share paid from the public purse. They argue that while the proportion of public money spent in Canada and the United States on healthcare is similar, Canadians end up ahead because they manage more services and a wider range of services for their dollar. Also noted is the fact that in the U.S., fewer than 30% of Americans are covered by government programs such as Medicare, Medicaid, and military care plans combined (Armstrong et al., 1998, p. 8).

The authors then look at healthcare spending from an individual perspective. Most Canadians pay almost nothing for health insurance — there are no deductibles, no user fees, no limits on contributions, no restrictions on services used, and no premiums for basic care coverage beyond taxes. This stands in stark contrast to the high deductibles, co-pays, and other fees associated with healthcare in the United States.

Key to this point is the idea that Canadian healthcare costs less because a large portion of it is publicly financed. The authors note that since Canada adopted its universal healthcare system, the Canada Health Act has implemented a policy of public administration that keeps healthcare spending lower and maintains the government's ability to provide healthcare services to the entire population. They argue that public administration is a more optimal approach for containing healthcare expenditures because administrative overhead remains low.

According to the report, U.S. hospitals maintain more detailed records of everything consumed by patients than Canadian hospitals do. The Canadian system suggests it would be wasteful to "go to the trouble of allocating the cost of insignificant items like toothpaste tubes to individual patients" (Armstrong et al., 1998, p. 8). Instead of itemizing items per patient, Canadian hospitals simply order supplies in bulk and distribute them as needed.

Canadian medical facilities keep costs down administratively by avoiding detailed per-patient accounts and eliminating the need to send itemized billing to private insurers (Armstrong et al., 1998). Canadian hospitals also do not maintain different billing standards for different private insurers and do not face the risk of unpaid bills, because payment is guaranteed. In the United States, there is constant concern that some bills may not be paid, covered, or approved, further complicating the healthcare issue (Armstrong et al., 1998).

In the United States, hospital administrative operations are very different. Administrators are required to keep extensive records of all patient consumption to facilitate billing to insurance companies and patients — partly in "anticipation of malpractice suits" (Armstrong et al., 1998, p. 8). As a result, administrative overhead in the United States is substantially higher.

A survey of one Canadian doctor also revealed that people were less likely to seek medical care for routine problems in Canada and more likely to visit a hospital only when the need was truly urgent.

Dynamics and Integrated Delivery Models

Another difference highlighted is that in Canada, no effort is allocated to separating eligible patients from ineligible ones, and no forms are required to determine whether patients qualify for insurance. Time is conserved rather than wasted, and "scrutiny to assess eligibility" is simply not an issue in Canada (Armstrong et al., 1998, p. 8).

Finally, the authors attempt to determine whether healthcare quality is better in Canada than in the United States. On measures of basic healthcare services, they find the Canadian system superior. In Canada, both infant mortality and maternal mortality rates are substantially lower — with maternal mortality approximately double in the United States compared with Canada (Armstrong et al., 1998). Canadians are also noted to have a longer life expectancy, and more Canadians live free from disability. Canadian patients also enjoy the freedom to select any physician or specialist they wish at any time.

The authors conclude that the Canadian system is superior to that of the United States, offering more flexibility, broader coverage, and better outcomes.

Pavarini, Peter A. & Shaffer, Anthony D. (1997). "Resolving Conflicting Laws and Policy in Integrated Delivery Systems Development." Journal of Law and Health, Vol. 12, Issue 1, pp. 85–120.

In this journal article, the dynamics of different healthcare systems are evaluated with particular regard to the problems healthcare providers face within the current system utilized in the United States. The authors' main emphasis is on the idea that the dynamics of many healthcare systems revolve around conflicting laws and management styles.

Shaffer and Pavarini begin by discussing the historical implications of healthcare services in the United States, noting that care has been delivered by providers largely organized as separate "economic and legal entities." They observe that hospitals, physicians, and other allied health professionals work in distinct roles rather than as an integrated whole, reducing the efficiency of the system (Pavarini & Shaffer, 1997, p. 85). This stands in contrast to healthcare delivery systems in other countries, which are generally funded wholly or in part by government entities — a key structural difference that distinguishes the U.S. system from those elsewhere.

The article notes that in light of ever-increasing healthcare costs, health systems face dynamic pressures that influence not only providers and patients but also purchasers, public organizations, and other stakeholders who demand re-evaluation of services to reduce costs and improve quality (Pavarini & Shaffer, 1997). While the U.S. is not alone in facing rapidly rising costs, other countries often meet these challenges through incentives and additional taxation — an approach largely opposed in the United States.

Several different systems are examined, including managed care systems where consumers must first consult with a primary physician — often referred to as a "gatekeeper" — to obtain approval for specialist care (Pavarini & Shaffer, 1997). The authors analyze the dynamics of several alternative structures that might improve the current U.S. system, aiming to show that different organizational models could improve patient satisfaction and relieve the administrative burden on independent physicians (Pavarini & Shaffer, 1997).

The authors note that massive changes are in order for the American healthcare system, due in part to uncontrollable and continuously rising costs. A notable trend is the movement away from hospital-centered systems, as well as a shift from fee-for-service reimbursement toward arrangements that allow the "sharing of financial risk" among providers (Pavarini & Shaffer, 1997, p. 89). This shift is partly a response to increasing trends in lawsuits and malpractice suits, which drive up healthcare costs in the United States.

Also noted is a trend toward hospitals and physicians forming networks that integrate delivery and insurance functions, allowing providers to sell their services directly to buyers (Pavarini & Shaffer, 1997).

The concept of managed competition theory is introduced — a healthcare delivery approach in which consumers are given enrollment options among various private health plans that "compete in the marketplace to provide the maximum value for subscribers' dollars" (Pavarini & Shaffer, 1997, p. 86).

Integrated healthcare delivery systems are also proposed, which would furnish patients with varying levels and types of healthcare services and coordinated case management (Pavarini & Shaffer, 1997). The authors propose that moving toward a more integrated industry in the United States would require affiliations and alliances between physicians and hospitals, providing consumers with a comprehensive package — including hospital, physician, and ancillary health services — that could offer "one-stop shopping" for all healthcare needs (Pavarini & Shaffer, 1997, p. 92).