Universal healthcare system equation

It is ?no news that a simple person in contemporary times has much more comfort than a king 300 years ago. Nobody had water treatment back then, meat had to be consumed promptly, food poisoning and virus infectious not rarely were responsible for many deaths, access to books were a privilege to courts and royal-related subjects, crossing an ocean was a three-month-long trip, there was virtually no health-related treatments, and technology relied mainly on rudimentary mechanical solutions. Life expectancy seldom reached 40 years on average.

Water treatment stations made water drinkable, sanitary dejects treatment through ducts and stations can deliver clean and near-drinkable water, foods can be safely stored in refrigerators or freezers, general food can be put under nitrogen gas and reach shelf life of months, cruising an ocean is way less riskier and can be done in less than 12 hours on an airplane, electronic and computing technology allow everyone to access books from virtually any place around the globe, ?languages can be learned with apps on free platforms, medical technology progresses offer better medicines and less invasive surgeries.

The result: people currently live 30-40 years more on average, if compared to than that époque. Naturally, more and more people will seek recreational habits to fulfill gained “extra time”. We have much fewer wars than in the past, we have many more comforts as well. What could, at first glance, be a fairy tale, quickly become a major challenge for governments, under two lenses: social security and healthcare systems. This article aims to explore the latter.

The courage to propose a universal healthcare system must be present and the will to sustain its complexity must also be reinforced. It means that every single citizen (universality) can access a vast and well capillarized infrastructure, capable of delivering healthcare services to virtually all cities nationwide, uninterruptedly.

Not only that, but the system must also provide integral care, meaning that it will actively over watch citizens from prevention, supplementary lab exams and imaging, clinical and surgical treatments, pharmaceutical assistance (medicines), up to rehabilitation. This is the concept of integrality.

This ideal falls into point C, shown below, which seems to be a high-hanging fruit. Brazil took this step, and afterwards we will understand how it made it possible.

The challenge is not a Brazilian exclusivity, it also belongs to all healthcare systems (HCS) scattered throughout the world, because this point does not belong to the reserve of possible curve, shown as a blue curve below:

The reserve of possible implies that there is a mandatory trade off every single HCS must face. One must walk only on top of the dark blue curve, due to the limitations of funding in healthcare. There are no other options left.

Either it takes the route near point A, which represents most of American-style healthcare management organizations (HMOs), mostly private, where a small part of population can have access to almost all brand new and recently launched technologies, promptly. This model has specifically a proclivity, on the long-term, to make overall health procedures more expensive, due to the entry of middlemen and the development of redundancies. An actual example of this spoiling effect is the reason why many Americans come to Brazil to perform annual checkups at much lower costs, receiving world-class or state-of-the-art caregiving by local private institutions.

Or, a country can head towards point B, which represents most of European models in place, where a basic package of services is offered to the entire population, and even if a person is willing to pay for extra services, there is no available personnel or infrastructure to provide the required services. Therefore, there is a delta (timewise) for technologies to hit the tarmac. As a result, countries can purchase medicines and medical technology at a much lower price than in United States.

A real example of the latter happened to a CEO to whom I worked with, whose mother fell and broke her femur, she. She lived in France. The surgery was performed quickly and correctly, but there was no physiotherapy for promoting her to leave the bed early and stimulate her to walk as soon as possible. Subsequently, and unfortunately, she developed pneumonia, a common complication for patients who stay in hospital bed after this sort of procedure and ended up passing away. The CEO had all the financial means to pay for how many physiotherapists he wished, but there was no one available.

Thus, how did Brazil make it? Actually, it is not as flattering as it might appear at first glance. What we managed to achieve is to provide a HCS capable of delivering point D, shown in figure 3 below, a solution orbiting the middle between the two afore mentioned “frameworks”. Let us appraise the chart.

There is a considerable gap between points C - HCS premises - and D – the actual performance of HCS. Evidently, this distance is non-negligible, and we can “double-click” on that for the sake of better understanding.

The average waiting line for a simple elective surgery of knee or hip replacement, or cholecystectomy can easily reach up to 3 years. But again, how universal HCS can be sold for general public beyond what it really is capable of delivering?

Before jumping head-first on to this analysis, let me recall that there are 5 basic steps for healthcare to fulfill individual needs. I would call them the five “A”s, or simply put, 5As. It applies both for private and public HCS.

Firstly, the patient must gain access to HCS, which is the first potential barrier, called accessibility. Rural zones, Amazon region, and deep countryside in a continental country can pose hurdles to accessibility. The second one is how easily a patient navigates the system, what are the expected timelines for surgeries, offer of laboratory and imaging exams, what is the capability of physicians to recognize symptoms as a specific disease and therefore, prescribing early the right treatment. This is the second “A”, which is awareness. This also entails how well the system has awareness of its own strengths and limitations, and as such, it can improve or perfect how it works.

The following is the affordability performance, id est, the capability of HCS purchasing and negotiating price points for every single technology. Some HMOs and governments prefer to centralize purchase to increase negotiation “pull force”, others, prefer to leave this accountability to the healthcare provider (decentralized purchase), so the logistics stay simpler. The fourth “A” is availability, this ultimately means that a service provider can assure a product or a service whenever it is indicated. And finally, the one which relies mostly on healthcare professionals (HCP) and patients, is the adherence to treatment. Most non-transmissible chronic diseases (NTCDs), like systemic hypertension or type 2 diabetes mellitus have an adherence as poor as 50%. Since the diseases are asymptomatic or silent, it often implies that for every year, patients will only use 6 full months of treatment.

Well, that said, now let us jump into the analysis of that gap between point C and point D, as alluded to in figure 3. Primary care and specialized care are not capable of keeping up with the growing demand, so proactive early diagnostic and treatment is not often possible. Emergency is another well-known bottleneck, and not rarely is the only citizens′ point of touch with HCS. Hence, many patients end up with no accessibility to navigate HCS whatsoever and might die without proper care. Let us appraise what happens on the chart:

Blue and red arrows symbolize the amount of people, or population percentage, who stay in each level of the chart. Left to right flow represents the natural history of diseases, or their progression. Patients who indeed gain access to HCS (blue arrow) are treated according to their needs and might follow two pathways. One, health condition improvement, and they get back to the lefthand part of the chart (the gray loop), or their disease can progress, despite being rightly treated, and eventually die.

The red arrow represents patients who are covered by universal HCS in theory, but do not reach officially HCS. Down the stream they can encounter two main routes: being absorbed by HCS at a certain point where they face open symptoms or clinical decompensation, requiring high complexity treatments, or continue to permeate the universe outside HCS, being offered services and support at a late and advanced stage of disease, which means higher mortality rates. ?

But why do they stay outside HCS? First reason, HCS only recognizes, paradoxically, a patient almost always when a person is ill. Secondly, public structures are under dimensioned for the growing demand. Third, a patient who is eventually ignored by HCS brings no cost to the system. Lastly, funding for HCS requires constant increase for capturing patients at an early stage.

Since technology in healthcare evolves quicker nowadays, with progressively higher aggregated value, it is natural that discussion of how far we can go, what we can and what we cannot provide to patients, as a society, is a hard call to make. Any decision which deals with morals and bioethics is harsh. No public man is willing to face it frontally, mainly because the topic might be transformed into a minefield.

Finally, economics plays a major role in how good HCS may become. Health-related technologies should focus on bringing back individual productivity. This is a major topic to be addressed and inquired by governments.

Let us assess the chart below, with the evolution of governmental health expenditures as a share of gross domestic product (GDP):

?United States has the largest expenditure in healthcare as percentage of GDP in the globe, although they were not able to lessen gross population mortality. Meanwhile, European countries spend nearly 12% of their GDP on HCS providing balanced services to population, with scarce limitations.

Nevertheless, both frameworks require increasing resources to fund innovation capture and federal listing.

In opposition, Brazil has not seen significant changes in governmental healthcare expenditures, and if we factor in inflation, there is an ongoing and clear erosion of purchase power of universal HCS, which results in obsolescence of its infrastructure, more lines for non-urgent procedures, gaps in pharmaceutical assistance and special surgical materials, and finally, even more people walking their lives witnessing natural history of diseases, outside the constitutional premises of HCS.

As a conclusion, it appears that the only answer to this economic and moral question is to turn back to patients (or societies) and inquire them to what extent or to what degree they want to co-participate or co-finance their own treatments. Aside from that, what we will endure is the galloping gap increase between what technology advances bring and what actually governments can deliver.