Blog 10: Uganda Health/Disease

Emily Crigger

                Uganda has one of the worst healthcare records in the world. Out of 191 nations they are ranked 186. From their life expectancy all the way down to their facilities they are at the bottom of the pile. The African Medical and Research Foundation (Amref), is trying so hard to change the life of the Uganda people.

                Healthcare is so incredibly poor in Uganda for several reasons, one being the lack of education that the Uganda people have. Many of the people in Uganda do not go to school but those of which whom do go to school are lucky, but the overall education system in Uganda is poor. In addition the random drug distribution, lack of trained medical staff and equipment are just a couple other factors that are impacting Uganda’s healthcare system altogether.

                Uganda’s budget for their healthcare system is extremely low and not effective for the healthcare that the country needs. Since the budget is funded by the international community, it is undermining all the progress made, which as a result has the potential to cause and ripple effect. Budgeting towards healthcare systems is a common factor that many countries experience and in the end have to revamp and make drastic changes with.

                Since Amref has been present in Uganda there have been many changes that are moving Uganda in the right direction as far as healthcare. There is a new health center that has brought treatment and vaccinations to many of the people in that community. In addition more than 300 local people have been trained as volunteer community healthcare workers. These newly trained healthcare workers are aiding in child birth, vaccinations, and spreading the word on the importance of proper healthcare.

                Since changes have been made the local people are now seeing the proper healthcare which they should have. As a result they are demanding better healthcare. They want even better trained healthcare providers, improved buildings where they receive healthcare, and stronger supply of medicines and instruments. This is creating a community that is heading in the right direction for the future of their healthcare systems.

Although they are in the beginning steps of this change, they have seen positive changes in their community. There is still a lot to be done and many more changes that will be put into effect but it is a process and one that the Uganda people are happy and excited for this process to continue.

http://www.guardian.co.uk/katine/2009/apr/01/healthcare-in-uganda

Blog 9: health.disease South Africa

Healthcare in South Africa

 

      Elizabeth Chester is the Associate Field Director at AMPATH Orphans & Vulnerable Children Program based in Kenya. AMPATH is a partnership between several North American academic health centers and the Kenyan Ministry of Health.  Originally established to deal with the HIV crisis in Africa, it has expanded to address the primary healthcare, chronic disease care, and specialty care needs of the African people. Chester presented a guest lecture at George Mason University to graduate students in a Comparative International Health Systems class. In the presentation, she shares her analysis of the successes and challenges of the healthcare system in South Africa.

      When apartheid ended in 1994, South Africa was forced to overhaul its healthcare system.  While this was an opportunity to build a healthcare system to address the needs of the entire population, success was not widespread. Healthcare became centered on hospitals, and during apartheid hospitals were placed in areas with a primarily white population. There were few medical facilities in rural areas, and the majority of the population - which is black – did not hare access to healthcare.  Provincial Departments of Health were then established in order to decentralize and hopefully meet the healthcare needs of the rural black population.

      South Africa is divided into nine provinces or provincial regions.  The country’s healthcare system is structured so that there are nine Provincial Departments of Health under one Federal Department of Health.  Within each of the nine Provincial Departments of Health are Health Regions and Districts. District-based primary care keeps control and delivery at a local level, and promotes affordable and accessible care. Clinics have been constructed to deliver this care and all 3,500 are managed by district authorities.  Children under the age of six receive free healthcare at these clinics, as do pregnant or breastfeeding mothers.  The hospitals are managed by provincial-level authorities.

      Chester notes that the AIDS epidemic has hit South Africa hard. Of the population, 23.5% are living with AIDS, and there have been more than six million HIV/AIDS deaths in South Africa through 2012.  AIDS has resulted in higher infant mortality, a lower life expectancy of 43 for males and 42 for females, and a negative population growth rate. So much time and funding has gone to fighting AIDS/HIV in South Africa that primary care needs of the non-affected population have not been met.

      The federal government pays for 40% of total healthcare expenditures for 80% of the population and this expenditure is 11% of South Africa’s budget. There is still inconsistent funding of South Africa’s healthcare system. The majority of South Africa’s population cannot afford to assist the government in funding healthcare. In urban areas the poverty level is 50% and in rural areas is 71%. Unemployment remains close to 40%.  Only 18% of South Africa’s population carries private health insurance.  South Africa depends heavily on non-profit groups and non-governmental organizations (NGOs) to fund its healthcare.

     There is a shortage of physicians in South Africa, particularly in the underserved rural areas. Many foreign doctors are brought in by the government to fill this need and the government has actually simplified the regulations to encourage more foreign doctors to come to South Africa.  Additionally, all new physicians and pharmacists are required to practice in an underserved area for one year before practicing in the area of their choice.  . Sadly, these changes have not improved the issue of physician shortage in the country. Unfortunately, many South African doctors are leaving the country and choosing to practice in Canada or the United Kingdom. Of those physicians who remain, the majority of physicians choose to work in the private sector, and most physicians, hospitals and pharmacists are found in the wealthier provinces of the country.

      Traditional medicine still plays a role in the healthcare of the people of South Africa. These traditional healers have deep roots in the culture, and 60% of the population consults them. In 2004, traditional healers were formally recognized by the government.  About 40% work out of a hut, house, or office, and 60% work at the clinics or hospitals.

 

 gunston.gmu.edu/healthscience/InternationalHealth/SouthAfricanHealth

 

 

Blog 8: Russia Health/Disease

Russia’s Healthcare System

     Dr. Boris Rozenfeld shares the current status of Russia’s healthcare system in this 2010 Rand report: The Crisis of Russian Health Care and Attempts at Reform. Dr. Rozenfeld is a lead researcher at the Center for Demography and Human Ecology, Institute for Economic Forecasting, Russian Academy of Sciences. The healthcare system in Russia has not developed well, has faced huge financial issues, and is not delivering effective healthcare to the population. The reason? Rozenfeld states, “This is mainly due to a continued lack of funds, medical and technical equipment and supplies, and, finally, to the ineffective organization of health care delivery services. “

     The problems with the healthcare system in Russia have developed over many years.  Although the recent economic downturn in the Russian economy has not helped the issues impacting healthcare, Rozenfeld makes it clear that it did not create the problem.  Instead he believes the political model of “state-paternalistic social system development” is the cause. This model was known for priding itself on the idea that the state would provide for its citizens’ entire healthcare as part of national pride, but when it came time for healthcare delivery to rely on the state, the state fell flat, delivering more propaganda than actual health care. This was all in spite of a huge number of doctors and an adequate number of hospitals.

       There also was an apparent lack of attention not only to the quality of care, but also to the effectiveness of the care.  Also, Rozenfeld describes a “complete absence of incentives for improvement of services in all kinds of medical institutions.”  On the part of the Russian population, their attitudes combined disastrously with the government’s ineffectiveness and inefficiency.  The Russian people were known to have an irresponsible attitude about their health, yet they wanted to be major consumers of what the government was offering.

     The three biggest issues confronting Russia’s healthcare system are: 1) continued economic instability, 2) ongoing operational difficulties in healthcare delivery, and 3) low prioritization of healthcare system funding. With inadequate funding, the construction, remodeling, and maintenance of health care facilities have come to a standstill.  Most healthcare facilities are in disrepair or dilapidated. To deal with the inefficiencies in delivery of health care, the government has attempted to introduce some free market principles, but this has backfired. Citizens who once had the state provide for their health care needs cannot afford to now pay for that care, so they defer seeking care.  Only the wealthy citizens – a small percentage of the population - can afford this approach, so the best available healthcare is delivered to a fraction of the people, and everyone else waits as their health deteriorates. According to Rozenfeld, state funding for healthcare allows the system to be maintained at “survival level only”.

     In 1993, Russia instituted Obligatory Medical Insurance (OMI) to help fund its healthcare system. If all citizens were required to obtain insurance, it was hoped that many of the funding problems would be eliminated. In the two decades since the policy was put in place, it is apparent it has failed. Employers making minimal profits are refusing to provide the insurance for their workers, and employees need their full paychecks to provide housing, food, and clothes for their families. In 2010, the amount of money collected through OMI is, according to Rozenfeld’s assessment, “too little to finance larger goals and is sufficient only for supporting the most basic set of health needs.”

     Russia’s healthcare system is in a downward spiral. Consistent and adequate funding must be found to improve the management of the system, upgrade facilities, and increase the population’s access. While there are an adequate number of physicians in Russia, they and all healthcare workers need to be paid a better wage. The annual earnings of all healthcare workers – including doctors – is 20% less than others with an equal number of years of education.

http://www.rand.org/pubs/conf_proceedings/CF124/CF124.chap5.html

Emily Crigger 

4-3-13

1:05 PM

 

Blog 7: Costa Rica Health/Disease

Emily Crigger

Health Care in Costa Rica

     In a 2010 position paper presented to the World Health Organization, Dr. Mario del Rocio Saenz, the former Costa Rican Minister of Healthcare, collaborated with two assistants to present a status update on Costa Rica’s healthcare system.

      It is interesting to note that universal healthcare is never mentioned as a right in the Costa Rican Constitution.  However, Costa Rica’s establishment of Caja

Costarricense de Seguro Social, more commonly known as CCSS or the Caja, clearly references that “the right to Health is a fundamental one” and  “all residents have the right to healthcare provisions  and the obligation to contribute with the preservation of health and to maintain the health of his/her family and community.”  Additionally, the Caja establishes that “the health of the population is a public interest guaranteed by the State.”  In essence, the government of Costa Rica mandates universal healthcare for its citizens.

       Costa Rica is one of the few Latin American countries offering complete and universal health care coverage in both financial and geographical terms. The health care system is sustained by workers, employers, and the government and 87 percent of the population is covered. The position paper describes six separate categories of beneficiaries set up by the Caja: 1) direct or employer-employee relationship, 2) self-insured (voluntary self- insured, 3) pensioner, 4) family insured (relatives of direct beneficiaries, pensioners, or self-insured beneficiaries), 5) insured by the State, and

6) non-insured (those with the capacity to pay but who choose not to but are still given free emergency room access).

     For health care delivery purposes, the country is divided up into 105 Health Areas covering 30,000 to 60,000 residents.  These health areas are further subdivided up into small population sectors of 4 residents. There are three distinct levels of healthcare offered in Costa Rica referred to as first, second, and third level of attention.  Across Costa Rica, there are 947 Equipos Básicos de Atención Integral de Salud or EBAIS (Basic Provision Units of Integrated Healthcare) which provide all care at the first level of attention. Care given at the second level of attention is provided in a network of

11 large clinics, 13 small hospitals, and 7 regional hospitals. ER services, diagnosis support, specialized outpatient consultation, and simple surgical treatments are all given as part of healthcare at the second level.  The care given at the third level of attention is provided at 4 specialized and 3 national concentration hospitals, and is the most technologically complex of the three levels of care.

  

      As stated already, Costa Rica’s healthcare system is funded by contributions from employers, employees, and the government. The government’s share of funding has shown a steady decrease.  The government’s share in 1993 was 18.3%, in 1999 it was 9.2%, and in 2001 was 7.3%.  In 2012, the governments share ranged from 0.25% to 0.50 %.   The non-insured’s healthcare access, which is primarily limited to emergency room care, is funded by the Costa Rican government through private and corporate donations to the Fund for Social Development and Family Welfare, and taxes on lottery tickets, alcohol, sales and tobacco sales.

     Costa Rican healthcare is “allocated” but in America we would refer to it as “rationed”.  The demographics of those living in each Health Area are analyzed, and then the necessary resources are moved to that area by Caja to provide healthcare specific to the needs of that area. Medications are also allocated to the different Health Areas of the country, and there can be a delay in receiving rarely-used medications for unusual diseases and illnesses.  Costa Rica’s healthcare system has remained significantly stable, experiencing a minor decrease in funding during the global economic challenges from 2007 – 2009. This was enough, however, for the Costa Rican government to pay much more attention to “global economic variables” such as production and employment, as well as a nationwide aging population and a growing unemployment rate.

     Costa Rica recognized early on that it wanted to be a nation whose citizens had full access to health care, and where employers worked together with employees and the state to make this happen.  The healthcare system there has evolved and adapted to become one where any citizen who wants quality healthcare has it, and those who do not still may access the system for emergency care.

http://www.who.int/healthsystems/topics/financing/healthreport/CostaRicaNo11.pdf

 March 17, 2013

5:50 PM

Blog 6: Canada Health/Disease

Emily Crigger

Healthcare in Canada

 

     Journalist Sarah Kliff shared insight into the Canadian healthcare system in her July 1, 2012 Washington Post article “Everything You Ever Wanted to Know About Canadian Health Care in One Post”.  In the article, Kliff takes the reader through the strengths and the weaknesses of Canada’s healthcare system, and how well the publicly- financed system works.

     Canada as a nation consists of 10 provinces and three territories. Each of these finance and manage a statewide health insurance program.  Canada’s healthcare system is built around the principle that all citizens will receive all medically necessary hospital and physician services.  These services, which are guaranteed under federal law in Canada, are given at no cost to the patient. There is no cost-sharing. 

     While access to hospital and physician services is guaranteed, each province and territory gets to decide what, if any, supplementary benefits are covered. Supplementary benefits cover such things as dental care, orthodontic care, and prescription drugs. In Canada, 66% of the citizens choose to take out private, supplemental insurance policies to cover these services, or their employers sponsor a plan to cover them for these services.

Canadian legislators have tried to expand the services the public health care system will cover to also include dental, orthodontics, and prescription drugs, but these efforts have bee unsuccessful.  Because most of the doctors in Canada are not government employees, they negotiate their payment at a fee-for-service rate.  Fee-for-service allows a doctor to bill for each individual service provided during an office visit or hospitalization.

    Canada spent 11.4 percent of its Gross Domestic Product (GDP) on health care in 2009. In comparison, the United States spent 17.4 percent of its GDP on health care in the same year. The following countries spent between 11.5 and 12 percent of their GDP in 2009 on healthcare and fall between what Canada and the United States spent: Denmark, Germany, France, and the Netherlands. There are two reasons Canada spends so much less of its GDP on healthcare than the United States. First, the “unit cost” of health care is less in Canada when compared to the United States.  Kliff uses the example of the cost of an MRI in Canada ($824) and the United States ($1,200) as an example of Canada’s less expensive unit cost of health care.  Second, the administrative costs of health care in Canada are much lower than in the United States.  For example, in 2010 Canadian doctors in the province of Ontario spent $22,205 in dispute with the Canadian government over payment for services. In that same year, American doctors spent

$82, 975 dealing with private insurance companies, Medicare and Medicaid in order to get reimbursed for services.

     Canadians are generally pleased with their health care system. Kliff points out that it has been noted that Canada’s survival rates for breast and colorectal cancer are high, and its strong primary care programs prevent costly hospital admissions. Kliff also cites a 2011 Gallup poll that reveals 57 percent of Canadians are satisfied or very satisfied with their access to health care, as compared to Americans who are only 25 percent satisfied or very satisfied with theirs.  However, Canadians are not generally pleased with the long wait times encountered to see a doctor -particularly a specialist- or to schedule elective surgery. To address this problem, Canada has required each province to set standards for wait times to see specialists and obtain procedures.

     Canadians are very proud of their healthcare system and consider it part of their national identity.  Kliff notes a study that concluded that 85 percent of Canadians believe that if the public plan for healthcare was eliminated, it would “result in a fundamental change to the nature of Canada. “ However, a large percentage of Canadians do feel that the government should increase health care spending to help reduce long wait times and further improve access to care.

 

http://www.washingtonpost.com/blogs/wonkblog/wp/2012/07/01/everything-you-ever-wanted-to-know-about-canadian-health-care-in-one-post/

Emily Crigger
3/7/12
8:50PM

Blog 5: Germany Health/Disease

Germany’s Healthcare System

     In the February 22, 2013 Health section of the New York Times, freelance writer Anne Underwood shares highlights of her 2009 interview with Uwe Reinhardt.  Reinhardt is a professor of health economics at Princeton University and is a leading researcher of the world’s health care systems. The highlights of the interview include Germany’s means of insuring all citizens, and why Germany’s healthcare system is such an efficient system.

     According to Reinhardt, Germany’s system is one that blends a private healthcare-delivery system with universal coverage and a sense of social harmony to create s system that brings satisfaction to most Germans. The German system mandates that all individuals have insurance, and it is up to each individual to select and enroll in a “sickness fund”.  The clear majority of Germans pay for their “sickness fund” coverage through a 50-50 agreement with their employer.  A “sickness fund” is much like a health insurance “plan” in the United States. There are over 200 sickness funds Germans may select from.  Employees select the fund, notify their employer of their choice, and pay half of the premium, and their employer pays the other half. Reinhardt notes that in Germany, employees would “balk” at the idea of their employer informing them what health plan they will be participating in.

      All employees in Germany must also carry unemployment insurance.  It is mandated just like health insurance. If a German citizen suddenly finds himself or herself unemployed, their unemployment insurance kicks in and covers the cost of their “sickness fund” premium. The unemployed are still covered for healthcare during their

time of unemployment. In the event a German citizen is unable to work, or unable to find work, and becomes poor, sickness fund premiums are paid by the government. The children of the poor continue to be covered by their parents’ plans because the plans are funded by the government.  If one is elderly and retired, their pension fund pays for the sickness fund.  As a result of all of these plans, there is one hundred percent universal coverage in Germany.

     Illegal immigrants are also covered for healthcare in Germany.  It is the position of the governments that once one is in Germany via legal or illegal means and chooses to stay, that individual has the right to access all social services that German citizens can access.

     The 200 “sickness funds” or public plans available are all non-profit.  Germany has a completely separate for-profit insurance industry.  One can move out of a public plan and   into a private plan.  However, there is a higher income requirement to do so, and you cannot move back into the public sector for coverage unless your income falls below the poverty line.  Interestingly, Reinhardt explains that 90% of all Germans are in public plans and stay in them. Only 10 percent of the German population is in a for-profit

plan even though many more are entitled to choose from a for-profit plan but do not.

     Germany’s healthcare system is a very efficient one, according to Reinhardt.  The administrative costs are much lower there because of the direct relationship of the patient and the doctor. When a patient goes to the doctor, the patient pays a small co-pay (approximately $20) for the first visit in each quarter. If the patient has more visits during that quarter, there are no more co-pays. All billing in Germany’s healthcare system is electronic.  The patient hands the physician his/her insurance card, the doctor codes in the services provided, the card is swiped, and two weeks later the physician receives payment for the service from the insurer.  There are rarely long waits for any level of healthcare in Germany.

     Drug prices are controlled in Germany by a system known as “reference pricing.” The public (sickness funds) and private plans group drugs into therapeutic categories. Patients are allowed to choose less expensive drugs that are covered under their plan or pay the difference between the cost of the covered drug and a more expensive option they want. Drug costs are kept low in Germany since most patients select the covered and less expensive drug if it works.

     Germany has a healthcare system that seems almost ideal.  All Germans are covered, all those coming into Germany (legally or illegally) and wishing to stay are covered, and Germans get to select the system of coverage they want. They have an investment in their care since they pay for half of their premiums if they are employed.  If they are unemployed for any length, their required unemployment insurance pays for their health insurance premium.  If they are poor, the government pays for their insurance.  If they are retired, their pension pays for their insurance. All children are covered under their parents’ plans. There are no long waits to see a doctor, and the doctor is promptly paid by the insurance company with possible co-pay being the only money a patient pays beyond their premium. The Germans appear to understand how to effectively implement universal health care coverage.

http://prescriptions.blogs.nytimes.com/2009/09/29/health-care-abroad-germany/

Emily Crigger

12:25PM

2/25/13