Tuesday, June 25, 2024


Dhaka Tribune


The two commandments of universal healthcare

Lessons learned from failing Western healthcare systems

Update : 10 Sep 2023, 09:33 AM

Can Bangladesh achieve universal healthcare? Sure. This was the major question Dr Shabnam Mostari answered from his article for this newspaper. Now onto the slightly more difficult part, can Bangladesh achieve the universal healthcare that Bangladesh would actually like to have?

The two grand commandments of healthcare systems: One, do not copy the Americans. Two, do not copy the British. There are all sorts of variations and possibilities, but as long as you remember commandment one and two then you will end up with something reasonable and useful. It's also possible to go better than just reasonable and useful -- for example copying Singapore could be a very good idea indeed. 

The background here is that up until the 1940s -- until effective antibiotics, that is -- there was little that healthcare systems could do other than bed rest and hydration. Of course, some problems were solved, at least in part. Quinine for malaria infections for example, also as a prophylactic. Amputations could be done if the patient was drunk and the surgeon wasn't. The problem was that anything invasive was likely to lead to a slow and agonizing death from gangrene.

There were many medieval recipes for this soup and that potion -- well, the ones that worked were those that said “cover the wound with fresh linen and then boil … ” the frog bits and snake gizzards. The linen stopped anyone trying to do anything to the wound itself, the potions were to distract from this bit that worked. Only with antibiotics could actual treatment start. 

Don't forget that up until the late 1920s a diagnosis of diabetes indicated only a few months to live. We really could do very little. 

So, when healthcare systems finally became viable, the structure was based around what societies were already doing at that time. As a result of wartime wage controls -- which left healthcare coverage as something uncontrolled, so it became the way employers competed for labour -- the US ended up with employment paid and related healthcare insurance. Do not use this system -- commandment one. 

Britain immediately post-war was almost as socialist as the Soviet Union. Therefore we ended up with the Stalinist idea of the NHS. The state not just as the insurer, the payer, but also the actual provider of all healthcare. Worth noting that they did it by simply nationalizing, without compensation, all of the extant charity hospitals etc. The NHS started in 1948. It built its first hospital in 1963. Commandment two -- don't do it the British way.    

We do actually face a real problem here. We want a healthcare system to be three things. Efficient, in that we get lots of healthcare for our money (whether tax or personal). Efficacious, in that we want it to actually cure things. Finally, we want it to be equitable. Healthcare is one of those things where -- rightly or wrongly -- most of us think there should be an equal chance of getting cured. 

Those three are really, really, difficult to balance. The American system is really efficacious for those who get into it. It's grossly inequitable and the cost, my dear, the cost! So don't do that. The NHS in Britain is the worst among rich world healthcare systems at “mortality amenable to healthcare” which means actually curing people of what ails them before it kills them. So don't do that either. 

What we need is a mixture of government and markets, socialism and capitalism, to balance those three. Singapore probably has the best mix although there are alternatives -- Sweden, Denmark, Germany, France all offer alternatives which vary the emphasis on the three components. 

There's no point in trying to have market incentives when we're thinking about who scrapes us up off the road after a car accident. But on the other hand having market forces pushing down the costs, and up the efficiency of, regular healthcare like vaccines, blood pressure monitoring, and all that, that seems like a pretty good idea. But then regarding vaccines, some of that is public health, so we want the government involved but perhaps not actually provide.

This really is a difficult area of policy. As I say, Singapore probably has the best mixture. Basic everyday health is paid for by the individual, but from a special, individual, account fed by their own taxes. What you don't spend gets added to your pension pot -- giving an incentive to be frugal but not so frugal that you don't live to get your pension. Serious problems, ghastly cancers, car smashes, all paid for by the government -- an  insurance policy that covers the entire population. Hospitals and doctors compete with each other to get that individual spending. That might well be as good as it gets. 

Yes, healthcare is different. We do need a mixture of government and markets, socialism and capitalism. But getting the right mix matters. Routine matters that can be dealt with by markets? Use markets. Horrendous costs that require government insurance? Use government insurance.   

The real point here though is that Bangladesh has an advantage. The currently rich countries built their healthcare systems from the ideas at hand in those late 1940s. Singapore did better as it built one decades later, with the experience of those examples before it. 

Bangladesh may be building one now, or from now on. That means it has many more examples to study, and much more information from which to build the best system possible. 

Yes, that mix between efficiency, equity, and efficacy, that's a matter for local desires to decide upon. But as long as commandments one and two are obeyed things should be fine. Don't have an American healthcare system and don't have a British one. Do better on the basis of what we know now.    

Tim Worstall is a senior fellow at the Adam Smith Institute in London.

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