Health services are among the most expensive and complex areas of social policy.
Using qualitative comparative analysis to explore 11 developed countries’ health services, this volume considers the links between a range of different outcome measures and levels of funding, social determinants and different types of health expenditures. It also reflects on how those systems responded to the first wave of COVID-19.
This ambitious text identifies which underpinning factors are associated with the strongest outcomes, providing a rigorous account of health systems and health policies in the context of their wider economies and societies.
This book has been about comparing health systems, and this chapter is structured around two final comparisons. The first takes factors which were important in terms of causality from the social determinants, funding and expenditure chapters, and sees how they combine for 10 countries (the inclusion of long-term care expenditure means that New Zealand must be omitted). The combinations of these factors are then explored in terms of their necessary and sufficient conditions in relation to health outcomes. The health outcomes measure has been chosen as the best overall benchmark against which health systems should be judged – if they are generating good health outcomes for their populations, then they are probably doing a good job. Other outcome measures can make a strong case for their importance as well, but as the UK demonstrates, strong health equity can also lead to poor health outcomes, and as the US demonstrates, strong care process measures do not necessarily lead to measures in other outcome measures.
Utilising the health outcomes measure also allows a final comparison, in which the sample of countries is expanded to 31 to see how the causal patterns in that wider sample compare to those in the original 10. Including an outcome measure for the 31 countries means finding a replacement for the Commonwealth Fund health outcomes measure, but a key composite of that measure is the OECD ‘preventative life years lost’ (PYLL) measure, which provides data for a wider range of countries and so allows a wider comparison to be made.
This chapter presents the book’s conclusions, including the key findings from each previous chapter. It also presents the solutions for low performance in relation to social determinants, health funding and health expenditure which were not included in previous chapters, to consider what they can add to our findings. It includes a further discussion of the role of the Australian healthcare system, which has been found to be unusual in its patterns of causal factors and outcomes in previous chapters, as well as a consideration of what the US and UK can learn in terms of health system change. It concludes with a discussion of some general lessons that the book offers and, finally, the strengths and limitations of the book as a whole.
Chapter 2 was concerned with the social determinants of health. It found that countries with high health outcomes have ~GINI as a necessary condition, and there are two sufficient solution pathways to that outcome, ~GINI*EDUC, or BEHAV*~GINI*HEALTHEXP, but with the former having higher coverage of countries, which were France, the Netherlands, Norway and Sweden. For high health equity, ~GINI was again a necessary condition, and the solution with by far the largest coverage and unique coverage was ~GINI*HEALTHEXP, which covered Germany, the Netherlands, Norway, Sweden and Switzerland.
For both high health outcomes and high health equity, ~GINI*HEALTHEXP was a necessary condition, with ~GINI*EDUC*HEALTHEXP forming the sufficient condition for the Netherlands, Norway and Sweden, but with Switzerland deviant for coverage, so also having high health outcomes and high health equity, but not forming a part of the solution set.
This chapter utilises the same method as the rest of the book (QCA) but with a different dataset. During the book’s writing, the COVID-19 pandemic began and spread across the world. This gave me two options – I could ignore it, as the pandemic was not in the original book proposal, or I could incorporate it, and see how different health systems had responded to the challenge that it offered. I have decided on the latter, but of course any analysis I can offer is limited in that, at the time of writing, the pandemic is far from over. This has resulted in some methodological choices about what I can and cannot write about, but I hope that the chapter offers an insight into the ‘first wave’ of the pandemic and so makes a contribution to the comparative analysis of health systems.
Understanding why some countries were more successful than others in responding to the pandemic in its first wave – with the analysis here running up to mid July 2020 – gives important insights into the relative importance of the structural influences which are now known to be important in containing the virus, as well as giving an opportunity to assess the success (or otherwise) of different countries’ COVID-19 testing regimes.
Comparative studies have the potential to bring insight into how COVID-19 risk factors and testing regimes interrelate, but there are significant data limitations in terms of what can and cannot be measured in a robust way at the time of writing. This necessarily means some compromises have to be made.
The way in which health systems are funded is often based on a series of political decisions which were made in the early development of different nations’ health systems, and yet, through processes of institutional reproduction, have remained remarkably intact today (Immergut, 1992b; Wilsford, 1995). As health systems absorb such substantial levels of resources, and because access to healthcare is not only recognised as a human right, but is also an international business of enormous scale, methods of healthcare funding in a particular country will be the result of a series of compromises between competing interests. Key stakeholders are those working in health services (with doctors usually having the most influence), government, public, private or not-for-profit providers of care, as well as other organisations such as insurance companies, patient representative groups and regulatory bodies. At election time the public will also have a say, but generally only from the ‘menu’ of options presented to them. Should events occur with particular salience to the general public (such as a rogue doctor or nurse, or a vulnerable person not receiving the right care), this can also mobilise change, especially should those events occur near an election.
This chapter explores the different configurations of the funding of health systems among the 11 countries included in the book, and the relationship between these configurations and access to healthcare, as well as a measure of the efficiency of the health system.
It therefore aims to discover whether there are patterns of healthcare funding that have necessary or sufficient relationships with healthcare access and measured efficiency, as well as whether there are any health systems which achieve both of these outcomes.
This book compares the health systems of 11 countries in terms of their social determinants, health funding and health expenditure, and explores how the different configurations of these factors, in turn, relate to a range of different outcome measures. It also compares a wider range of countries in relation to the factors found most important for the 11 countries, as well as exploring the first-wave response to COVID-19 in 2020. By exploring health systems in terms of several of their most important aspects, we can assess what they have in common and in difference, and whether those commonalities and differences are linked to better or worse outcomes.
No empirical work takes place in a theoretical vacuum. Things that seem important are more likely to be measured, and those measures often already come in clusters, based on the relationships that we assume exist between them. It is therefore important to actively think about what it is we are trying to measure, what theories are explicit (or implicit) in those measures, and then whether the empirical findings that we find support or challenge those theories.
It is also really important in comparative research to have a method for linking together the existing data and theory, and for testing it in a robust and transparent manner. Not everyone will agree with the findings in this book, but they will be able to see exactly where they agree or disagree. I hope this can lead to debate, and in turn to greater understanding.
When comparisons of different health outcomes are carried out, there is still often an assumption that the reasons for those differences must be due to the performance of the health services in those countries. Politicians and policymakers debate league tables of health outcomes as if the results are entirely dependent on what goes on in healthcare services, and plans are put in place to attempt to address what have been identified on problem areas (Greener, 2016). However, it may often be the case that the health outcomes differences between different countries may be due to factors outside of the direct control of healthcare services.
Healthcare services are undoubtedly important, and the book will explore how they are funded, and what the money is spent on, in Chapters 3 and 4. But however important healthcare is, our health depends on a range of other factors that fall outside the remit or control of healthcare organisations and institutions (Schrecker and Bambra, 2015).
In respect of our own lives, we are fully aware that health services are not the only, or perhaps even the most important, factors in determining our health. Whether we can access health services (or not) when we are ill or injured is clearly important. This will be especially the case where people have a serious injury or life-threatening illness, but is also the case for the millions of people with long-term health problems that may require medications or medical devices, as in the case of diabetes or asthma.
Typologies of health system expenditures tend to be based on their degree of publicness (Blank et al, 2018, p 73), or countries are compared on the basis of their total spend on healthcare (Kotlikoff and Hagist, 2005). However, there is still relatively little work which explores different categories of health expenditure and how these contribute to good or bad care, and whether that care, in turn, leads to better or worse health outcomes.
In terms of arguments around levels of expenditure, there is often a general assumption that greater healthcare expenditure allows the purchase of more health services, and that this should lead to better health outcomes. However, this clashes with critical work, perhaps best exemplified by Illich (1977b), suggesting that increased spending on healthcare may itself be detrimental (Blank et al, 2018, p 260), with medicine being portrayed as a ‘disabling profession’ (Illich, 1977a) that prevents us from trying to find our own sources of well-being. As well as the disabling profession critique, Illich argued that the toxic or dangerous effects of medicine (its ‘iatrogenetic’ dimension) were not being taken into account, and raised questions that more recent authors (O’Mahony, 2016) have used as a basis for questioning the legitimacy of many medical interventions, which they find fall short of the standards of evidence which medicine aspires to (Stegenga, 2018).
There have been significant debates on the implications of trying to shift expenditure between primary and secondary care, which has been explored both in terms of individual health systems, but also comparatively (Peckham and Exworthy, 2003).
The UK Government had substantial warning about the new coronavirus and, in broad outline, what they might expect. The first death in China was announced on 11 January 2020, and the first confirmed cases appeared in Italy and the UK at the end of January. The first death occurred in England on 5 March. The World Health Organization (WHO) declared a public health emergency of international concern on 30 January and confirmed the existence of a pandemic on 12 March. By the end of January, it was clear that the virus was being transmitted from person to person, that it had a serious effect on those contracting it, and that there was the potential for it to become a pandemic. Commentators have broadly agreed that the UK Government was nevertheless slow to acknowledge the seriousness of the situation and to respond; the editor-in-chief of the British Medical Journal recorded the verdict of their editorial writers as: ‘Too little, too late, too flawed’ (Godlee, 21 May 2020). However, not all contributions from academics have agreed (for example, Cairney, 020).
The Government considered that it was well prepared for the pandemic. Prime Minister Johnson made this clear after he chaired his first COBRA meeting on 2 March – in fact the fifth that had been held on the new coronavirus – when he said: ‘…let me be absolutely clear that for the overwhelming majority of people who contract the virus, this will be a mild disease from which they will speedily and fully recover … Our country remains extremely well prepared, as it has been since the outbreak began in Wuhan several months ago’ (Johnson, 3 March 2020).
The majority of people in residential and nursing homes for older people are over 80 years old and particularly vulnerable to the ravages of COVID-19. Almost half – 46 per cent – of all excess deaths in England and Wales from the beginning of the pandemic to early August took place in care homes. In addition, the excess death rate for recipients of domiciliary care was similar to that for care home residents (Glynn, 13 July 2020). The UK was not alone in experiencing a high death rate among care home residents: Spain, Belgium, Canada and the US were all hit particularly badly in this regard, together with Sweden, albeit that a higher proportion of over 65s live in care homes there (Grabowski, 2020). Care homes in England recorded a 79 per cent increase in excess deaths from the week ending 13 March to the week ending 26 June (the figure for Wales was 66 per cent, for Scotland 62 per cent and for Northern Ireland 46 per cent). In England, 44 per cent of homes reported at least one case of suspected or confirmed COVID-19; the highest figure for UK countries was 65 per cent for Scotland (Bell et al, 2020). Unsurprisingly, nursing homes registered more cases and more deaths than residential homes. But other factors due to structural changes in provision, such as higher death rates in larger homes, beg additional explanation (as the total number of care homes has fallen, the number of large homes – with 45 beds or more – has increased.