Sustainable healthcare: trends urge need to put prevention before cure

In the long run we may all be dead but in the medium term we are increasingly being pulled into the orbit of healthcare while still alive. The fact that people around the world, whether as patients, employees or funders, are experiencing the rising share of income channelled into tackling disease has sparked a debate about sustainability.

Advances in recent decades as a result of preventive vaccines, enhanced nutrition, improved sanitation and economic growth, have all contributed to lower infant mortality and ever longer lives. Such factors mean that, although population growth is slowing, the world is inhabited by a record 7bn people.

At the same time, a shift towards more urban and sedentary lifestyles and the growing commercialisation of dense, processed and manufactured foods, have added to risks. So far, rising obesity and metabolic disorders such as diabetes in richer and poorer countries alike have failed to reverse extensions in life expectancy. But they have brought new costs through medical complications.

As birth rates decline and the population ages, the dominant types of disease have shifted and intensified, with the emergence of many more long-lasting chronic conditions, cancers and degenerative illnesses such as dementia. The ratio of working people to dependants has tipped towards the latter, increasing the pressure on funding for all.

Such tensions have long been highlighted in Europe. Following a postwar period of investment in improved healthcare in response to rising living standards and public expectations, strong government-backed health systems have come under additional budgetary constraints since the financial crisis of 2008.

In Greece, for example, there are reports of patients seeking help from humanitarian agencies after slipping through gaps in the public health system. Campaigners have pointed to a surge in HIV infections linked to the abandonment of targeted prevention programmes, notably for drug users.

In a new paper in the British Medical Journal, Helena Legido-Quigley at the London School of Hygiene and Tropical Medicine warns that, as a result of recent and planned healthcare cuts in Spain, “we are seeing detrimental effects on the health of the Spanish people and, if no corrective measures are implemented, this could worsen with the risk of increases in HIV and tuberculosis.”

In far poorer parts of the world, the crisis in agricultural supplies that, over the past few years, has prompted intense discussion on “food security” has resulted in a surge in physical and mental development problems in young children.

The economic squeeze has been reflected in healthcare problems in the US, even though its spending on health, at 18 per cent of gross domestic product, outstrips that of all other countries. But inequality of access remains a concern, with variations in cover exacerbated as people lose their jobs or move between regions and insurers.

If the United States provides some of the best, most exhaustive and innovative care in the world for those who can afford to pay, even wealthy Americans do not always enjoy better results than their peers in Europe. The poor and middle class often struggle, and co-payments and loopholes can leave them with inadequate access to treatment.

Yet there are signs of improvement, even in an age of austerity. President Barack Obama’s efforts to extend medical cover to all tapped a broader trend towards universal healthcare, reflected in policies in countries and regions as diverse as Ghana and rural China.

Jim Yong Kim, head of the World Bank, signalled a shift in policy when he told the World Health Assembly in May: “Every country in the world can improve the performance of its health system in the three dimensions of universal coverage: access, quality and affordability.”

His views chime with those of the academics David Stuckler and Sanjay Basu, who caution against a short-termist approach. In their book The Body Economic, they argue that healthcare cuts in response to austerity are counter-productive and have caused significant long-term problems such as infections and a rise in suicide rates.

There is much debate over how best to respond to budgetary pressures, with many suggesting that the introduction of “co-payments” – or the sharing of costs – by patients whenever they see a doctor discriminates against those most in need. Some argue that a more rational approach is to trim the package of available free essential care at the point of delivery.

Despite the alarm over rising costs, many in the industry downplay the concerns. Ian Read, chief executive of Pfizer, the US pharmaceutical company, says: “The question is not whether we are spending too much on healthcare, but whether we are spending enough.” He says, for example, that statins such as Lipitor, the company’s “blockbuster” cholesterol-lowering medicine, have saved healthcare systems hundreds of billions of dollars as a result of reduced heart attacks and related complications.

His argument is partly in reaction to a desire among healthcare systems to squeeze prices and demand for commodities such as drugs through “health technology assessment”.

Organisations such as the UK’s National Institute for Health and Care Excellence (Nice) judge the cost effectiveness of medicines in addition to regulators’ work on safety and efficacy.

The result, notably in Europe, has been an ever-higher hurdle for drug companies to leap in order to achieve reimbursement for their products.

That may well be justified, given an article in the latest issue of the journal Health Affairs, which has identified a consistent decline in the incremental benefits of new medicines since the 1960s.

The pharmaceutical industry is also at least partly right to highlight two other areas that merit more attention: the need for more efficiency in non-drug costs (given that medicines account for only 10-20 per cent of total expenditures) and the scope to spend less money on treatment and more on prevention.

In the US, the advent of accountable care organisations reflects an attempt to move from paying doctors per consultation towards rewarding them for improved outcomes. Similar experiments are taking place elsewhere.

Most fundamentally, demographic and disease trends alike point to the need for a substantial shift in resources and innovation towards prevention.

Some of the biggest killers, such as smoking, would appear clear candidates for more active policies – although efforts in countries such as Australia to impose plain packaging on cigarettes are meeting fierce legal resistance from the tobacco industry.

Tackling most lifestyle diseases is proving far more difficult. There are few proven models to reverse obesity, but it seems clear that there is a need for greater funding, research and political boldness. The key would be to mix behavioural science with checks on the food industry and to incorporate innovation in management, architecture and urban planning alike, to promote more healthy lifestyles.

Without greater efforts on prevention, there will be no cure for many of the diseases that develop, or the rising costs that they incur. That is certain to create new financial as well as human pain ahead.

Source Financial Times