Does more money mean better health
By Dr Brighton Chireka
Does more money mean better health? Governments the world over have been rightly accused of not funding their health systems well and the Zimbabwean government is no exception. A lot of debate has been taking place in social media asking the same question: does more money mean better health? I have found that there is a lot of finger pointing taking place. The patients are blaming health professionals for not having empathy, love and care. The health professionals in turn are blaming the government for not paying them well and medical aid societies for not paying on time. The conclusion that has come from these debates is that the government must pour in more money into the health system and, if that happens, all our health problems will be solved. I ask again does more money mean better health?
I have noticed the same trend in the United Kingdom (UK) just before their general elections. Politicians were promising the public that they will have better healthcare. There will be more general practitioners (GPs) and their services will be 24/7. I am a general practitioner (GP) and it took me 5 years of training in Zimbabwe and a further 2 year internship before I moved to the UK. I then did further 3 years of GP training to become qualified. This meant that it took me 10 years to qualify as a family doctor.
Well, some may say it took long for me because I moved from one country to another which is true – so let’s look at a British-born GP. The British-born GP will train for 5 years as an undergraduate and then do 2 years of foundation training and about 3 years training for GP. Not surprisingly the duration of training is about 10 years and, obviously, the training keeps changing so this may not be the exact case today but the point is that doctors are not biblical manna that falls from heaven. The promise of better healthcare soon after a general election is sadly a false promise. Politicians tend to simplify reality and in the process give people empty promises.
Sadly, the public like to hear these lies and they go in their large numbers and vote these politicians into power hoping for a new future come post-election time. Anyone who today comes and says I will pour millions into the Zimbabwean health system will be seen as the messiah but my question is, “does more money mean better health?”
Do not get me wrong, I am an advocate for proper funding of the health system and also for proper remuneration of health care professionals but I do not just end there. I will urge once again the government to seriously commit enough resources and offer effective political leadership. However, there are other things which if not corrected will result in these resources going down the drain.
We all know that no one will knowingly put money into a pocket that has holes and expect to keep that money. The same applies to our health system, a lot needs to be done to make sure that resources are not wasted. It is said in Christianity that those that are loyal with little things can be trusted with a lot of things. What are we doing with those meagre resources at our disposal? Are we siphoning the little resources available? Are we wasting instead of efficiently utilising those resources?
What are we doing with what we have in our hands? Failure to acknowledge and fully utilise what we have in our hands will result in perpetual failure even if more money is pumped into the health system. We know that culture eats strategy for breakfast so we need to address our culture. The culture of corruption, making quick buck and reaping where we did not sow and also of putting the blame on someone and not doing self-criticism must be addressed if any money is to bring value to our health.
Zimbabwe is in a better position to learn from the mistakes that were made by other countries. For example the costs of care in the United States are high—exorbitant. U.S. spends more on healthcare than any other country but it is ranked outside top 30 countries in the world as far as the health of its people is concerned.
Obviously there are so many reasons why it is like that and a detailed analysis is beyond the scope of this article. My point here is that we need to be efficient in the way we use resources and focus on quality and not quantity of care. We must move away from a system that rewards mediocrity to one that pays by results. We use a payment system that has caused problems in America and we are asking for more funding which is right but I doubt if it will bring value to our health.
Let us look at some of the issues that need to be addressed as we ask for more funding from our government. We must also remember that these cannot be tackled at the same time. I would suggest that we start now to address these issues one at a time.
Paying for More Doesn’t Always Get You More
Under the current fee-for-service system, most doctors, hospitals, and other providers receive a payment for each service, be it a visit at their surgery, lab test, or medical procedure—regardless of whether or not they help (or harm) the patient. In other words, provider payment is based on the quantity of care provided, rather than the care actually needed by the patient, or the effectiveness of the treatment. Sadly at times providers don’t feel pressure to limit themselves from prescribing services that may not be necessary.
A sad scenario of the current system is that a patient or medical aid pays thousands of dollars to have a knee replaced and is discharged home. If the patient develops complications due to the mistakes or negligence by the surgeon or his team, the patient is asked to pay more cash to be seen and to have another operation to correct the mistake. If the patient cannot raise the money, some health professionals can refuse to see that patient. That system must stop and the patient must not continue to suffer.
Personally my policy in the Free National Health Service (NHS) is that if I see a patient today and tomorrow they want to see me or speak to me about the treatment that I would have given them, I will see them even if it means seeing more patients on that day. If a lot of patients are wanting to speak to me a day after seeing me then I need to reflect on my skills as a doctor. It may mean that I am rushing patients and not explaining or sharing options with them properly. I should not be paid more for (my mistakes) doing a bad job and the same applies to any doctor.
Poorly Coordinated Care
It is well known worldwide that a small proportion of every population uses most of the resources. This relatively small slice of the population incurs such high costs because most of these individuals have complex medical problems. The problems include common but difficult-to-manage chronic diseases like diabetes and heart failure, HIV/AIDS as well as respiratory diseases such as tuberculosis (TB). Chronically ill people take more prescription drugs, undergo more tests and procedures, and are hospitalised more often than people in good health.
But the costs for these patients really skyrocket when the care they receive is poorly coordinated: when patients are referred by their primary care provider to a specialist, move in and out of the hospital, and transition from the hospital to home care or a long-term care facility, all with little oversight or communication between providers. In this environment where there is no proper primary care service, patients may undergo the same lab tests multiple times, they may get the wrong combination of medications, and serious conditions may get misdiagnosed.
This not only leads to unnecessarily high costs, it also means poor care for the patients who most need help. It’s scary that patients move from one GP to another but their medical notes are not transferred and some patients are registered with several GPs. This chaotic health service will never get better even if we pour more millions into the system. What is needed is coordination of care. I will touch on integration and coordination of health services in my next article.
Avoidable Hospital Readmissions
Research has found that in most countries without well-coordinated health care, 25% of elderly patients discharged from hospitals end up being readmitted within 30 days, costing the health system many millions. Many of these readmissions could be prevented – and billions saved – if hospitals, doctors, and community health programs worked together to assist patients who are returning home or moving on to a nursing home or rehab facility.
Discharged patients need clear instructions on how to care for themselves at home, as well as help in scheduling and keeping follow-up appointments, sticking to a prescribed medication plan, and making necessary lifestyle changes. Communication here becomes the best pill that these patients can get from their empathetic healthcare professionals.
Litigation due to failure to treat patients well can be costly to the hospital and also to the health professional involved. If patients are treated with tender, love and care they are less likely to complain or sue. They will accept that to err is human and not sue but they expect an inquiry or audit to be carried out and lessons must be learned so that the chances of the same mistake happening are minimised. Pouring money to uncaring and not bothered health professionals will be costly for the employer in this case government as it will pick up the bill for negligence. On paper, the government may be pumping lots of money without the resources being used for the right things.
The level of corruption is unacceptable and must be addressed as soon as possible. It beggars belief that whilst we are crying for more resources from the government we have some hospital officials who are defrauding the public willy nilly. How can a hospital lose millions of dollars without quickly noticing it? The culture of putting the blame on the general economic meltdown must stop. Let us account for the little that we are receiving and go back to the government with a genuinely empty bag not because our pockets are full.
Cost of services in Zimbabwe
Does more money mean better health ?
We also need to look at the cost of health services in our country. We are now one of the most expensive countries in the world. How can that be when we have the cheapest labour in the world, not that it’s good but we need to know then who is getting all the profits. There is need to understand and acknowledge that we are using hard currency and our prices should be ethical and not to try and make our patients suffer.
I am not saying health professionals are taking all the profits in the private sector but I am calling for a review of how we are charging patients in the private sector. The debate has sadly not taken place but it must start now or else the cost of our health will remain very high. Surely, we cannot become one of the most expensive countries in the world. Does that money in the private sector equate to better health care? This needs to be looked at and a genuine debate must begin or else the public will continue to suffer.
Too Much Care
There is a trend that rich people and those on medical aid are now spending millions of dollars on medical services that do nothing to improve their health—and which may even be harmful. This “excess care” can be a by-product of poor care coordination, such as when a patient has tests in his doctor’s office and then another one two weeks later in the hospital. Some patients are sadly getting infections in the hospitals resulting in medical aid companies or families paying more. This should not have happened in the first place as some of these patients did not even require hospital admission but because they have the “money” and afford admission.
Overtreatment is also a big problem: opting for surgery when medication or less invasive procedures would be equally effective (and less risky), is just one example. Use of most expensive and “strong” antibiotics for simple conditions is a major problem. Together, the combination of overuse and misuse of medical services, along with elevated prices, helps explain why quality of health care may not match the high level of spending.
If you look at hospitals, we pay for time spent in their beds even if no treatment was received. Operations are cancelled and patients spend days in hospitals not receiving treatment but the bill will still be going up. Most of the reasons can be avoided and include things such as failure to make sure that there is blood for the patient, or fluids for the patient and also whether the patient is fit for the operation, non-attendance by a consultant and overbooking, to just mention a few. This cannot continue to be paid for. Delayed discharge costs a lot to the government, medical aid and patients and must be addressed, not to fund it by asking the patient to pay more money to the hospital that is causing the problem.
There are some in our society who think that every cough and cold must be treated with antibiotics. They go further in their demands and ask for “very strong” antibiotics such as cephalexin or Augmentin. They claim that amoxicillin does not work for them and put a strain on the resources be it from government or medical aid. There is no medical justification in most cases of prescribing brand names of drugs instead of generic ones. Yes, there are exceptions to this and each doctor is allowed to use his/her clinical judgement to decide with the patient the best treatment.
Some patients have no respect for nurses at clinics and also GPs so they got to the hospital for minor illnesses. The public need to be educated that inappropriate attendance at the hospital is expensive, time-wasting and dangerous. Th patient can get other infections and serious patients may not be treated in time because the doctors will be busy dealing with non-life threatening illnesses.
Government must do their part in fully funding the health systems. Then the national and local clinical leadership must look at ways of avoiding wastage to the little resources that are put into the system. There is need to look at new ways to transform how we deliver patient care and how we pay for it. It is the wearer of the shoe who knows how painful it is. In view of that when we design the systems in our health patients must be involved. Not only involved but must be at the heart of our decision making.
We need to see things through the eyes of patients. We also need to think with their mind-sets not forgetting that one day we will all be patients and will use the same services. Let’s focus on quality of our health systems and positive patient experience of the health services. Gone are the days of wastage and focussing on numbers at the expense of quality. We want more money and we call for open and transparent use of that money to bring a high quality and safe health care system.
This article was compiled by Dr Brighton Chireka who is a GP and a Health Commissioner in South Kent Coast in the United Kingdom. You can contact him at: firstname.lastname@example.org . Read more of his work on his blog at DR CHIREKA’S BLOG
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Dr Chireka has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. Views expressed here are personal and do not in any way , shape or form represent the views of organisations that Dr Chireka work for or is associated with.