THE WORLD'S BEST IN HEALTH CARE: LEARNING FROM GOOD PRACTICES

Abstract

Reinert reviews WHICH COUNTRY HAS THE WORLD'S BEST HEALTH CARE? by Ezekiel J. Emanuel.

THE WORLD'S BEST IN HEALTH CARE: LEARNING FROM GOOD PRACTICES WHICH COUNTRY HAS THE WORLD'S BEST HEALTH CARE? Ezekiel J. Emanuel. New York, USA: Public Affairs, 2020. 466 p.

Ranking can be a good start for any comparative analysis. We live in a society in which measurement, quantification and ranking have become commonplace, from pure curiosity (the 10 best roller coasters) to the creation of instruments that facilitate decision-making (the best MBAs). When a self-described compulsive ranker is an expert in public health policy, the result can be encouraging, not because of the ranking, but because of the proposed comparative analysis model of health care systems in different countries. Health care management researchers are aware of the importance of this analysis for the development of the area, but they understand the challenges in carrying it out due to the complexity of these systems and the nonstandard data that are being used for comparison purposes. Professor Emmanuel's work presents parameters for comparing 11 countries, and highlights the challenges and good practices in health care management around the world.

Ezekiel J. Emanuel is a professor and co-director of the Healthcare Transformation Institute at the University of Pennsylvania. In addition to his academic work, he was an advisor to the Director-General of the WHO and the Director of the Department of Bioethics at the US National Institute of Health. He has written and edited 14 books and over 300 scholarly articles, and he has also been the author of numerous newspaper articles.

Despite his passion for ranking, he finds it inappropriate to rank health care systems as their structure depends on the emphasis that each country places on the dimensions comprise them. If ranking is not appropriate, comparative analysis provides four valuable lessons: (1) no health care system is perfect, since the challenges that health care engenders for all countries result in difficulties that have to be solved; (2) lessons can be learned from the common problems that are faced, even by countries whose systems are considered excellent; (3) it is not possible to define which health care system is the best, but it may be possible to distinguish the good ones from those that are not minimally acceptable; (4) the dimensions of health care systems' analysis become clearer, as do the experiences of other countries in each dimension, which can throw light on future paths for the public policies that are required for improving them.

The comparative analysis involves 11 countries: Australia, Canada, China, France, Germany, Netherlands, Norway, Switzerland, Taiwan, the United Kingdom and the USA, which were intentionally chosen because of their differences, some of them having public funding, while others are privately funded, with insurance either being compulsory, or not. These are also the countries that appear most frequently in international debates about the topic, and all of them, for one reason or another, could be acknowledged as a model to follow.

Eight topics were evaluated for each country: (1) history; (2) coverage; (3) financing; (4) payment; (5) the delivery of health care; (6) prescription drug regulations; (7) human resources and (8) future challenges. History is key to understanding health care systems, because one of the arguments is that path-dependence makes it difficult to implement solutions that may have worked well in other countries. Two points are worth noticing: (1) the existence of universal health care systems is recent; (2) after universalization was implemented, there has been no case of reversion. Brazil is a similar case, with recent universalization and no reversal of the process so far. As Machado, Baptista and Lima (2012) highlighted, health care became universal in the country with the 1988 Constitution, in which health was recognized as a right, whose universalization was guaranteed by the creation of the Unified Health Care System (Sistema Único de Saúde - SUS). Subsequent decades have been characterized by battles for its effective implementation.

Seven of the challenges shared by these countries are also discussed: cost pressure; the high price of prescription drugs; reducing inefficiency and unnecessary treatment; the coordination of patient care; incompatible care institution characteristics that focus on treating traumas and infections, and the need for continuous care for patients suffering from chronic illnesses; mental health care; and, finally, long-term care for the elderly and how to pay for it. These challenges follow a worsening tendency due to the increase in the average age of populations and the development of more expensive treatment technologies. All these challenges affect Brazil (Saldiva, 2018), and the country is a benchmark in some of them, such as its Family Health Strategy (Estratégia Saúde da Família) program, which is internationally recognized for its coordination of patient treatment and long-term care (Machado, Melo, & Paula, 2019).

Finally, the author relates the pandemic to health care systems, arguing that they cannot be merged, as the response to the pandemic requires more than a functioning health care system: "The adequacy of the response depends upon political judgment and leadership to rapidly institute public health measures and the competence of the public health infrastructure to implement them effectively and swiftly". Without the political will to implement the necessary measures, there is no possibility of a positive response from the system, a lesson that the Brazilian government seemingly has not learned during this pandemic.

A point that requires reflection is the lack of emphasis on political dispute in the construction of these systems. Despite his PhD in Political Philosophy and historical contextualization that shows the disputes between interest groups, the author stresses path dependence in its economic sense, mitigating political challenges. In the case of Brazil political disputes involve health care actions aimed at the community and public health, and others of a private nature (Machado et al., 2012), culminating in a shared system between universalization of the public system and the supplementary private health care sector. Of those countries with universal health care, Brazil is the only one in which more is spent on health care in the private system than in the public one, even though the latter serves a greater proportion of the population (Silveira, Noronha, Funcia, Ramos, Moraes, Castro & Noronha, 2020).

Another criticism is that, in spite of defending the universalization of health care, the author accepts that all the dimensions he analyzed are of equal value, and the one that should receive most attention is a matter of choice. The universalization of health care in Brazil resulted from the political struggle of the Health Movement for the democratization of health (Cruz, 2017), which did not end with the universalization that is embedded in the Constitution. The disputes continue with the deregulation of complementary health care (Machado et al., 2012) and proposals for the creation of "affordable" health insurance for those on a low income (Saldiva, 2018).

The book presents an excellent comparative analysis model and is written in accessible language. Contributions to the area of Public Health Care Administration range from the systematization of the diagnostic model to the description of the good practices adopted to improve the efficiency of the systems. Good public and private management practices are also presented, especially innovations in cost management and the creation of incentives for the more efficient management of resources. It is written for academics, professors, and researchers working in the health, economics and management areas, who are looking for a synthetic comparative analysis for use when discussing the problems faced in Brazil. For Ezekiel, the appropriate way of facing up to the challenges that access to quality health care presents is in the ability to optimize the management of the resources invested, without losing sight of the ultimate goal, which is people's well-being.

Sidebar

AUTHORS' CONTRIBUTION

Mauricio Reinert was the only author of the review, being responsible for its conception, writing and final proofreading of the manuscript.

References

REFERENCES

Cruz, S.A.M. (2017). A criaçâo do Sistema Único de Saúde. Rio de Janeiro, RJ: Gramma.

Machado, C. V., Baptista, T. W. F., & Lima, L. D. (2012). Políticas de saúde no Brasil. Rio de Janeiro, RJ: Editora Fiocruz.

Machado, H. S. V., Melo, E. A., & Paula, L. G. N. D. (2019). Medicina de Família e Comunidade na saúde suplementar do Brasil. Cadernos de Saúde Pública, 35(11). doi:10.1590/0102-311X00068419.

Saldiva, P. (2018). Saúde. In: J. Pinsky (Org.), Brasil: O futuro que queremos (pp. 25-41). Sāo Paulo, SP: Contexto.

Silveira, F. G., Noronha, G.S., Funcia, F.R., Ramos, R.L.O., Moraes, R.M., Castro, L.C., & Noronha, J.C. (2020). Os fluxos financeiros no financiamento e no gasto em saúde no Brasil. Rio de Janeiro, RJ: Fundaçâo Oswaldo Cruz.