Between Healthcare Access and Excess

Site Staff — Sun, 29 Apr 2007 04:02:51 +0000

The health of a nation is directly proportional to the type of health care access it offers. The healthcare access in turn is mainly dependent upon the amount and manner of resource allocation.
While healthcare is part of basic rights in the developed world, people in the third world still face an uneven quality and access to health care. For the public in the third world the grind of other pressing issues like food, shelter, and security often overshadow occasional health bumps. Therefore, healthcare policy is on the back burner for the policy makers and the public alike. Given the facts, is it unrealistic to expect universal health coverage from your government and society? Is universal healthcare that critical for the health of a nation? Finally, and most importantly is it even feasible in countries like Pakistan?

Maybe some figures would help. According to the WHO, the Infant Mortality Rate (IMR) in the U.K. for the year 2004 was 5.3, while it was 6.7 in the U.S. and a dismal 80.2 in Pakistan. Similarly, the life expectancy in the U.K. for the year 2004 was 78.5; it was 77.4 for the U.S. and 64.9 for Pakistan. U.S. data – although vastly better than Pakistan – still occupies the bottom rung of the Western world much to the chagrin of public health experts here and amidst much public disapproval.

This may come as a surprise to some that think that the U.S. healthcare system is the most advanced and sophisticated in the world – which it is. What could possibly explain this disparity? The US spends 15.2 % of its GDP on healthcare, the UK only 8% while Pakistan spends a paltry 2.4%. What is the underlying reason for the U.S. to lag behind other Western nations despite a very robust healthcare budget? The answers to these lies in the manner healthcare resources are allocated in the U.S. In this case, it is the lack of universal and basic healthcare in the U.S. that sets it back.

Public heath experts in the U.S. have long argued this point. According to the U.S. Census Bureau, about 16% of the Americans are uninsured. According to the same source, with an uninsured rate at 19.0 percent among children in 2005, children in poverty were more likely to be uninsured. While the in the U.K. healthcare is universal for at least basic health services. Contrast that to Pakistan where there is no health coverage at all. According to the WHO, 72% of the total healthcare expenditure in Pakistan is private expenses, of which 98% are out-of-pocket expenses. This factor alone puts a damper on the frequency and extent of medical care sought by the public. These disparities in health insurance translate into poor health outcomes as noted above.

Lack of universal healthcare in the U. S. and Pakistan highlight the same fact – albeit in starkly different ways. The U.S. with all its excellence in tertiary care and R&D is still a laggard in basic health numbers in the Western world. No matter how much you spend on fancy medicine, basic health coverage for all (or lack thereof) still makes a difference. In Pakistan as in any other third world country, the conclusions are more straightforward – no health coverage means very poor collective health.

Whereas in the US healthcare has become a juggernaut that is becoming more and more unruly, it is in dire need of a jumpstart in Pakistan. Experts have pointed out various reasons for that ranging from lack of political will to poor resource allocation to inept allocation processes. On a psychosocial level, the greatest impediments to a better health care system in Pakistan come from general public malaise and institutional cynicism with the deep-rooted belief that our moribund system is incurable. Unless we can overcome these psychosocial and political hurdles through a strong leadership or grassroots effort or both, the future does not look too good.

This article was also published at the Pakistan Link website.

The Aid Debate

Site Staff — Mon, 25 Dec 2006 00:42:16 +0000

According to the Millennium Project "More than one billion people in the world live on less than one dollar a day. In total, 2.7 billion struggle to survive on less than two dollars per day". Eradication of poverty is a noble yet Utopian goal according to many. When Jeffery Sachs published his "The End of Poverty: Economic Possibilities for Our Time," amid much fanfare it was considered by some as the answer to this perennial problem. The book had a gusto that was infectious, a vision that was grand and a flair of a rock star (its introduction was written by Bono). According to Sachs who also works for the Millennium Project "Extreme poverty can be ended, not in the time of our grandchildren, but our time" – a lofty claim indeed. One of the key factors to end poverty is through aid given by rich countries. However, there are problems with this approach. There is often a disparity between the money pledged and the money actually donated. Also, the goal of optimal amount of aid as defined by 0.7% of the national income is rarely realized. An average American on the other hand thinks that the US gives about 25% of its budget in foreign aid (the actual number is less than 1%). A recent book by William Easterly, "The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good," suggests that the world’s official aid agencies especially the World Bank, the International Monetary Fund, the UN, have been peddling the same failed aid plans for the last 50 years or so. He is critical of the Sachs idea of big money and big push to end the poverty trap. Instead he makes a distinction between Searchers and Planners. Planners approach the problem from supply side, go big and mostly underachieve. The Searchers think small, piecemeal steps and bring about a slow change. According to him Searchers achieve the most in the end. Easterly does no go without a challenge though. Amartya Sen is pretty critical of him. The most serious charge against Easterly is not about his premise though. According to Sen his analysis falls short of academic standards. For example Sen points out that his statistical analysis fails to establish a negative association between economic aid and poverty. Sen goes on to say:

"Many such studies are also impaired by difficulties in identifying what is causing what. For example, a country’s economic distress may induce donors to give it more aid — which may, in terms of associative statistics, suggest a connection between aid and bad economic performance. But using such a correlation to prove the bad effects of aid turns the causal connection on its head. Easterly tries to avoid such pitfalls, but the statistical associations on which he draws for his comprehensive pessimism about the effects of aid do not offer a definitive causal picture." Many such studies are also impaired by difficulties in identifying what is causing what. For example, a country’s economic distress may induce donors to give it more aid — which may, in terms of associative statistics, suggest a connection between aid and bad economic performance. But using such a correlation to prove the bad effects of aid turns the causal connection on its head. Easterly tries to avoid such pitfalls, but the statistical associations on which he draws for his comprehensive pessimism about the effects of aid do not offer a definitive causal picture."

It is hard to prove negative or positive association in this sort of studies where there are too many variables involved. Often it is hard to measure progress or change in concrete terms. For some the answer lies in too-little-too-late approach by the donor countries while for others it is the corrupt and inefficient bureaucracies of the countries accepting donations that are to blame. We thus see two opposing paradigms pitted against each other. One is for big push and big money and the other is for piecemeal change that comes from within. The former premise appeals to most of the people in the third world and many whistle blowers and to people who are weary of big organizations like the World Bank, the IMF and the UN. The latter makes sense to most of the people in the Western world. Perhaps like many other debates this one is also too metaphysical to reach one true conclusion – perhaps the final answer lies in the eyes of the beholder.

The Ethics Observer » Poverty

Between Healthcare Access and Excess

The Aid Debate