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OPINION MATTERS
Musings on the future of
health care systems
BY FERDINAND SIEM TJAM
FMR. PERMANENT SECRETARY MINISTY OF HEALTH SURINAME AND
FMR MEDICAL OFFICER, WORLD HEALTH ORGANIZATION
In the summer of 2000, the World Health Organization
published its World Health Report 2000. This report
considered a national health care system to consist of
three components: health service delivery, fairness of
financing and responsiveness to the need of consumers. It
focussed mainly on activities of patient care, which is also
the main activity of health care systems in Europe and the
USA. A review was made of the prevailing systems and
services of the WHO member states, and the results were
ranked according to their scores. Based on the above criteria,
the health care system of France was ranked as the number
one in the world. This finding raised quite a number of
eyebrows. It caused robust debates within the various
Regional Committees of the World Health Organization
and in national Ministries of Health. Doubt was cast on
the approaches, methodologies and information used for
compiling the ranking in this report. Interestingly, there
was little reaction from Academia, university departments
and health research institutes, and recently, little has been
said of health care systems.
In the summer of 2003, an extreme heat wave hit the
European continent and in the space of a few weeks, over
ten thousand mostly elderly persons reportedly died in
France alone. The prevailing view was that the French
health care system was to be blamed. It had been
deficient in its surveillance, care, early warning and
effective measures in dealing with the heat exhaustion and
dehydration that caused many elderly patients to die. Just
this summer, there was another outburst of anger among
some sectors of senior health care workers in France.
They were of the opinion that the French health care
system’s financing for up-to-date equipment and
remunerations had been lagging behind for too long.
Threatened action could be averted only just in time by
government intervention.
One can ask the question: what went wrong in a health
care system that was found by the World Health
Organization to be the number one only a few years
before? Did the French health care system deteriorate that
quickly? Or had the evaluation of the WHO, so widely
discussed, been incorrect, or was the health care system
concept defined by WHO different from what the people
in France think it should be? Conceivably, the answer is: all
of the above.
The care of the vulnerable and weak elderly is a matter of
domestic, or domiciliary care rather than ‘health care’. Their
need is primarily social, financial and organizational,
including human contact, assistance with cooking, shopping
and moving outdoors. Today, the care for the sick, infirm
and elderly is predominantly dealt with through institutions
and organizations rather than families. Reportedly, this
approach is weak in attention and interest for the dependant
person. And typically, heat exhaustion and accompanying
dehydration is more a matter of attention than medical care.
It remains debatable whether the domiciliary care for elderly,
who effectively suffer from a range of conditions that cannot
be alleviated or improved with a medical intervention,
should be considered a part of the responsibility of the
‘health care system’. The industrial action about insufficient
financing for up-to-date equipment and appropriate
remunerations is an expected and regular eruption in the
social landscape of any society. To what extent should this be
laid at the door of the ‘French health care system’?
In the approach taken by the World Health Report 2000,
financing was given a high profile. However, financing can be
argued to be an essential part of a system in the same way as
gasoline can be argued to be an essential part of an
automobile. Without the gasoline, the car cannot function.
But when considering the automotive concept of the car,
gasoline, not being specific to the car, is generally not
considered a major component of its design and operation.
Evaluating a health care system by the fairness of its
financing is like measuring the knowledge and practice of a
physician by his billing practices. How did the financing
component increase to such importance in the global
perception of a national ‘health care system?’
By the early 1990s, communism was all but gone and
socialism had taken a back seat. Demographic changes in
How did the financing
component increase to such
importance in the global
perception of a national
‘health care system?’
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00 | World Hospitals and Health Services | Vol.40 Vol. No.2 40 No. 3 | World Hospitals and Health Services | 47