What do we really want from health funding?

Even in this golden  age of medical and surgical wizardry and developing gene science, all wrapped and ribboned in IT, we owe our health to things which won’t appear in budgets or election platforms in the ‘health’ category.

Although our relatively clean air, potable water, dependable quality food supply, education and low levels of poverty matter intensely in keeping us healthy, you will not find a line for them in the spreadsheets of those seeking our vote – at least not in the section labelled ‘health’.  True, The Climate and Health Alliance has welcomed the recent commitment by the federal ALP to a National Strategy on Climate, Health and Well-being, but this is unusual and there’s many a slip ‘twixt strategy and action. 

The recent federal budget reversed the perverse freeze on rebates for general practice, thank goodness. But with the medical literature revealing growing scepticism about ‘pay for performance’, more money into PIPs seems odd.  Medical research through the future fund fared well.

But more generally we are treated to the spectacle of goodies falling out of Santa’s Christmas sack – a few hundred thousand for each of two dozen clinics, scanners, screening programs, special allowances and other items designed to be enjoyed even as the dollars are quickly consumed. 

The days of big projects in health – like Medicare – the equivalent of Snowy Mountains II, appear to be over, yet integrated care and the new data technologies call for such responses. 

With rising numbers of people needing care for multiple chronic diseases, questions are being asked – not about the amount we spend on health care, but about where the money is going, and whether we citizens are getting value, in terms of quality of life, for our taxes.

There must be a limit to spending on health care or it could swallow the entire budget. Both as individuals and as a nation, we have many calls on our treasury, of which health care is just one.  Other countries roll spending on health and social welfare into one budget, and you can see why. In the US, the Department of Health, Education and Welfare was formed in 1953 and operated until 1980. 

But whatever the administrative architecture, spending on health – public and individual – competes with defence, education, and many other warranted demands of a civil society.

Given our specific interest in funding for health care, just how crucial is money to good health care?  Would more money improve life expectancy?  Would it improve quality of life? 

International experience demonstrates that there is an upper limit to the amount a country can spend on health care leading to improvements in life expectancy.  The US overspends wildly. If you imagine a graph that plots expenditure against life expectancy, you will see that big gains occur in health in poorer countries once they increase expenditure from low levels.  Little dollops, big gains.  The assumption here is that, if a country can afford to increase spending on health care, it will also have invested in other features of prosperity, such as better food, clean water, sanitation and immunisation.

But the graph does not continue upward for ever.  A limit is reached where increasing investment does not achieve further gains in life expectancy.

While life expectancy is a robust proxy measure for health, it does not measure quality of life, a health marker for which we have scant data. But it is the best available globally so we use it.  Comparisons of life expectancy show that:

“in 1800 no country had a life expectancy above 40 [Shakespeare was an ‘old man’ in his 40s when he wrote Lear] In the UK life expectancy before 1800 was very low, but since then it has increased drastically.

“In less than 200 years the UK doubled life expectancy at birth, and similar remarkable improvements also took place in other European countries during the same period.… People in some sub-Saharan African countries still have a life expectancy of less than 50 years, compared to 80 years in countries such as Japan …

“A century ago life expectancy in India and South Korea was as low as 23 years – and a century later, life expectancy in India almost tripled, and in South Korea almost quadrupled.“

These gains in longevity run in parallel not only with increasing prosperity, but with ever more years of age-related disability and chronic illness.  For relatively small investments huge dividends can be reaped

https://ourworldindata.org/health-meta

In Australia, we have reached the top part of the graph where greater expenditure in health care is not likely to increase life expectancy.  Our life expectancies are among the best in the world. This is not to deny the value in the incredibly expensive therapies which can help treat some patients with cancer and other precision targets, but they are exceptions.

There’s a billboard on a nearby church that asks, “What do you really want?”  This is a fair question to ask of our health care system.  As a society we can, and already do, spend more on health care because of its value in achieving improved quality of life. 

A desperate and expensively acquired few more days or weeks of life, or a better life-long quality of life?  The answer might well guide our health investment differently.  It may require quite different budgetary commitments to the ones we usually make when we think of ‘funding health’  Worth considering when Santa comes our way.

Published in he Medical Observer 16 April 2019 https://bit.ly/2GrF2GT