In New Zealand we’re pretty lucky when it comes to our health system. Our socialised health care system means that we pay some of the lowest prices for pharmaceuticals in the world, have mostly free access to secondary health care and subsidised primary health services.
Yet, yesterday when I was at the pharmacy I witnessed an old man who couldn’t pay for his prescription. It went like this, the old man goes up to receive his prescription, the pharmacist informs him that it will be $14 (which means it must be off the regular schedule of funded medicines), the man looks surprised and then leaves without picking up his subscription. When I tweeted about this yesterday alot of people replied that they would have paid for the mans prescription, I would have too but it was one of those things that happened quickly and I processed slowly.
Anyway, my initial tweet seemed to hit a nerve.
This got me thinking, is it a health system issue? and if so how could it be addressed? All the sorts of the things that would make my lecturers in the school of Population Health very pleased with me, but I quickly came to the conclusion that no, it is not a health system issue.
There are many ways to measure health system performance, talking about that itself would probably drive you silly but three fairly simple indicators are access, efficiency and quality.
The thing is that to satisfy any of these measures entirely there needs to be trade off’s. I.e. You could train and hire lots of new doctors to improve access but this may impact on quality, or you can improve the quality of services by increasing the amount of time a doctor can spend with a patient, but then less patients get the opportunity to be seen. In the example of the old man, you could make pharmaceuticals even cheaper than they already are with Pharmac (or even free) but the money would have to come from somewhere else. Think about cancer treatment – we want more and better treatment so where do we get the money? The government has decided to do it by raising prescription prices.
That last example is going to suck a lot for some people, but the thing is it’s a tough job getting the right balance and generally, New Zealand does fairly well. According to the OECD report, Health at a Glance, 2011, New Zealand’s life expectancy at birth is above OECD average (and the UK and US), and health care is comparatively cheap – we have one of the lowest rates of out of pocket expenditure as a share of final household consumption in the OECD. Notably we spend below the OECD average on our health system yet consistently produce better outcomes than the US (who spend the most).
Now I’m not saying that New Zealand’s health system is perfect. We still have issues with equity, waiting times, cost of primary services, health professional shortages, all that fun stuff. But the fact is that health is an area of infinite demand and finite resources. We can do better but I don’t think that it’s entirely up to the health sector.
This is where the definition of what health is gets useful. According to the WHO,
‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’
It’s pretty self explanatory, but to illustrate further Dahlgren and Whitehead do a pretty good job of demonstrating how this works. Enter, The Rainbow Model.
Clearly, health or ill health is not a single event. It’s the culmination of a variety of influences that conspire together to reach an outcome. For this reason maintaining and facilitating health is not the sole domain of the health system. It’s a part of every day life.
So what about that old guy in the pharmacy? Was his inability to afford his prescription the health systems fault or a symptom of the wider state of our society?
I’m going to look towards the latter. We already do well in terms of health care but we don’t do very well in terms of having an equal and thriving society.
It’s no secret that John Key has said in the past that low wages are a good thing – that they increase productivity, while Bill English proclaimed that low wages are key to giving us an advantage against Australia. Meanwhile, we now have a youth wage, because young workers should be thankful just to have a job (or something) and an increasingly punitive social welfare system thanks to Pulluptheladderbehindyou Bennett.
At the same time, McDonald’s is cheaper than raw vegetables, Coca Cola is cheaper than water and class/gender/generation niggling seems to be at a high. We can’t afford to keep superannuation as it is, but old people (who don’t own homes) can’t afford to rent them. Oh and there are still massive gaps between Maori and Pacific people and New Zealand Europeans across most things that people measure. You get the picture right? Or do I need to keep going…
Hopefully if you’re still reading this you’re intelligent enough to get what I’m driving at. But I suppose the big question is what do we do about it?
One suggestion is a living wage. This is being promoted by a huge list of organisations and is based on the idea that a living wage is the minimum hourly income necessary to achieve basic needs. It’s informed by the general level of wages in a country, the cost of living and the relative living standards of social groups and economic factors. Now, I’m not sure how achievable this is but I do think that it is something that is morally valuable to attempt to achieve.
One thing is certain. We can’t keep falling back and trying to make failed neo liberal market driven concepts work. A strong society is one that works together for the benefit of all and values prevention over cure. Personally I believe that a person’s health is their most valuable asset, but it’s something that starts far before the health system gets involved.
And for those people obsessed with dole bludgers and free loaders, it’s actually more expensive to do nothing than to help. Sorting out issues that are faced by people on low incomes is not about removing their obligation to participate in society but is about facilitating independence. To go back one last time to that old man – not only is it morally foul that an old man can’t afford his medicine, but to speak to that monetary driven paradigm, it’s actually cheaper for everyone to make sure that he gets it now rather than in hospital.
If you want bite sized versions of my rants and ramblings or just to tell that I’m wrong then follow me on twitter @madicatt