Edward T. Wimberley
Florida Gulf Coast University, Fort Myers, Florida
Khi V. Thai
Florida Atlantic University, Fort Lauderdale, Florida
I. OVERVIEW: HEALTH AND HEALTH CARE IN A GLOBAL MARKET
This book is devoted to issues relating to health care delivery, finance, and policy on an international scale. The international viewpoint provided within this text is intended to broaden the perspective of students, policymakers, lawmakers, health care providers, and administrators who assume that the health-related problems they are confronted with are somehow unique to their particular culture or market. There is little doubt that cultural, social, economic, and historical factors significantly shape health care policy and provision within any given nation. Nevertheless, it must be recognized that within the millennium health care will increasingly become an integral component of a global market in which nations compete for health-related technology, Pharmaceuticals, human resources, programs and services, and financing (Lazarus, 1999; Medical Marketing and Media, 1999; Velasquez and Boulet, 1999).
A. Health Care Costs, Access, and Delivery
Access to affordable, effective, and quality health care is without doubt the dominant theme that unites all of the Organization for Economic Cooperation and Development (OECD) nations discussed within this text. Access not only includes making health care available to the largest portion of a nation's population; it also involves providing the appropriate level or type of care. How the issue of access is approached depends upon current economic, cultural, and political characteristics of nations, as well as upon the historical pattern of health care delivery within nations, and the nature of the health care infrastructure that is currently in place.
The global nature of the world's health care market is clearly observable within the OECD nations included in this book. Nations with varying economic capacities for providing quality health care for their populations find themselves in a situation where increased global communications heightens consumer expectations regarding what constitutes optimal "quality" and "accessible" health care. Such communication allows providers and citizens to remain current with the latest available medical technologies, procedures, and Pharmaceuticals, which in turn motivates practitioners and their patients to seek these latest approaches and technologies.
Since access to such resources is costly, nations either find themselves endlessly spending national resources to keep up with the most current medical technologies and approaches and/or seeking to limit (i.e., ration) access to expensive technologies, Pharmaceuticals, and procedures. Australia and the United Kingdom are examples of nations where rationing has been employed for some period of time, with generally broad-based public support (Bloor and Maynard, 2000; Lapsley, 2000). In nations such as the United States (Wimberley and Rubens, 2000; Pohl, 2000) where access to care is largely associated with access to employer-based health insurance, skyrocketing health care costs driven by medical technologies and pharmaceutical developments can result in:
A complete or partial lack of access to health care for those lacking insurance coverage or financial resources,
Limited access to services for those who have access to health insurance or coverage, and
Immediate and full access for those with comprehensive insurance coverage, or for those with access to sufficient cash resources to pay for services regardless of costs.
As will be seen throughout this text, health care costs have created international problems of access to health care insurance and services. In virtually every nation, citizens can be categorized as falling within a group of "haves," "have some," and "have nots," in regard to access to even basic health care services. In every case citizen demand for such coverage is high, and is increasingly linked to rising consumer and practitioner expectations of quality, accessibility, and costs. However, each nation is experiencing some degree of mismatch between citizen expectations and economic realities. In the end, each nation is in competition with every other nation for a greater share of health care resources.
Unfortunately, there is no real upper limit on health care costs, particularly if nations and their citizens continue to pursue the most up-to-date health care technologies, products, and services. Something has to give, and in most instances what is "giving" is the delivery and financing models utilized within nations. Today, virtually every nation is pursuing some form of ''rationing," "reengineer-ing," "revamping," or "restructuring," of its health care systems. Patterned upon cost-containment strategies developed in the United States and exported abroad, these strategies are increasingly subsumed under the concept of "managed care." As the managed care philosophy becomes more prevalent internationally, issues of quality, access, and cost are becoming a subject of virtually constant international debate and discussion.
B. Health-Related Human Resources
A related theme to the one discussed above is the issue of national access to and training of persons engaged in medical, nursing, and allied health professions. As will be seen throughout this text, there are significant variations in the supply, training, and quality of health care providers from nation to nation, despite a significant degree of continuity of caregiver roles across nations and cultures. Unavoidably, citizen satisfaction with their nation's health care system is related to the perceived quality of providers. Where health care providers are well trained and where they remain current with modern technologies and treatments, citizens seem to be uniformly pleased with the quality of care that they receive (Pohl, 2000; Patel and Rushefsky, 2000). However, where training is perceived to be inadequate or lagging, consumer confidence falls (Bourganskaia et al., 2000).
This issue is of particular importance since most nations experience a tendency on behalf of their citizens to proceed directly to tertiary-specialist-level care without initially going through primary-care providers. The result of such practices is an overutilization of specialty care that, in turn, overrelies on technological, procedural, and pharmaceutically based interventions, even when equally or more effective interventions can be accessed less expensively at the primary care level. To remedy the penchant of the public to overutilize tertiary and inpa-tient resources, nations around the globe are making access to primary-care resources more available, while limiting access to specialty medical providers. As a consequence, some providers report that they now feel that they are being asked to practice outside their levels of competency (Evetovits, 2000).
C. Public and Environmental Health
This book also addresses issues relating to public and environmental health issues, particularly those aspects of public and environmental health that can result in the prevention of diseases and disorders. While these issues apply to every nation discussed in this text, it is a particularly important issue for the former "Soviet bloc" nations. Historically, these are the nations that have experienced some of the worst environmental and public health problems relating to unfettered industrial and weapons production during the Cold War era (Bourganskaia et al., 2000; Evetovits, 2000). However, having observed this, environmental and public health problems relating to disease prevention are common themes for all nations, particularly for those emerging nations that emulate the currently industrialized countries.
D. Disenfranchised Populations
The chapters to follow also uniformly reflect problems in providing access to disenfranchised populations and groups within their national borders. In some cases, these groups may be categorized by age (children and the elderly), working status (unemployed and underemployed), ethnic or cultural status (such as Native Americans or aboriginal peoples) (Lapsley, 2000; Malcolm, 2000), or by virtue of their lack of resources to access the health care system. Likewise most of the nations discussed in this book are experiencing geographical challenges in providing quality, affordable, and accessible services (Bourganskaia et al., 2000; Patel and Rushefsky, 2000; Angeletti, 2000; Niakas, 2000; Malcolm, 2000). In most instances these challenges involve providing services to rural areas, while in other cases, such as in Italy, equality of access varies with the region of the country within which one resides.
E. Demographics and Population Aging
Finally, this book discusses issues of demographics and aging that not only relate to current cost, consumption, delivery, and access issues, but also relate to the future demands and needs of the world's health care systems. In virtually every nation discussed in this text, the aging of the population, coupled with increases or decreases in the birthrate, has resulted in a variety of strains on national health care systems (Wimberley and Rubens, 2000; Rieko and Kazue, 2000). Such strains typically involve the capacity of a nation to pay for needed health care services for the elderly, the capacity to plan for future needs, and the willingness of the society to assume a larger role in caregiving as opposed to leaving this responsibility to individuals and families. Inherent to this discussion is the issue of intergenerational equity and fairness.