The shifting
landscape of healthcare in Asia-Pacific
Healthcare in Australia,
China, India, Japan, and South Korea has seen substantial success, with life
expectancy rising markedly over the past two decades in each country. In
health, however, the playing field never stays constant with changing risks
presenting challenges for each country. This study looks at current and likely
future disease loads for these five countries as well as how healthcare systems
are set to cope with them. Its key findings include:
Non-communicable diseases
already dominate the current health burden in the five countries
in this study.
Traditionally,
communicable diseases are associated with developing countries and
non-communicable diseases (NCDs) with developed ones. Japan, Australia, and
South Korea made the epidemiological transition to an NCD-dominated health
burden some time ago. In recent years, China has joined them, with 85% of its
mortality coming from NCDs in 2010. Even in India, a majority of deaths (53%)
came from this group of diseases and the figure is likely to grow. Communicable
diseases inevitably remain a potential threat to all countries, and an ongoing,
widespread challenge to health systems in India and China, but the main health
burden is, and increasingly will be, NCDs.
The impact of specific
NCDs affecting the five countries vary greatly, with China and India now the
worst affected.
A common set of risks
accounts for much of the growth in the number of NCDs, including: ageing; unhealthy
lifestyle choices around smoking, diet, and exercise; environmental pollution;
and urbanisation. The extent of these risks, however, varies greatly between
countries so that the specific NCDs affecting populations also differ markedly.
Excessive salt consumption, for example, elevates the number of strokes in East
Asian countries while excessive caloric intake means that heart disease is a
bigger problem in Australia. Air pollution, meanwhile, is driving up chronic
obstructive pulmonary disease (COPD) and lung cancer incidence in China and
India. Currently, the voluntary and
involuntary risks experienced in developing countries are exacting a heavier
price than those in developed ones: according
to the WHO, in South Korea, Japan, and Australia, the combined probability of
dying from cancer, heart disease, diabetes, and COPD between the ages of 30 and
70 is just over 9%. In China, though, it is 19% and in India 26%.
Mental illness is too
often an unrecognized part of the burden.
Mental illness is a
significant NCD, but, because it is directly responsible for few deaths,
mortality data tends to hide the size of its impact. In terms of total years
lived with disability by a population, though, the health burden is
huge—between 20% and 30% of the total. Service provision
for those with these conditions is usually insufficient. Although China and
India are beginning reforms in this area, health care personnel and
infrastructure remain insufficient to meet patient need. Japan and Korea,
meanwhile, remain wedded to care in isolated hospitals rather than the
community based provision which is current best practice. Although Australia
has gone furthest in the right direction, it still has a long way to go.
The NCD challenge
requires patient-centred, accessible healthcare systems.
Most healthcare systems
were developed for, and are still bestsuited to, acute care. At our current
state of medical knowledge, though, NCDs are largely chronic conditions which
require long-term management. A system capable of meeting this challenge well
needs to: give appropriate attention to cost effective prevention as many NCDs
are preventable; be accessible so that care will be more than sporadic and
episodic; provide patient-centred care, in which healthcare providers support
patients to manage their own conditions rather than dictating from above; and
be integrated so that it can provide each patient with coherent, customised
care—a need typically best serviced by a strong emphasis on primary care. Such
a system would benefit not only those with NCDs, but describes the type of care
which experts in communicable disease such as tuberculosis and HIV also
advocate.
None of the healthcare
systems in this study meet this ideal and several are worryingly illsuited to
face their current healthcare burden.
Each of the countries
covered has weaknesses:
Australia—Although it has strong
assets within its healthcare system, these require integration around the
patient rather than exhibiting a provider focus. Currently patients can find it
difficult to navigate the complexity.
China—The country’s recent
healthcare reforms have so far failed in their goal to establish integrated,
patient-centred, accessible care. Instead provision typically involves
episodic, very brief interaction with harried staff in hospitals. Moreover,
costs remain high and frustrations have damaged patient-clinician trust to such
an extent that two-thirds of Chinese do not trust doctors’ professional
opinions.
India—The country’s healthcare
system is still almost entirely organised around acute care to an extent that
even the health ministry acknowledges that efforts against NCDs are only
“nascent.” High costs also make regular care difficult for much of the
population to afford. Both these factors make effective chronic care extremely
difficult: one interviewee estimated that half of the country’s 62 million
diabetics do not even know they have the condition.
Japan—Japanese healthcare has
many strengths, but is doctor-dominated, hospital focused and has a weak role
for primary care. The result is poorly integrated provision in which patients
face lengthy waits for very short consultations as doctors and specialists are
in short supply. It is also an open question whether the current system is
financially sustainable when funding relies on a debt-strapped government.
South Korea—Despite impressive
improvements in its healthcare system in recent decades, South Korea shares
some of Japan’s flaws, including weak primary care, an overemphasis on
hospital-based provision, and too few clinicians. The quality of care also
needs more attention and provision for those with mental illness is
particularly poor given the need.
Initiatives both large
and small point to changes that can work.
There is no simple way to
create a perfect healthcare system, but diverse initiatives in the countries in
this study show that change is possible in a range of important areas:
Prevention—Effective prevention
involves winning people over as well as creating conditions which make healthy
choices easier. This can occur at various levels. In Seoul’s Gangdong district,
health counselling centres based in the community rather than in healthcare facilities
are attracting large numbers of citizens and having a measurable, positive
effect on health indicators. At the national level, Australia’s anti-tobacco
efforts, through decades of consistent, coherent activity combining education,
regulation, and taxation have brought down smoking rates from 38% in the
mid-1970s to 13% today.
Universal access—China’s healthcare reform
efforts have, as noted above, substantial weaknesses but it would be wrong to
overlook their successes. The widespread extension of insurance has helped
allow a substantial increase in use of healthcare facilities as well as an expansion
of basic provision such as vaccinations and ante-natal care.
Patient-centricity—The Flinders Chronic Condition
Management Programme in Australia has created self-management support processes
that involve true partnership between patient and clinician, putting into practice
the oftespoused wish for patient-centric, integrated care. Early studies
indicate that it is improving healthcare outcomes as well.
Technology—Information and
communication technology have important innovations to offer medical care.
Japanese surgeons and diabetologists are using big data to shape understanding
of best practice. Cardiac surgeons, who were pioneers in the effort, have seen more
than a decade of improved outcomes. IT is not limited to well-off countries. In
India, the Swasthya Slate is a point-of-care device that allows healthcare
workers to conduct 33 different tests on the spot and feed the data to more
senior clinicians if appropriate.
Reshaping care—If doctor-delivered,
hospital based care is too expensive for dealing with an NCD-based disease
load, what alternatives might exist? Long Term Care Insurance in South Korea
has for several years been providing subsidised social care for the elderly and
has shown the potential for reducing levels of social hospitalisation—the
long-term housing of the elderly in hospitals for lack of a better alternative.
In India, meanwhile, the Accredited Social Health Activist programme has helped
train 900,000 community health workers in rural areas. Maternal and child care
have especially benefitted.
Courtsey- The Economist
Intelligence Unit Limited 2015
