Global dimensions of unnecessary care: Julio Frenk

Below is Dr. Julio Frenk’s speech from the 2012 Avoiding Avoidable Care conference.

The global dimensions and implications of unnecessary care
Julio Frenk, MD, PhD

Thank you very much. Good morning to everyone. I’d like to start by thanking the Lown Cardiovascular Research Foundation and the New America Foundation, especially my good friend, Vikas Saini, and Shannon Brownlee for this invitation. It is always an honor to participate in any activity where Bernard Lown is present and providing his eternal inspiration. At the Harvard School of Public Health, we are immensely proud of being associated with his fantastic legacy, now as Professor Emeritus of our faculty. He continues to be one of the true heroes at the School and I know well beyond its walls.

I’ve been asked to reflect on the global dimensions and implications of avoidable care. And my message in my brief remarks will be very simple. It is clear that avoiding unnecessary care is a global concern. It is crucial, not only for developed countries where most of the research literature on the topic has emerged, but also increasingly for low and middle-income countries. The fact is that we are in the midst of the most tense and intense transition in health matters in all of human history. And what used to be a firmly simple view of the world is now being challenged by growing levels of complexity and by very intense and rapid change. We used to have a simple view where the world was divided in poor countries, mostly suffering from infectious diseases, malnutrition, maternal mortality on the one hand, and then on the other hand, rich countries mostly suffering from noncommunicable disorders. That reality is no longer true. And what we see is the need for new ways of thinking. The old conception of international health, which mostly meant infectious diseases of poor countries, is completely out of date with today’s reality. And when I talk about global health, I like to start by saying that global health is not foreign health. It’s not what we do when we’re outside of the United States. Because, what’s happened in our world is that global is no longer the opposite of domestic. There’s no longer a meaningful distinction because anything that happens anywhere in the world affects everybody else.

To my mind, the key notion of our own global health is the concept of interdependence. And we have become much more interdependent. The main force driving interdependence in health is the global transfer of health risks and opportunities. Inadequate partners of practice and unnecessary technology are among them. So, I’ll try to talk a little bit about that.

First, as I said, the picture has become much more complex. Today, most developing nations in the world (and by the way, I think we are going to have to avoid that term, “developing nations.” We are talking about such a heterogeneous group of countries that the term has become totally meaningless.) But low-income or middle-income countries are suffering today from what I would call a triple burden of disease. There is still clearly an unfinished agenda of common infections, undernutrition, and reproductive health problems, especially maternal mortality. And although great progress has been made on the global scale, we must not forget that there are still about 275,000 women who die every year, who lose their life in the act of giving life, who lose their life during pregnancy and childbirth; 99% of those deaths happen in poor countries. But there are still about 4 million children who die from vaccine-preventable diseases. Things that just shouldn’t happen in the 21st century. So we do have an unfinished agenda.

Without having fully solved that unfinished agenda, practically every developing country in the world is now facing the emerging challenges represented by noncommunicable diseases and the growing epidemic of injury, both unintentional, so-called accidents, and intentional through violence. Finally, if that was not enough, most countries at all levels of development are increasingly exposed to the health consequences directly related to globalization, such as the spread of pandemics, like HIV/AIDS or more recently H1N1, the health consequences of primary change, which affect countries around the world, and also very importantly, the health risks associated with the global dissemination of unhealthy lifestyles. The latter is largely responsible for the silent pandemic of obesity, which some have called globesity, exactly to underscore the global nature of this problem.

Thus, it is a much more complex picture. And it makes priority setting even more complex than it used to be. It underscores the absolute need for health systems that perform in an adequate manner.

The first challenge is that health systems around the world have just not kept up with this much more complex reality. It may sound strange to say it here, sitting in Cambridge, or Somerville, Massachusetts, but, you know, most countries of the world actually are underinvesting in health. When we’re sitting here with 17% of GDP going to healthcare, it sounds a little bit foreign, but the fact of the matter is that most countries are underinvesting. Developing countries definitely need more money for health, but in the words of another giant of health like Bernie Lown, the great Professor Ramalingaswami of India, it’s not only necessary to get more money for health, but also more health for the money. That is at the core of the topic of this great conference.

As I said before, in our old understanding we had a clear simplistic view of the world. Risks flowed from south to north. Poor people migrating would carry germs and other risks. And solutions flowed from north to south. That was the paradigm of the old models of international health. I think today in a much more complex view of health interdependence, that dichotomy just doesn’t hold. Many, many risks flow from north to south. The tobacco industry is a great example of that. Differential standards of occupational and environmental health and safety associated with trade patterns is another example of risk flowing from north to south. And a major example is the transfer of inappropriate models of care and technologies that underlie a lot of the avoidable care problem.

Signs of unnecessary medical care are emerging all along the cycle of care. It starts with the definition of a particular disease or risk factor. It goes onto the prevention of ailments. It continues into the process of clinical diagnosis and then into the prescription of treatments. So, for example, conditions that were previously considered mere inconveniences, like baldness or wrinkles or certain sexual difficulties associated with aging, are being medicalized and the thresholds that separate the healthy from the sick are sometimes arbitrarily lowered. Pharmaceutical products are being prescribed for conditions like mild hypertension that could be prevented with changes in lifestyle. Tests are routinely ordered for disorders that usually don’t require them, such as performing scans for a simple headache. Patients are increasingly overtreated by prescribing unnecessary drugs or procedures. And in addition to the direct iatrogenic or potential for iatrogenic harm, unnecessary interventions break the delicate balance between risks and benefits that, in the work of my mentor, Avedis Donabedian, is the very essence of the definition of the quality of care, that balance between risks and benefits of care.

Now, the point is that these trends towards avoidable care are present in low and middle-income countries. This is driven by a number of factors, but the fact is that the healthcare industry, this industrialization of care that Bernie was talking about this morning, is a global phenomenon because this is a global industry. The health economy represents 10% of the world economy today – about $6 trillion. And although a single country, and I’ll leave it to your afternoon reflections to guess which country it is, accounts for 40% of global spending in health, still even the poorest countries in the world are exposed to substantial expansion of investments that don’t necessarily reflect the epidemiologic priorities.

So there is a convergence, both in the epidemiologic profile with the emergence of noncommunicable diseases and also in the policy considerations that countries are having to face. Although there’s a huge variation in local conditions, particularly the degree of democratic governance, the presence or extent of social inequality, the policy concerns have also acquired a universal character. It is precisely in order to confront some of these challenges that during the six years I had the enormous privilege of serving as minister of health of my country of birth, Mexico, we actually did implement a comprehensive reform that started in 2003. I don’t have much time now, so I’ll just say that we wrote into the law the need for systematic evaluation of the reform. There’s a whole body of literature about this reform, including a series of seven articles in The Lancet published in 2006 and afterwards.

To summarize, let me tell you that last month, Mexico was able to announce to the world a major milestone: the achievement of universal health coverage. Because that reform was motivated by the fact that there were 50 million uninsured people, a problem not unlike the one in the United States. Access to insurance was linked to formal salaried employment, and what that reform did, as did the health reform in Massachusetts and as does the Affordable Care Act, is to de-link access to insurance, and instead of treating it as a benefit of employment, it treats it as a right of citizenship, a right of living in a country. It is a right. It’s not a benefit of employment. That is a conceptual shift with profound ethical implications which unfortunately we don’t have time to go into. I very much agree with what Bernie said this morning, policy has to be accompanied by a process of ethical deliberation and a clear will to assume health as a right and not a benefit or a merchandise.

If a new insurance scheme were introduced in the U.S. policy would have been called a public option, which we call Seguro Popular in Mexico. Last month it achieved a goal of insuring 52 million previously uninsured persons who are now fully covered by this new insurance scheme. Therefore, Mexico has now reached the globally cherished goal of universal coverage that has alluded most poor nations and a notorious rich one.

I will end by saying that the only way to make this sustainable is to adopt a comprehensive approach. And I think this holds important lessons for the United States. When you expand insurance and remove financial barriers to demand, the expansion of demand will become unsustainable unless you accompany such expansion of financial protection with two other pillars of comprehensive reform. One is a renewed emphasis, a whole new generation of prevention, or measures directed towards disease prevention and health promotion that tackle the social determinants of ill health, a reason why people get sick in the first place, and that allow for early detection and timely prevention of disorders. Otherwise, the downstream effect of expanding insurance, without the upstream preventive interventions, will make the system unsustainable. Many countries that have expanded insurance paradoxically have actually cut back on public health and preventive interventions, which is a self-defeating proposition because it loses not the economies of skill but the economies of aggregation when you deal with the upstream and the downstream. In Mexico we create a separate fund to protect investments in public health and preventive care as is the case with the Affordable Care Act, although that’s the part of the legislation that’s most at risk of repeal if that comes to happen.

So the first pillar is a new generation of preventive and health promotion activities. The second pillar is of course health insurance, financial protection against the consequence of illness. And the third is innovations in delivery – new modes of delivery that accompany the capacity to provide surveillance about the nature of care. In our case, the connecting point was to define an explicit package of guaranteed benefits or entitlements that allowed for three things. First, it empowered patients because it made them conscious about their entitlements as a result of being insured. Secondly, it operationalized the concept of the right to healthcare by saying this is exactly what it is. But third and most importantly, it provided a blueprint both for planning of deployment of facilities and acquisition of technologies and human resource planning, and also for an attempt to reduce unjustified variations of care, which is so much at the heart of the problem we are dealing with. The problem of unjustified variations that are not justified in terms of outcomes, but that explode both the volume of care and especially of unnecessary care.

As I said not only do risks flow from north to south at present, including inappropriate models of care and certain technologies, but also now solutions flow from south to north. And I’m particularly impressed by the notion coined in India of frugal innovation, where actually I think there’s a lot to learn. That’s allowing countries like India and China and other emerging countries, to leapfrog, and that’s the only way we are going to be able to deal with the triple burden of disease. But I think it also offers important lessons as rich countries face the need to contain costs as a result of physical constraints. Frugal innovation refers both to specific technologies like devices and new forms of organizing care, and it also includes managerial patterns that allow us to better monitor the quantity and quality of care. I think in that respect, we have a lot to learn from each other. So, I look forward to conferences like this one, where we can have an opportunity for shared learning. I think the ideas surrounding this conference are crucial for the future of health systems all over the world, both in highly developed countries that are facing the imperative of cost control, while insuring the continued nature of universal access to care, and with emerging and developing countries which are facing this complex health transition and the need to make the most of limited resources. In all cases, I am convinced that a just world will require well-performing health systems that give a real meaning to the quest which is truly universal: the quest for high-quality services that protect every single person in our interdependent world. Thank you very much.



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