There’s good news to report on health care in America. Obamacare has increased coverage by 10 million people, spending growth has dramatically declined, and preventable hospital errors such as drug mistakes fell 17 percent from 2010 to 2013, saving 50,000 lives. In the U.S., at least, it appears possible to increase efficiency, cost-effectiveness, and access all at the same time.
The picture is less positive across much of the developing world. While the call for universal health care in every country is now the official stance of the World Health Organization, attempts to meet that goal have often seen limited returns. The overwhelming focus on quantity of care is ignoring a massive problem with quality and efficiency. Unless that’s addressed, a lot of money will be spent on expanding access—with little impact.
A World Bank review of extending universal health coverage in developing countries found that providing subsidized or free care did increase access to those services, especially by the poorest people. Such schemes also reduced recipients’ out-of-pocket expenses associated with health care. There were also some successes related to health outcomes. Argentina’s Plan Nacer, for example, provided services to pregnant women and young children, which was associated with a 2 percentage point reduction in early newborn mortality.
Yet only five out of 18 studies of coverage roll-out found a positive impact on health indicators such as death rates or reduced sickness. In India, for example, the government has started paying mothers who deliver children in hospitals. As a result, from 2005 to 2011, the number born in a health facility more than doubled in nine Indian states. But the massive increase in institutional births had no impact on infant mortality. If anything, according to World Bank researcher Jishnu Das, the rise of hospital births is “remarkably consistent with the halting of a slow decline in infant mortality.” Rwanda has seen a similar phenomenon: a big rise in births with a skilled attendant with no impact on health.
Across countries, there is no relationship between overall levels of health expenditures and health outcomes at a given income per head, nor a link between health inputs such as doctors and nurses per capita and health outcomes. The number of hospital beds per person worldwide actually fell by a quarter from 1960 to 2005, even as global health massively improved—with average planetary life expectancy climbing from 52 years to 69 years.
One reason for the gap between health inputs and health outcomes is the low quality of care. Though many health-care practitioners are hard working and honest, a lot aren’t. In 2003, if you turned up unannounced to a health-care facility in India and asked to see a staff member, 40 percent of staffers who were meant to be there were absent. Among doctors in rural Bangladesh in 2004, that figure was above 70 percent.
And hospital staffers are often ignorant of the right approaches or face incentives to provide the wrong treatments. A 2013 survey in Kenya found that only a little over half of doctors and nurses could diagnose at least four out of five common conditions when their major symptoms were described—malaria with anemia, diarrhea with dehydration, pneumonia, tuberculosis, and diabetes. When it came to treatment, health providers adhered to less than 43 percent of the clinical guidelines governing management of these conditions. Public providers only followed 44 percent of the guidelines for managing maternal and newborn complications.
The lack of a relationship between the availability of health care and life expectancy in developing countries goes beyond weaknesses in hospitals and clinics. It’s also related to the fact that what kills most people in poor countries are conditions that don’t require hospitals to fix. In sub-Saharan Africa, the five leading killers are malaria, HIV, lower respiratory infections, diarrhea, and malnutrition. Further and growing causes of mortality across the developing world include traffic accidents, tobacco usage, and health conditions related to being overweight. Clean water, access to and use of toilets, condoms, soap, vaccinations, and and bed nets, alongside better nutrition, tobacco controls, and road safety measures can prevent the majority of these deaths. Doctors and nurses save thousands of lives a day, but infrastructure and public health interventions—neither requiring highly trained medical staff—save many millions each year. Often, the medical system can do little more than provide palliative care when these other approaches aren’t used or don’t work.
Doctors, nurses, and hospitals remain vital to a country’s well-being. The Ebola virus outbreak in West Africa has demonstrated that there are times when only skilled care in medical facilities can adequately protect the public. It has also shown that even in health systems that are as weakly governed, understaffed, and woefully underfunded as Liberia’s or Sierra Leone’s, many people are willing to risk their lives, day after day, to help.
But when most people are dying from conditions that can be prevented at the cost a few cents, in countries where total health expenditures can be as low as a few dollars per year per person, it’s folly to divert scarce resources to expanding broken health-care systems. Doing so will only mean that more people are going to die. While governments and donors should spend more money on the health needs of the world’s poorest people—they should also insist that money is spent efficiently, rather than on simply chasing an illusory goal of universal coverage.