Speaking of: : Health, Wealth and Wisdom

As the Clinton Administration ponders how to overhaul America’s health care system, the World Bank has been pinpointing weaknesses and strengths in other nations’ systems.

In its survey, “World Development Report 1993, Investing in Health,” the bank finds plenty to criticize while acknowledging that “health conditions around the world have improved more in the past 40 years than in all of previous human history.”

Governments often underfund the most critical and cost-effective programs, such as immunization, while overfunding specialized training programs, the report contends. The poor often lack access to basic health care, while private and public insurance is subsidized. The report also highlights inefficient deployment and supervision of health care workers and use of hospital beds.

The cure? Combining private and public resources may help iron out the problems, the report concludes. And that seems to be the direction in which the Clinton Administration is heading.

PAYING THE BILLS

As might be expected, richer nations spend more on health care than poor ones. But that’s only part of the story. They also differ in how they spend the money.

Around the world, clinical services are financed through four main channels. Two are private: out-of-pocket payments and voluntary insurance. Two are public: general government revenue and compulsory insurance (sometimes known as social insurance) that is either publicly managed or heavily regulated by governments.

Generally, poorer nations offer little or no insurance and depend on private payments. Richer nations expand coverage to more people and use more public spending. Among the richest nations, the United States spends more than the average while relying less on government funding.

The World Development Report favors a health care system that combines different types of organizations, including non-governmental agencies and private doctors and hospitals. It contends that some governmental regulation is needed to ensure the safety and quality of private care, achieve broad coverage of the population and discourage practices that lead to overuse of services and escalating costs. Group (1990 per capita income): Low income ($100-$600) % of GNP: 2-7 Money spent on health care in 1990 per person: $2-$40 Characteristics: Little or no insurance; Private payments account for more than half of all money spent on health care; Private organizations serve key administrative and funding roles. Examples: Bangladesh, India, Pakistan most sub-Saharan African countries *Group (1990 per capita income): Middle income ($600-$7,900) % of GNP: 2-7 Money spent on health care in 1990 per person: $20-350 Characteristics: PRIVATE INSURANCE for the affluent only and held by less than 10% of the population; Government-funded health care for low- and middle-income residents Examples: South Africa, Zimbabwe *Group (1990 per capita income): Middle income ($600-$7,900) % of GNP: 3-7 Money spent on health care in 1990 per person: $20-$400 Characteristics: SOCIAL INSURANCE provides coverage for most middle-class workers and is supported by mandatory worker and employer contributions and sometimes by government funds; Government-funded health care for the poor Examples: Costa Rica, South Korea, Turkey *Group (1990 per capita income): Formerly Communist economies of Europe ($650-$6,000) % of GNP: 3-6 Money spent on health care in 1990 per person: $30-$200 Characteristics: Public clinical services are either of low quality or are collapsing. Examples: Czech Republic, Poland, Slovakia, republics of the former Soviet Union *Group (1990 per capita income): Established market economies, except the U.S. ($5,000-$34,000) % of GNP: 6-10 Money spent on health care in 1990 per person: $400-$2,500 Characteristics: Almost universal coverage, usually provided directly by the government or by social insurance Examples: France, Germany, Japan, Norway, Sweden, Britain *Group (1990 per capita income): United States ($22,000) % of GNP: 12 Money spent on health care in 1990 per person: $2,800 Characteristics: A combination of private voluntary insurance and public funding

PAGING DR. EXCESS

Advanced countries have more doctors. But more is not always better, the World Bank finds.

During the 1960s and 1970s, many governments used subsidies to rapidly expand physician training. By the 1980s, the established market economies, Latin America and parts of Asia were having trouble absorbing growing numbers of physicians.In Mexico, for instance, 18% of physicians in major cities were unemployed or working in non-medical jobs, according to a 1988 survey.

The report also blames an oversupply of specialists for pushing up costs and endangering lives by increasing the rate of risky operations. The range is dramatic: In Chile, 75% of doctors are specialists, compared with 20% to 50% in some European nations.

The report hedges on the ideal ratio of nurses to physicians, saying it depends on the organization and financing of health care. But as a rule of thumb, nurses should exceed physicians by at least 2 to 1 for adequate health care at minimal cost, it suggests.

Doctors Per 1,000 People Sub-Saharan Africa: .12 India: .41 China: 1.37 Other Asia and Asian islands: 0.31 Latin America and the Caribbean: 1.25 Middle Eastern crescent: 1.04 Formerly Communist economies of Europe: 4.07 Established market economies including the U.S.: 2.52 United States: 2.38 World: 1.34 Nurse-to-Doctor Ratio Sub-Saharan Africa: 5.1 India: 1.1 China: 0.5 Other Asia and Asian islands: 3.0 Latin America and the Caribbean: 0.5 Middle Eastern crescent: 1.5 Formerly Communist economies of Europe: 2.2 Established market economies including the U.S.: 2.1 United States: 2.8 World: 1.4

BEDTIME STORIES

Minimum health care requires about one general-care hospital bed per 1,000 people, according to the World Development Report. India is on the low end of the scale; the champs are formerly Communist nations, with a whopping 11.4 beds per 1,000 people. But numbers don’t tell the whole story. Many nations devote too much hospital space to specialized research and training at the expense of beds for generalized, primary care, the report contends. Hospital Capacity: Beds per 1,000 people: Sub-Saharan Africa: 1.4 India: .7 China: 2.6 Other Asia and Asian islands: 1.8 Latin America and the Caribbean: 2.7 Middle Eastern crescent: 2.9 Formerly Communist economies of Europe: 11.4 Established market economies including the U.S.: 8.3 United States: 5.3 World: 3.6

GETTING SHOTS

Immunization is one of the most cost-effective medical programs, preventing disease at minimal cost, the World Bank notes. Sub-Saharan Africa immunizes the fewest children, China the most. Among advanced economies, the United States has a lower-than-average rate.

Percentage of Children Immunized by Their First Birthday (Third dose of DPT*) Sub-Saharan Africa**: 52% India: 83% China: 95% Other Asia and Asian islands: 81% Latin America and the Caribbean: 71% Middle Eastern crescent: 75% Formerly Communist economies of Europe: 77% Established market economies including the U.S.: 80% United States: 67% World: 80% * Diptheria, pertussis (whooping cough), tetanus ** Regional and world figures are weighted averages. SOURCE: World Development Report 1993, Investing in Health