To What Extent?

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To What Extent Should Government Control National Healthcare?

The general health of the population today must be considered one of the greatest marvels of human civilization and ingenuity. Pregnant women no longer have to dread the 10 percent risk of death at childbirth that used to be usual; a newborn in Canada today can expect to live 80 years; death related to childhood infections is now rare; the long-term outcome of childhood leukemia has changed from 85 percent mortality to 85 percent survival; patients with cataracts, osteoarthritis and heart disease benefit from surgery that was unimaginable 40 years ago; many cancer patients can now be offered substantial relief and some even long-term survival. The focus now in well-developed countries such as Canada is on personal healthcare services, but we still must keep in proper perspective the indirect societal factors that are mainly responsible for making and keeping people healthy. I learned a salutary lesson as a young and enthusiastic surgeon, a member of the team sent from Glasgow University in 1966 to help establish the new medical school in Nairobi. At a meeting with the Kenyan minister of health, we were complaining about the lack of drugs and equipment at the hospital when he interrupted, thanked us warmly for our service and politely explained that his major priorities as health minister were schools, safe water, houses, sewers and nutrition. We did not find this very endearing at the time, but he was displaying an excellent understanding of the determinants of human health. Living in Canada, we have high expectations for relief of ailments that in past generations were accepted as normal accompaniments of daily living and aging. The scope of these services has expanded to an extent that Justice Emmett Hall in 1964 could never have contemplated as he drafted the recommendations for Canada’s national medicare system. The federal legislation enacted two years later established a publicly funded insurance plan to cover all “necessary medical services” provided by physicians and hospitals. The system has continued to live up to that mandate to a remarkable degree while multiple new drugs and health services have become available and eagerly accepted by the public. But now we come to the sticking point. The fact that continuous limitless growth of health services cannot possibly be sustained—in any system—is a fairly recent realization that still seems to escape many providers and politicians alike. There are two major interrelated issues in dealing with the fact that without major policy changes our healthcare system is unsustainable: the limits of funding and the appropriateness of services. The first has been under continuous discussion, but remarkably little attention has been paid to the second. For both issues there is compelling information about the problems and credible research on potential solutions, but the serious need for change seems to face an even more serious lack of political enthusiasm. Some of the solutions would be well within governments’ powers to adopt and implement. It is fascinating that almost all the attention in the national debate about how to solve the supply/demand equation recently has focused on the supply side—more doctors, more nurses, more hospital beds, more drugs, more operating rooms, more, more, more. The committees chaired by Don Mazankowski and Michael Kirby both concentrated on finding new and more funding for health services, whether by looking at all possible sources as suggested by Mazankowski or by staying only within the public domain as in Kirby’s report. If the use of Avastin were extended to all patients with early colorectal cancer, the cost in Canada would be around $4 billion annually. The Romanow Commission took a broader view, with the clear message that new funding alone will not help in the long run unless the expectations of the public can somehow be curbed. It is absurd to imagine that any healthcare...
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