Prerequisites for healthcare in our age

Resolution of the MTA Presidential Committee for Health on the challenges facing healthcare in the 21^st century

Preface

Health has always been considered to be a precious value, and the quality of Click here to see gallery of eventthe health care system is one of the most important indicators of the level of development of modern societies. Consequently, predictions made during the beginning of the 21^st century forecast the dramatic rise in healthcare expenditure in the coming decades. Besides professional challenges, globalization, climate change and mass migration put also public health issues in the focus of attention. As a result of all this, health care playing a crucial role in present societies, has arrived at a turning point.

Besides the WHO, even high level socio-political organizations pay more and more attention to health care. Out of the Sustainable Development Goals published by the UN for the period between 2015 and 2030, 20% refer to health, and Goal 3 specifically focuses on health. According to the statement by the European Commission Com(2014) 215 final, the three main tasks of health care systems are (i) enhancing efficiency; (ii) improving accessibility; (iii) increasing adaptability. The document highlights the obligation of member states to provide an adequate health care system that does not exclude any group of society from health services.

In addition to political and social circles, authoritative international scientific organizations (like IAPforHealth, IoM, ALLEA/FEAM, UK AMS) are also showing a growing interest in health care. Articles are published in leading scientific journals, international conferences are held and series of articles are published regarding this issue.

The basic question of health care in the 21^st century is how the growing needs and expectations stemming from aging societies and expanding technological possibilities can be coordinated with economic competitiveness and social justice? It is the basic responsibility of governments to operate a health care system at a satisfactory level that can be accessed by the citizens, and to provide resources for such a system. However, as the increase in needs cannot be satisfied by solely increasing the budget, it is important to improve the efficiency and adequacy of utilizing the resources, including novel ideas to deliver care. Namely, for the first time in the history of medicine, health political and scientific organizations, besides requesting more resources from the national budget, draw attention also to the waste in health care and the need for reduction of redundant or not cost-effective medical interventions.

Responding to the call of international scientific organizations, the President of the Hungarian Academy of Sciences (HAS) established the HAS Presidential Committee for Health in 2017. The task of this committee is to study the 21^st century challenges of health care, present the universal crucial problems of our time based on scientific surveys, and inform all those using or providing services, as well as the professional executives and decision makers of the challenges.

This document summarizes the most important findings of this analysis in 10 points. Some points of the Prerequisites for healthcare in our age discuss the background of the enormous need for resources in the 21^st century; examine whether these needs are real; elaborate on the principles and possibilities to control the health budget sensibly; and draw attention to issues which must be taken into consideration in order to be able to provide adequate solutions for the global problems of health care.

This document does not discuss the current anomalies of the Hungarian health care system. Being a scientific analysis, it cannot be regarded as a recommendation either. However, by making this resolution public, the HAS’document wishes to enlist those critical points that should be regarded as crucial by decision makers in the course of reorganizing the Hungarian health care system.

Prerequisites

1. Growing demand for resources owing to technological development

The most important reason for growing expenditures of health care in modern societies is the extremely rapid development of medical technology. The scientific-technological development of the past fifty years has resulted in fundamental changes in every discipline and lead to amazing results. The chances of staying alive grew for patients with diseases that were incurable before; however, new challenges also arose. The development of technology is intertwined with research in medical biology: knowledge obtained through research and technological development stimulate one another by several factors. Besides researchers’ motivation and market interests, development is initiated by the changes in the spectrum of illnesses, which arise due to several factors. New pathological conditions emerge and diseases believed to have been defeated reoccur owing to (i) new, provocative effects of the environment (such as diet, climate, air-pollution etc.); (ii) stress inducing situations caused by socio-economic, cultural and lifestyle changes; (iii) the globalization of old and new infectious diseases owing to the large-scale travelling of people. International competition built on the original motivation of researchers, as well as the resulting innovative competition is expanding in a spiral-like fashion. These are the factors behind growing budgetary needs of health related fields, a considerable part of which is made up by the wage costs of specially educated personnel operating relevant technology.

2. Increasing costs owing to the growing number of patients

The target population of the health care system has expanded significantly. Owing to socio-economic, cultural, lifestyle changes and to a considerable extent to the development of the health care system, life expectancy at birth is constantly growing: populations are aging. This tendency induces the need for increasing resources both because chronic illnesses accumulate in elderlies, and also because “health” during old age requires regular special care. But the target population is growing, in addition to the population aging, also due to the modification of the concept of “health”. Owing to technological development, it is becoming possible to identify signs of future health risks of symptom-free people (using genetic tests or modern imaging techniques), and the number of available techniques for identifying inadequate reproductive capacity and the risks of future off-spring is also growing. Today, the future health risks of symptomless individuals and the biological limitations of reproductive capacity both determine the “health” of a person besides present well-being. Population-wide screening programs are already based on this predictive and transgenerational extension of the health concept. Consequently, people considered to be “healthy” become users of the health care system owing to the identification of future risks. As the concept of health has broadened with the dimension of time, the boundary between health and illness has become indistinct.

Both the rapid development of medical technology and the growing number of individuals requiring health care, set moral obligation to the societies to provide resources for the increasing needs from the national income based on the priority of “health”, which is a universally recognized value. The driving force behind this obligation stems from the fact that the health of individuals and society are both considered to be highly valuable for humanity.

3. Control and restrain of health budgets

Although the modern states must provide sufficient resources for health care, the health budget can not rely on unlimited extent from the national income. It is imperative to find effective mechanisms to control health budgets in a sensible way, to keep expenditure in check and to allocate resources effectively. Major challenges of the 21^st century societies concerning health care stem from the tension between objective (increasing cost of technology) and subjective (high individual and societal expectations for health delivery) factors. The most important factor in the growing costs of technology is the price of individual elements of new techniques including devices, medicines, and the wages necessary for operation. (An important task of the near future should be to analyze the market conditions determining pricing and the health gains produced!) However, also the form, i.e. how the care delivery is organized is of growing importance. As possibilities are widening, the limits of their rational application are becoming clear. Expectations from health care are not on a par with either available resources or real needs. ‘The best treatment for everybody, everywhere, in every case’ as expected cannot fully be provided by even the richest countries. As a consequence, studies on the strategies for the health care systems in the 21^st century give equal emphasis to the justified need for increasing the health budget and to the control of the budget on well-founded professional and ethical grounds.

4. Cost-effectiveness of medical interventions

Concerning the analysis of the effect of the technological boom on rising costs, it is of fundamental importance to determine the requirements for health services for different medical disciplines. Although professional autonomy and the individual right of the doctor to decide are crucial in medical practice, there is a growing need for professional and ethical standards. Scientific evidence is available for the services to be provided (evidence-based medicine), but at the present level of our knowledge, this evidence is not the absolute standard. In order to evaluate more and more elaborate diagnostic processes and the emerging new treatments, it is of growing importance to identify processes that are clinically useful (clinical utility). Besides professional motives, defensive strategies – such as using new diagnostic methods without consequences for the therapy – play a crucial role, while services provided by non-medical professionals (including psychology, social work, physiotherapy) are exploited to a lesser extent. Accountability for reasonableness, i.e. deliberation of which available diagnostic processes and therapies contribute to health preservation in reality, is hardly applied. Therefore, by employing health technology assessments it is necessary to redefine the concept of ‘health care needs’ for each medical profession for the planning of the health budget, with special emphasis on precision medicine and digital medicine, including telemedicine and Big Data processing. Bilateral discussions of health care needs by doctors and patients must play a crucial role in the allocation of resources (treatment at a central unit or near the patient’s home, role of expert centres, etc.), in the determination of minimal professional requirements, in the organization of professional education and supervision, and in the formation of a coherent health care system that includes all of the above based on a rational policy.

5. Expectations towards the health care system

Besides professional rules on using technology, expectations towards the health care system greatly influence the rational management of the system itself. Possibilities offered by the latest technology are often perceived in a distorted manner by the general public, which is successfully fuelled by the media, the advertisements of various therapies and medicines. Heightened expectations and the professional need for using available technology can hardly be met by the nationally financed health care system. The concept of “health need” cannot be applied in a homogenous manner today owing to technological development, and the expectations of consumers cannot be fulfilled even in the richest countries. Therefore, individual and social opinion about the health care system must be guided in a realistic direction by trustworthy and clear communication: on the one hand, the special socio-economic role of health must be emphasized; on the other hand, exaggerated expectations towards the health care system should be diminished.

6. Health-conscious behaviour, self-care

Modern health care systems are adaptive, they follow social and scientific-technological changes. They have let traditional biomedical viewpoints behind, and build instead on the P4 medicine policy (Predictive, Preventive, Personalized, Participatory). Future medicine is personalized and precise, but in order to achieve this, medicine must be extended towards the patient. Without the cooperation of the public and without self-care and awareness of the responsibility of the individual, no health care system can be operated with a socially acceptable budget. Consequently, health conscious living practices of the population should be promoted. Unhealthy diets, insufficient physical exercise, smoking, overexertion, etc. pose significant risks when it comes to morbidity and mortality. The modern concept of health-consciousness includes also being informed about therapy and cooperation. In order to improve this, targeted information should be provided and education should be promoted. However, besides teaching people to be health-conscious, it is indispensable that governments play a role in providing possibilities for healthy choices and promoting these choices (e.g. infrastructure, price policy, etc.).

7. Harmonizing moral policies in the health care system

At present, one scene of conflicts concerning health care is the conflict of two moral principles. At the direct interpersonal physician-patient interphase, every medical interventions are based on the individuals’ right for health, while at public level the health system is based on the moral principle of solidarity. If the limited nature of the budget were to be counterbalanced by the introduction of ordered lists of prioritization policies, i.e. taking the interests of all members of the population into account according to the principle of solidarity, this could lead to a conflict with the individual morality at the physician-patient level. Medical personnel has sworn to do their best for the patient (cf. Hippocratic Oath!) and the patients are looking to get the best possible treatment on the basis of the right for health. Consequently, to consolidate the conflict between individual and social morality, a compromise should be attained, a key to which is that the public should acknowledge and accept ordered lists and the principles of prioritisation based on professional and ethical judgments. In this process, the most important basic principles are (i) to maximize health gains on the level of the population; (ii) equity; and (iii) equal opportunity. The UN’s Universal Declaration of Human Rights offers a possibility to apply the principle of priority emphasizing that conditions and the resources for realization are to be acknowledged (cf. General Comment 14): if resources are limited, compromises are unavoidable even in public health policies.

8. Tasks and responsibilities for the rational management of the health care system

As a result of technological development, the number of diagnostic and therapeutic processes that do not contribute to a considerable degree to the main goal is growing. These interventions are still applied owing to the vagueness of doctors’ needs, unrealistic expectations, defensive strategies etc., resulting in large-scale overuse. This is a highly sensitive field, and limiting the number of unjustified interventions poses different challenges to those working at different levels of the health care system. At the level of doctor–patient interactions, the medical specialists have a professional role (to offer the “best practice”). At the level of management policy, the tasks include (i) the creation of appropriate conditions; (ii) management; (iii) the prescription of minimal conditions of practice; and (iv) supervision. The management policy should take the dominant responsibility for the rational health care system, they should regularly consult professionals, manage the new system and organize assessment and supervision. The results of several analyses offer a basis for this task, just to name a few: (i) health technology assessment; (ii) cost-effectiveness analysis; (iii) evidence-based medicine; (iv) accountability for reasonableness, for each branch of medicine. Policies for deciding on reasonableness of medical interventions can only be successful if employees working with patients also feel responsible for the achievement of the common goal, i.e. for setting up a health care system that is effective, is based on solidarity and is aligned with the interests of other players of the health care system as well. Therefore, doctors are expected to restrain themselves from enforcing their own, unjustified and selfish interests and from following their old faulty habits.

9. Coexistence of public and private health care systems

Owing to the boom in technological development, every available resources, including the private providers, must be involved in order to realise the goal of health care, i.e. providing high-quality care to as many people as possible. Hence, it is imperative to set up a transparent system of coexistence for public and private health care systems. The desirable proportion of public and private sectors must be determined by thorough justification, in which the lines of duty are clearly defined. Although the ratio of private sector in the national health care system needs political decision, professionals also play crucial role in this process, by providing reliable statistics regarding capacities of care and public needs. Such analyses help to form opinions about the desirable proportion of services covered by “prepaid” insurance system and direct out-of-pocket payment. Policy makers should set up a professional, ethical and legal frameworks in equal measure for both public and private health services, and regular supervision should be attended for both systems constantly.

10. Notions to harmonize the health care system, the need for complex adaptive systems

Health care systems based on constantly developing knowledge and technology can only achieve results at population level if the vertically arranged health service system is coordinated by a horizontal program that stems from wide discussions with the public (public health strategic program), which should be built on a long-term concept and independent of political terms. This program should be the milestone of the future health vision of the given country (e.g. whether the health system should be focused on primary care or hospital-based service). Besides determining the structure of health delivery, resource allocation and supervision of health services, this program should also provide a framework for harmonizing the different parts of the system. Without system-based order, each measure, even of best intentions, may fail or become even counterproductive. The achievement of the program needs open public debates and wide public engagement.

The crucial role of health care and the systematic management of health care systems in developed societies is not only highlighted by the WHO. Authoritative scientific forums also declare that achieving the three most important goals of the UN’s Sustainable Development Goals (i.e. economic growth, social fairness, environmental protection), what is more, for achieving the whole program, the fulfillment of Goal 3 about health is a prerequisite. The interdisciplinary health care teams must be viewed as complex adaptive systems by focusing more on the actors’ interactions with each other than on the achievements if the individual actors.

Closing remarks

Each statement in the present document is based on documents by authoritative professional and scientific organizations and articles published in prestigious scientific journals.

The majority of the above has already been discussed during debates organized by the MTA Presidential Committee for Health in the past two years. Opinions expressed during these meetings and also following such occasions have contributed a great deal to the compilation of this document.

Some key concepts are italicized in this document. Some of these are widely known terms used in a uniform manner, others are supported by detailed professional content. An elaboration on these concepts exceeded the limits of this study. As a result, italicized concepts should be regarded as references.

The Committee regards Prerequisites… as their own framework program and wishes to elaborate on each point by collecting questions, making propositions and suggesting alternative solutions.

Complied by the MTA Presidential Committee for Health, headed by György Kosztolányi, President of Section of Medical Sciences and Veronika Ádám, Vice President of Section of Medical Sciences