Evolution of Healthcare Systems: Past, Present, and Future

1. An Introduction to the Geography of Health Chapter 8: Geographies of Healthcare Source: NIH 2008b Photo by Peter Anthamatten

2. An Introduction to the Geography of Health Foundations of Medical Thought and Practice The practice of medicine originated over 4000 years ago when people began to systematically address symptoms of disease. During the initial development of medicine, most disease was attributed supernatural explanations. This image shows a Hindu goddess of smallpox. Anthamatten and Hazen Chapter 8

3. An Introduction to the Geography of Health In Chinese, Ayurvedic, and ancient Greek medical traditions, health is seen as inseparable from the environment. Medical treatment was often dedicated to restoring balance between individuals and their surroundings. Asclepius,Greek god of medicine Photo by Nina Aldin Thune Anthamatten and Hazen Chapter 8

4. An Introduction to the Geography of Health With the ascendance of germ theory in the mid-nineteenth century, biomedicine became the dominant medical paradigm. Biomedicine explains disease and prescribes treatment on the basis of biological evidence and hypothesis testing. Source: NIH 2008a Anthamatten and Hazen Chapter 8

5. An Introduction to the Geography of Health Folk medicine refers to medical beliefs that are passed down through generations as general knowledge within a particular community. In a professional medical system, by contrast, a formalized training system is used to pass a widely-accepted body of knowledge and practice from practitioner to practitioner. Anthamatten and Hazen Chapter 8

6. An Introduction to the Geography of Health Alternative Medical Systems In spite of the dominance of the biomedical paradigm, traditional forms of medicine remain an important source of healthcare for many populations, particularly in remote rural areas where folk medicine may be the primary source of healthcare. This image shows an advertisement for traditional medicine in rural Belize. Photo by Helen Hazen Anthamatten and Hazen Chapter 8

7. An Introduction to the Geography of Health There has also been a resurgence of interest in complementary and alternative medicine (CAM) in the West, often in recognition of the limits of biomedicine. CAM includes approaches as diverse as massage, herbal remedies, and faith-healing, and may include both professional and non-professional medical systems. What are some of the advantages of CAM over traditional biomedicine? What are some of the criticisms of CAM? Anthamatten and Hazen Chapter 8

8. An Introduction to the Geography of Health Many alternative therapies have been criticized because there is no plausible biological mechanism to explain their healing powers. Some governments, such as those in the US and the UK, have investigated alternative therapies using empirical methodologies. This scientist is conducting research for the National Center for Complementary and Alternative Medicine, Division of Intramural Research. Source: NIH 2008c Anthamatten and Hazen Chapter 8

9. An Introduction to the Geography of Health Healthcare Provision and Access Health geographers are interested in the factors that mediate the use of available healthcare resources. Source: NIH 2008b This includes the study of healthcare provision; healthcare utilization, where and how people seek care; and healthcare accessibility, who is able to use existing services. Anthamatten and Hazen Chapter 8

10. An Introduction to the Geography of Health Source: WHO 2010 This map shows the average annual per capita value of healthcare expenses, including both government and private expenditures. Anthamatten and Hazen Chapter 8

11. An Introduction to the Geography of Health The relationship between spending on healthcare and population health indicators such as life expectancy and infant mortality rate is not linear. This scatterplot shows average per capita healthcare expenditure compared to the under-five mortality rate for high-income OECD countries. Source: WHO (2010) Anthamatten and Hazen Chapter 8

12. An Introduction to the Geography of Health What factors might mediate the relationship between health spending and health outcomes? What do you think explains some of the “outliers,” such as the US, where both under-five mortality rates and spending are high, or Finland, where both are low? Source: WHO (2010) Anthamatten and Hazen Chapter 8

13. An Introduction to the Geography of Health The structure of healthcare systems, their efficiency of operation, and their accessibility are factors that can influence whether healthcare spending translates into improved health. Source: WHO (2010) Anthamatten and Hazen Chapter 8

14. An Introduction to the Geography of Health Stark differences in the cost of care have led to medical tourism, whereby patients from affluent countries seek care abroad, with the goal of finding high-quality care at lower cost. This pharmacy is located at a dock for cruise ships in Belize City, Belize, and serves affluent tourists arriving from the US and other high-income countries. Photo by Helen Hazen Anthamatten and Hazen Chapter 8

15. An Introduction to the Geography of Health Source: WHO (2006) Global disparities in affluence have led health workers to migrate to high-income countries, often from low-income countries, many of which have a domestic shortage of health workers. Anthamatten and Hazen Chapter 8

16. An Introduction to the Geography of Health Healthcare Systems Most governments have mechanisms to provide or regulate healthcare for their populations. Healthcare systems can be distinguished by who manages healthcare and who pays for it. Anthamatten and Hazen Chapter 8

17. An Introduction to the Geography of Health In universal healthcare systems, healthcare is both paid for and managed by the government. In these systems, everyone is guaranteed access to healthcare and the healthy essentially subsidize the sick. In the Beveridge Model, exemplified by the UK’s National Health Service, healthcare is funded through taxes and individuals pay nothing or little for healthcare (Reid 2009). Anthamatten and Hazen Chapter 8

18. An Introduction to the Geography of Health In a Bismarck Model healthcare system, the government mandates a non-profit insurance system that is paid for by employers through employee paycheck deductions, but doctors and hospitals are privately run. Typically, all citizens must sign up for an insurance program, and the insurance programs are required to accept all who apply for coverage. Examples of countries that use this system include Germany, Switzerland, and France (Reid 2009). Anthamatten and Hazen Chapter 8

19. An Introduction to the Geography of Health The National Health Insurance Model, such as Canada’s, is similar to the Bismarck Model, except that health insurance is centralized via a non-profit, government-run insurer (Reid 2009). This single-payer system leverages economies of scale, and enables the single insurer to negotiate aggressively in order to keep healthcare costs down. Anthamatten and Hazen Chapter 8

20. An Introduction to the Geography of Health The Out-of-Pocket Model is the healthcare system equivalent of a free market. In this system, medical care is provided to those who can pay on a per-use basis. This model is common in places where governments cannot afford an elaborate healthcare system (Reid 2009). Anthamatten and Hazen Chapter 8

21. An Introduction to the Geography of Health Healthcare and Aging Populations The provision and management of healthcare has become an important issue, particularly as populations age, creating a large dependency ratio. • Dependency ratio = • Number of people under 15 and over 65 Number of people aged 15–65× 100 Anthamatten and Hazen Chapter 8

22. An Introduction to the Geography of Health Source: US Census Bureau (2010) Countries, such as Japan, that have experienced dramatic declines in fertility over the last several decades face a daunting healthcare challenge. Anthamatten and Hazen Chapter 8

23. An Introduction to the Geography of Health This diagram shows the average annual healthcare costs per capita by age cohort. Data from Alemayehu and Warner (2004) Healthcare costs rise rapidly as populations age. Anthamatten and Hazen Chapter 8

24. An Introduction to the Geography of Health Healthcare Accessibility and Utilization In all healthcare systems, some individuals and groups do not benefit fully from existing services because of inequalities in access to care. The study of healthcare accessibility and utilization often focuses on healthcare barriers—the geographic, economic, social, and cultural reasons why individuals do not receive effective healthcare. What are some specific examples of barriers to healthcare? Anthamatten and Hazen Chapter 8

25. An Introduction to the Geography of Health Key Types of Barriers to Healthcare Physical: The proximity of healthcare resources; whether resources are close enough to use. Economic: The affordability of resources; people may not be able to pay for the services they need. Cultural: The cultural accessibility of resources; if people are unable to speak the language of healthcare staff, for example, healthcare may not be delivered effectively. Which barriers are most important in high-income vs. low-income contexts? How could policymakers reduce these barriers? Anthamatten and Hazen Chapter 8

26. An Introduction to the Geography of Health Primary Healthcare Although the term “primary healthcare” is often used as shorthand for basic healthcare such as vaccination and nutrition programs, its original meaning was promoting health for all people in ways that encourage community self-reliance. The term “selective primary healthcare” is sometimes used for campaigns that tackle basic healthcare issues, but do not genuinely involve the participation of the target communities. Anthamatten and Hazen Chapter 8

27. This clinic in Costa Rica is part of a nationwide program to serve rural populations. An Introduction to the Geography of Health What are some of the advantages and disadvantages of providing healthcare through small community clinics? Photo by Peter Anthamatten Anthamatten and Hazen Chapter 8

28. An Introduction to the Geography of Health Geographies of Care Moving beyond the literal idea of healthcare, critical geographers view healthcare as an inherently political, economic, and cultural concern. “…caring for person-to-person relations involves understanding how difference is socially constructed, and so a critical ethic of care must be coupled with analysis of the structures and institutions that reproduce exclusion, oppression, environmental degradation, and the like” (Lawson 2007: 7). What sorts of factors is Lawson referring to in this statement? Anthamatten and Hazen Chapter 8

29. An Introduction to the Geography of Health Feminist geographers have pointed out that the work of caring is unevenly distributed, with women bearing the brunt of care work. Such ideas have been extended to interrogate how who provides care is socially constructed. How do social norms influence our understanding of who does, or should do, care work? Photo by Helen Hazen Anthamatten and Hazen Chapter 8

30. An Introduction to the Geography of Health Source: NIH 2008d Inequalities of access to care is another focus of geographies of care. For instance, critical geographers have argued that the changes that have occurred with recent neoliberal healthcare reform have tended to shift the burden of caring from the public to the domestic sphere. This not only increases the burden for domestic caregivers but may also leave many, such as the homeless and mentally ill, without care. Anthamatten and Hazen Chapter 8

31. An Introduction to the Geography of Health Therapeutic Landscapes As researchers have broadened their understanding of influences on health to include humanistic approaches that consider individual experiences, therapeutic landscapes are considered as sources of healing. Leukerbad, Switzerland, has a reputation for healing that stems from ideas about the therapeutic properties of mineral springs. Photo by Peter Anthamatten Anthamatten and Hazen Chapter 8

32. An Introduction to the Geography of Health More recently, scholars have extended the concept of therapeutic landscapes to encompass the therapeutic nature of everyday spaces, particularly living and working environments. Photo by Peter Anthamatten Anthamatten and Hazen Chapter 8

33. An Introduction to the Geography of Health Conclusion Healthcare sits at a critical intersection of political, economic, and cultural geographies. In efforts to deliver healthcare equitably, or in more efficient and effective ways, we must consider both the structures within which healthcare is embedded and its place-specific nature. Anthamatten and Hazen Chapter 8

34. An Introduction to the Geography of Health Discussion Questions • Is a biomedical understanding of the mechanism through which a particular therapy works required for it to be a valid healthcare method? If not, how can we effectively regulate alternative and complementary therapies that do not fit the biomedical mold? • Is the flow of healthcare professionals around the world according to market demands an overall positive phenomenon, or should we strengthen regulations to control this flow? • What system is used to provide healthcare in the country where you live? What are some of the pros and cons of this system? What are some of the current controversies surrounding this system? • What barriers to healthcare can you identify in your local community? How might healthcare access be improved? • What types of landscapes do you perceive as therapeutic? How do your ideas of therapeutic landscapes differ from those of a classmate? Why do you think your ideas differ? Anthamatten and Hazen Chapter 8

35. An Introduction to the Geography of Health References Alemayehu, B. and Warner, K. E. (2004) ‘The lifetime distribution of health care costs’, Health Services Research, 39: 627–42. Conradson, D. (2005) ‘Landscape, care and the relational self: therapeutic encounters in rural England’, Health & Place, 11: 337–48. [NIH] National Institutes of Health. (2008a) “Inverted Microscope” NIH Image Bank. [Online]. Available: < http://media.nih.gov/imagebank/display.aspx?ID=97 > (Accessed 3 Jan 2011). National Institutes of Health. (2008b) “Nurse / Patient” NIH Image Bank. [Online]. Available: <http://media.nih.gov/imagebank/display.aspx?ID=10> (Accessed 3 Jan 2011). National Institutes of Health. (2008c) “Scientist at Bench” NIH Image Bank. [Online]. Available: < http://media.nih.gov/imagebank/proc/download.aspx?src=slides/hi_NCCAM80723477.jpg > (Accessed 3 Jan 2011). National Institutes of Health. (2008d) “Warren Grant Magnuson Clinical Center” NIH Image Bank. [Online]. Available: <http://media.nih.gov/imagebank/display.aspx?ID=36> (Accessed 5 Jan 2011). Lawson, V. (2007) ‘Geographies of care and responsibility’, Annals of the Association of American Geographers, 97: 1–11. Reid, T. R. (2009) The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, New York: Penguin Press. US Census Bureau (2010) International Database (IDB). US Census Bureau. [WHO] World Health Organization. (2006) Working Together for Health: The World Health Report 2006, Geneva: WHO. WHO. (2010) WHO Global Health Observatory [Online]. Available: <http://apps.who.int/ghodata/> (Accessed 29 October 2010). Anthamatten and Hazen Chapter 8