Levels of health care

In the curative domain there are various forms of medical practice. They may be thought of
generally as forming a pyramidal structure, with three tiers representing increasing degrees of
specialization and technical sophistication but catering to diminishing numbers of patients as
they are filtered out of the system at a lower level. Only those patients who require special
attention either for diagnosis or treatment should reach the second (advisory) or third
(specialized treatment) tiers where the cost per item of service becomes increasingly higher. The
first level represents primary health care, or first contact care, at which patients have their initial
contact with the health-care system.
Primary health care is an integral part of a country’s health maintenance system, of which it
forms the largest and most important part. As described in the declaration of Alma-Ata,

primary health care should be “based on practical, scientifically sound and

socially acceptable methods and technology made universally accessible to individuals and
families in the community through their full participation and at a cost that the community and

country can afford to maintain at every stage of their development.” Primary

health care in the developed countries is usually the province of a medically qualified physician;
in the developing countries first contact care is often provided by nonmedically qualified
personnel.
The vast majority of patients can be fully dealt with at the primary level. Those who cannot are
referred to the second tier (secondary health care, or the referral services) for the opinion of a
consultant with specialized knowledge or for X-ray examinations and special tests. Secondary
health care often requires the technology offered by a local or regional hospital. Increasingly,
however, the radiological and laboratory services provided by hospitals are available directly to
the family doctor, thus improving his service to ... (300 of 16486 words)

Encyclopedia of Public Health: Access To Health Services

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Rural environments present unique challenges for health care access. There are often shortages
of medical personnel in rural areas, as well as transportation and distance barriers to care and an
increasing economic destabilization of rural health care services.
Since the mid-twentieth century, physicians have favored urban and suburban practice locations
over rural areas. Physicians often need lucrative practices to repay high education debts, and they
have been trained to use costly new technologies in diagnosis and treatment. Rural practice
locations typically generate lower income for the physician and have fewer and older technology
resources than urban and suburban locations. Modern medical school graduates are rarely well
prepared to practice in rural environments. Consequently, rural communities suffer chronic
physician shortages.
Physician shortages are most visible in primary prevention, diagnosis, and treatment. Public
health systems and an array of alternative primarycare providers often fill in the gaps. Primary
care may be provided by nurse practitioners, physician assistants, or home-health nurses.
Practice locations include publicly or charitably subsidized comprehensive primary-care centers
or categorical service clinics (e.g., prenatal care, family planning, immunizations) situated in
central locations, mobile clinics, and in patient's homes. Specialty physician services (such as
psychiatry or dermatology) may also be available through intermittent clinics in local facilities,
such as health departments, churches, or schools.
Advances in medical technology, increasing costs, and market forces contribute to the economic
destabilization of many rural health care systems. Small rural health care providers, especially
hospitals, cannot afford the equipment and personnel necessary to treat the entire array of
modern disease and injury. Coronary bypass surgery, artery repair, advanced trauma care, and
other complex procedures require specialized medical teams, equipment, and facilities. Such
resources are economically viable only in hospitals and surgical centers with high volumes of
patients. Consequently, rural residents must often travel great distances to access more costly and
complex levels of care.
Accessing complex care in urban medical centers often generates a patient perception that all
rural hospital care is of lower quality. People with financial resources and the ability to travel
tend to use distant urban centers even for less complex needs. The majority of patients admitted
to rural hospitals are either too frail to withstand travel to distant hospitals or cannot afford either
the travel or the cost of care in urban areas. Neither of these populations generates
reimbursements adequate to cover the costs of services. Many rural hospitals and providers have
diversified services to increase revenues. However, this strategy often fails and the hospital must
close. Closures leave the very old, the disabled, and the poor with no access to hospital inpatient
care, and the entire community is left with no access to urgent or emergency care. In addition,
the area suffers from the significant loss of employment.
As costs increase, public and private insurers must struggle to control their expenditures. Prices,
or fee scales, for services include the minimum estimated cost of providing each service. Price
controls most severely affect rural health systems, especially home-based or mobile services.
Because of the distances between service locations or patient residences, the cost per unit of
service is often many times greater than in urban locations. For example, a home health nurse
may visit five patients in a morning within an urban apartment building, while a nurse in a rural
setting may visit only one or two patients, spending most of the time traveling. The urban nurse
will be reimbursed for five visits and the rural nurse for two, yet the time expended is the same.
Home-based services in rural areas must, therefore, access public or charitable subsidization in
order to remain economically viable.
Low population density and greater travel times and barriers in rural areas affect service
availability, the ability of people to get to those services, and the economic viability of the
services. Lower population density also means a lower volume of patients and less provider
income. Reduced fees and the refusal of insurers to pay for care often destabilize private
professional practices in rural areas, leading to greater shortages of personnel.
The lower the population density and the larger the area over which the population is distributed,
the fewer the available health services and the longer the travel distances to access these services.
Emergency medical services in such areas are scattered over great distances and often staffed
with volunteers who have other jobs. Emergency care for severe trauma or major acute illnesses,
such as stroke and heart attack, may take longer to arrive than in other areas, causing increased
morbidity and mortality. Poor roads or geographic barriers, such as mountains or rivers, magnify
the effects of distance. More remote areas with the capacity to pay for the technology, such as
western Kansas, are beginning to use telemedicine to improve access for primary care and
certain specialty care, such as psychiatry and dermatology.
(SEE ALSO: Immunizations; Migrant Workers; Poverty and Health; Prenatal Care; Prevention;
Primary Care; Public Health Nursing)
— SUSAN W. ISAAC; HEATHER REED

US History Encyclopedia: Health Care

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The term "health care system" refers to a country's system of delivering services for the
prevention and treatment of disease and for the promotion of physical and mental well-being. Of
particular interest to a health care system is how medical care is organized, financed, and
delivered. The organization of care refers to such issues as who gives care (for example, primary
care physicians, specialist physicians, nurses, and alternative practitioners) and whether they are
practicing as individuals, in small groups, in large groups, or in massive corporate organizations.
The financing of care involves who pays for medical services (for example, self-pay, private
insurance, Medicare, or Medicaid) and how much money is spent on medical care. The delivery
of care refers to how and where medical services are provided (for example, in hospitals, doctors'
offices, or various types of outpatient clinics; and in rural, urban, or suburban locations).
Health care systems, like medical knowledge and medical practice, are not fixed but are
continually evolving. In part, health care systems reflect the changing scientific and technologic
nature of medical practice. For instance, the rise of modern surgery in the late nineteenth and
early twentieth centuries helped create the modern hospital in the United States and helped lead
to the concentration of so many medical and surgical services in hospital settings. However, the
rise of "minimally invasive" surgery a century later contributed to the movement of many
surgical procedures out of hospitals and into doctors' offices and other outpatient locations. A
country's health care system also reflects in part the culture and values of that society. Thus,
physicians in the United States, Canada, France, Germany, and Great Britain follow similar
medical practices, but the health care systems of these nations vary considerably, reflecting the
different cultural values and mores of those societies.
Traditional Medical Practice in America
For the first century of the republic, almost all physicians engaged in "general practice"—the
provision of medical and surgical care for all diseases and for all patients, regardless of sex and
age. Typically, doctors engaged in "solo practice," whereby they practiced by themselves without
partners. Doctors' offices were typically at their homes or farms. Reflecting the rural makeup of
the country, most physicians resided in rural settings. House calls were common. Payment was
on the "fee-for-service" basis. Doctors would give patients a bill, and patients would pay out of
pocket.
Medicine at this time was not an easy way for an individual to earn a living. Many physicians
could not be kept busy practicing medicine, and it was common for doctors to have a second
business like a farm, general store, or pharmacy. Physician income, on average, was not high,
and doctors often received payment in kind—a chicken or box of fruit rather than money.
Doctors also experienced vigorous competition for patients from a variety of alternative or lay
healers like Thomsonians, homeopaths, and faith healers.
In the last quarter of the nineteenth century and first quarter of the twentieth century, fueled by
the revolution in medical science (particularly the rise of bacteriology and modern surgery), the
technologic capacity and cultural authority of physicians in the United States began to escalate.
Competition for patients from alternative healers diminished, and most Americans thought of
consulting a doctor if they needed medical services. The location of care moved to doctors'
offices for routine illnesses and to hospitals for surgery, childbirth, and major medical problems.
Indeed, the hospital came to be considered the "doctor's workshop." In 1875, there were 661
hospitals in the United States containing in aggregate about 30,000 beds. By 1930, the number of
acute care hospitals had increased to around 7,000, and together they contained about one million
beds. Since most hospitals were concentrated in cities and large towns, where larger
concentrations of patients could be found, doctors were increasingly found in larger
metropolises. In the 1920s, the U.S. population was still 50 percent rural, but already 80 percent
of physicians resided in cities or large towns.
Before World War II (1939–1945), about 75 to 80 percent of doctors continued to engage in
general practice. However, specialty medicine was already becoming prominent. Residency
programs in the clinical specialties had been created, and by 1940 formal certifying boards in the
major clinical specialties had been established. Decade by decade, fueled by the growing results
of scientific research and the resultant transformation of medical practice—antibiotics,
hormones, vitamins, antiseizure medications, safer childbirth, and many effective new drugs and
operations—the cultural authority of doctors continued to grow. By 1940, competition to
"regular medicine" from alternative healers had markedly slackened, and the average U.S.
physician earned 2½ times the income of the average worker. (Some medical specialists earned
much more.) Most physicians continued in solo, fee-for-service practice, and health care was not
yet considered a fundamental right. As one manifestation of this phenomenon, a "two-tiered"
system of health care officially existed—private rooms in hospitals for paying patients, and large
wards for indigent patients where as many as thirty or forty "charity" patients would be housed
together in one wide open room. In many hospitals and clinics, particularly in the South, hospital
wards were segregated by race.
Table 1
Specialization in Medicine

191
American Board of Ophthalmology
6

193
American Board of Pediatrics
3
Specialization in Medicine

193
American Board of Radiology
4

American Board of Psychiatry and 193

Neurology 4

American Board of Orthopedic 193

Surgery 4

American Board of Colon and Rectal 193

Surgery 4

193
American Board of Urology
5

193
American Board of Pathology
6

193
American Board of Internal Medicine
6

193
American Board of Anesthesiology
7

193
American Board of Plastic Surgery
7

193
American Board of Surgery
7

American Board of Neurological 194

Surgery 0

The Transformation of Health Care, 1945–1985

The four decades following World War II witnessed even more extraordinary advances in the
ability of medical care to prevent and relieve suffering. Powerful diagnostic tools were
developed, such as automated chemistry analyzers, radioimmunoassays, computerized
tomography, and nuclear magnetic resonance imaging. New vaccines, most notably the polio
vaccine, were developed. Equally impressive therapeutic procedures came into use, such as
newer and more powerful antibiotics, antihypertensive drugs, corticosteroids,
immunosuppressants, kidney dialysis machines, mechanical ventilators, hip replacements, open-
heart surgery, and a variety of organ transplantations. In 1900, average life expectancy in the
United States was forty-seven years, and the major causes of death each year were various
infections. By midcentury, chronic diseases such as cancer, stroke, and heart attacks had replaced
infections as the major causes of death, and by the end of the century life expectancy in the
United States had increased about 30 years from that of 1900. Most Americans now faced the
problem of helping their parents or grandparents cope with Alzheimer's disease or cancer rather
than that of standing by helplessly watching their children suffocate to death from diphtheria.
These exceptional scientific accomplishments, together with the development of the civil rights
movement after World War II, resulted in profound changes in the country's health care delivery
system. Before the war, most American physicians were still general practitioners; by 1960, 85
to 90 percent of medical graduates were choosing careers in specialty or subspecialty medicine.
Fewer and fewer doctors were engaged in solo practice; instead, physicians increasingly began to
practice in groups with other physicians. The egalitarian spirit of post–World War II society
resulted in the new view that health care was a fundamental right of all citizens, not merely a
privilege. This change in attitude was financed by the rise of "third-party payers" that brought
more and more Americans into the health care system. In the 1940s, 1950s, and 1960s, private
medical insurance companies like Blue Cross/Blue Shield began providing health care insurance
to millions of middle-class citizens. In 1965, the enactment of the landmark Medicare (a federal
program for individuals over 65) and Medicaid (joint federal and state programs for the poor)
legislation extended health care coverage to millions of additional Americans. Medicare and
Medicaid also brought to an end the era of segregation at U.S. hospitals, for institutions with
segregated wards were ineligible to receive federal payments. Third-party payers of this era
continued to reimburse physicians and hospitals on a fee-for-service basis. For providers of
medical care, this meant unprecedented financial prosperity and minimal interference by payers
in medical decision-making.
Despite these accomplishments, however, the health care system was under increasing stress.
Tens of millions of Americans still did not have access to health care. (When President Bill
Clinton assumed office in 1993, the number of uninsured Americans was estimated at 40 million.
When he left office in 2001, that number had climbed to around 48 million.) Many patients and
health policy experts complained of the fragmentation of services that resulted from increasing
specialization; others argued that there was an overemphasis on disease treatment and a relative
neglect of disease prevention and health promotion. The increasingly complicated U.S. health
care system became inundated with paperwork and "red tape," which was estimated to be two to
four times as much as in other Western industrialized nations. And the scientific and
technological advances of medicine created a host of unprecedented ethical issues: the meaning
of life and death; when and how to turn off an artificial life-support device; how to preserve
patient autonomy and to obtain proper informed consent for clinical care or research trials.
To most observers, however, the most critical problem of the health care system was soaring
costs. In the fifteen years following the passage of Medicare and Medicaid, expenditures on
health care in dollars increased nearly sixfold, and health care costs rose from 6 percent to 9
percent of the country's gross domestic product (GDP). Lee Iacocca, while president of Chrysler
in the late 1970s, stunned many Americans by pointing out that U.S. automobile companies were
spending more per car on health premiums for workers than for the steel that went into the
automobiles. Public opinion polls of the early 1980s revealed that 60 percent of the population
worried about health care costs, compared with only 10 percent who worried about the quality of
care. Millions of Americans became unwillingly tied to their employers, unable to switch to a
better job because of the loss of health care benefits if they did so. Employers found their
competitiveness in the global market to be compromised, for they were competing with foreign
companies that paid far less for employee health insurance than they did. In the era of the soaring
federal budget deficits of the Reagan administration, these problems seemed even more
insurmountable.
Table 2
U.S. Health Care
Costs

Percentage of
Dollars
GDP

1950 $12.7 billion 4.5 percent

$40 billion
1965 6 percent
(est.)

1980 $230 billion 9 percent

2000 $1.2 trillion 14 percent

The Managed Care Era, 1985–present

In the mid-1980s, soaring medical care costs, coupled with the inability of federal regulations
and the medical profession on its own to achieve any meaningful cost control, led to the
business-imposed approach of "managed care." "Managed care" is a generic term that refers to a
large variety of reimbursement plans in which third-party payers attempt to control costs by
limiting the utilization of medical services, in contrast to the "hands off" style of traditional fee-
for-service payment. Examples of such cost-savings strategies include the requirement that
physicians prescribe drugs only on a plan's approved formulary, mandated preauthorizations
before hospitalization or surgery, severe restrictions on the length of time a patient may remain
in the hospital, and the requirement that patients be allowed to see specialists only if referred by
a "gatekeeper." Ironically, the first health maintenance organization, Kaiser Permanente, had
been organized in the 1930s to achieve better coordination and continuity of care and to
emphasize preventive medical services. Any cost savings that were achieved were considered a
secondary benefit. By the 1980s, however, the attempt to control costs had become the dominant
force underlying the managed care movement.
Unquestionably, the managed care movement has brought much good. It has forced the medical
profession for the first time to think seriously about costs; it has encouraged greater attention to
patients as consumers (for example, better parking and more palatable hospital food); and it has
stimulated the use of modern information technologies and business practices in the U.S. health
care system. In addition, the managed care movement has encouraged physicians to move many
treatments and procedures from hospitals to less costly ambulatory settings, when that can be
done safely.
However, there have been serious drawbacks to managed care that in the view of many observers
have outweighed its accomplishments. Managed care has not kept its promise of controlling
health care costs, and in the early years of President George Walker Bush's administration, the
country once again faced double-digit health care inflation. In the view of many, the emphasis on
cost containment has come at the erosion of the quality of care, and the dollar-dominated medical
marketplace has been highly injurious to medical education, medical schools, and teaching
hospitals. Managed care has also resulted in a serious loss of trust in doctors and the health care
system—creating a widespread fear that doctors might be acting as "double agents," allegedly
serving patients but in fact refusing them needed tests and procedures in order to save money for
the employing organization or insurance company. As a result, the twenty-first century has
opened with a significant public backlash against managed care and a vociferous "patients' rights
movement."
Ironically, many of the perceived abuses of managed care have less to do with the principles of
managed care than with the presence of the profit motive in investor-owned managed care
organizations. Nonprofit managed care organizations, such as Kaiser Permanente, retain about 5
percent of the health premiums they receive for administrative and capital expenses and use the
remaining 95 percent to provide health care for enrollees. For-profit managed care companies, in
contrast, seek to minimize what they call the "medical loss"—the portion of the health care
premium that is actually used for health care. Instead of spending 95 percent of their premiums
on health care (a "medical loss" of 95 percent), they spend only 80, 70, or even 60 percent of the
premiums on health services, retaining the rest for the financial benefit of executives and
investors. Some astute observers of the U.S. health care system consider the for-profit motive in
the delivery of medical services—rather than managed care per se—the more serious problem.
However, since 90 percent of managed care organizations are investor-owned companies, the
for-profit problem is highly significant.
Future Challenges
The U.S. health care system has three primary goals: the provision of high-quality care, ready
access to the system, and affordable costs. The practical problem in health care policy is that the
pursuit of any two of these goals aggravates the third. Thus, a more accessible system of high-
quality care will tend to lead to higher costs, while a low-cost system available to everyone is
likely to be achieved at the price of diminishing quality.
Certain causes of health care inflation are desirable and inevitable: an aging population and the
development of new drugs and technologies. However, other causes of soaring health care costs
are clearly less defensible. These include the high administrative costs of the U.S. health care
system, a litigious culture that results in the high price of "defensive medicine," a profligate
American practice style in which many doctors often perform unnecessary tests and procedures,
the inflationary consequences of having a "third party" pay the bill (thereby removing incentives
from both doctors and patients to conserve dollars), and the existence of for-profit managed care
organizations and hospital chains that each year divert billions of dollars of health care premiums
away from medical care and into private wealth. Clearly, there is much room to operate a more
efficient, responsible health care delivery system in the United States at a more affordable price.
Yet the wiser and more efficient use of resources is only one challenge to our country's health
care system. In the twenty-first century, the country will still face the problem of limited
resources and seemingly limitless demand. At some point hard decisions will have to be made
about what services will and will not be paid for. Any efforts at cost containment must continue
to be appropriately balanced with efforts to maintain high quality and patient advocacy in
medical care. Better access to the system must also be provided. Medical insurance alone will
not solve the health problems of a poor urban community where there are no hospitals, doctors,
clinics, or pharmacies. Lastly, the American public must be wise and courageous enough to
maintain realistic expectations of medicine. This can be done by recognizing the broad
determinants of health like good education and meaningful employment opportunities, avoiding
the "medicalization" of social ills like crime and drug addiction, and recognizing that individuals
must assume responsibility for their own health by choosing a healthy lifestyle. Only when all
these issues are satisfactorily taken into account will the United States have a health care
delivery system that matches the promise of what medical science and practice have to offer.
Bibliography
Fox, Daniel M. Health Policies, Health Politics: The British and American Experience, 1911–
1965. Princeton, N.J.: Princeton University Press, 1986.
Fuchs, Victor R. The Health Economy. Cambridge, Mass.: Harvard University Press, 1986.
Gray, Bradford H. The Profit Motive and Patient Care: The Changing Accountability of Doctors
and Hospitals. Cambridge, Mass.: Harvard University Press, 1991.
Hiatt, Howard H. America's Health in the Balance: Choice or Chance? New York: Harper and
Row, 1987.
Ludmerer, Kenneth M. Time to Heal: American Medical Education from the Turn of the Century
to the Era of Managed Care. New York: Oxford University Press, 1999.
Lundberg, George D. Severed Trust: Why American Medicine Hasn't Been Fixed. New York:
Basic Books, 2000.
Mechanic, David. Painful Choices: Research and Essays on Health Care. New Brunswick, N.J.:
Rutgers University Press, 1989.
Rodwin, Marc A. Medicine, Money, and Morals: Physicians' Conflicts of Interest. New York:
Oxford University Press, 1993.
Rosen, George. The Structure of American Medical Practice, 1875–1941. Edited by Charles E.
Rosenberg. Philadelphia: University of Pennsylvania Press, 1983.
Rosenberg, Charles E. The Care of Strangers: The Rise of America's Hospital System. New
York: Basic Books, 1987.
Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign
Profession and the Making of a Vast Industry. New York: Basic Books, 1982.
Stevens, Rosemary. In Sickness and in Wealth: America's Hospitals in the Twentieth Century.
New York: Basic Books, 1989.

Wikipedia: Health care

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Home > Library > Miscellaneous > Wikipedia

This article has been nominated to be checked for its neutrality.

Discussion of this nomination can be found on the talk page. (November 2009)

For other uses, see Health care (disambiguation).

Surgery one of the most invasive, difficult and expensive procedures in medicine.

The International Red Cross and Red Crescent Movement is a well-known

international relief movement.

Health care (often healthcare in British English), is the treatment and management of illnesses
of the elderly, and the preservation of health through services offered by the medical, dental,
complementary and alternative medicine, pharmaceutical, clinical sciences (in vitro diagnostics),
nursing, and allied health professions. Health care embraces all the goods and services designed
to promote health, including “preventive, curative and palliative interventions, whether directed
to individuals or to populations”.[1] The definition of to recognize, tough to define," Albany
Times-Union November 12, 2009</ref>.
Before the term health care became popular, English-speakers referred to medicine or to the
health sector and spoke of the treatment and prevention of illness and disease. The social and
political issue of access to healthcare in the US has led to public debate and confusing use of
terms such as health care (medical management of illness or disease), health insurance
(reimbursement of health care costs), and the public health (the collective state and range of
health in a population). The public health is related most to economic development and wealth
distribution, and health insurance is a business which both provides and restricts reimbursement
for healthcare itself in the event of disease, or in access to of medical healthcare in individual
health-seeking, -promoting or -maintaining behaviours.

Contents
[hide]
• 1 Health-care industry
• 2 Research
○ 2.1 World Health Organization
• 3 Economics
• 4 Systems
• 5 Politics
• 6 Health care by country
 • 7 See also
• 8 Notes
• 9 External links

Health-care industry
Main article: Health care industry

The delivery of modern health care depends on an expanding group of trained professionals
coming together as an interdisciplinary team.[2][3]
The health-care industry incorporates several sectors that are dedicated to providing services and
products dedicated to improving the health of individuals. According to market classifications of
industry such as the Global Industry Classification Standard and the Industry Classification
Benchmark the health-care industry includes health care equipment & services and
pharmaceuticals, biotechnology & life sciences. The particular sectors associated with these
groups are: biotechnology, diagnostic substances, drug delivery, drug manufacturers, hospitals,
medical equipment and instruments, diagnostic laboratories, nursing homes, providers of health
care plans and home health care. [4]
According to government classifications of Industry, which are mostly based on the United
Nations system, the International Standard Industrial Classification, health care generally
consists of Hospital activities, Medical and dental practice activities, and other human health
activities. The last class consists of all activities for human health not performed by hospitals or
by medical doctors or dentists. This involves activities of, or under the supervision of, nurses,
midwives, physiotherapists, scientific or diagnostic laboratiories, pathology clinics, ambulance,
nursing home, or other para-medical practitioners in the field of optometry, hydrotherapy,
medical massage, music therapy, occupational therapy, speech therapy, chiropody, homeopathy,
chiropractice, acupuncture, etc. [5]

Research
See also: List of health care journals, List of medical journals, List of pharmaceutical
sciences journals, List of bioinformatics journals, and Medical literature

Top impact factor academic journals in the health care field include Health Affairs and Milbank
Quarterly. The New England Journal of Medicine, British Medical Journal, and the Journal of
the American Medical Association are more general journals.
Biomedical research (or experimental medicine), in general simply known as medical research, is
the basic research, applied research, or translational research conducted to aid the body of
knowledge in the field of medicine. Medical research can be divided into two general categories:
the evaluation of new treatments for both safety and efficacy in what are termed clinical trials,
and all other research that contributes to the development of new treatments. The latter is termed
preclinical research if its goal is specifically to elaborate knowledge for the development of new
therapeutic strategies. A new paradigm to biomedical research is being termed translational
research, which focuses on iterative feedback loops between the basic and clinical research
domains to accelerate knowledge translation from the bedside to the bench, and back again.
In terms of pharmaceutical R&D spending, Europe spends a little less that the United States
(€22.50bn compared to €27.05bn in 2006) and there is less growth in European R&D spending.[6]
[7]
Pharmaceuticals and other medical devices are the leading high technology exports of Europe
and the United States. [7][8] However, the United States dominates the biopharmaceutical field,
accounting for the three quarters of the world’s biotechnology revenues and 80% of world R&D
spending in biotechnology. [6][7]
World Health Organization
Main article: World Health Organization

See also: Global health

The World Health Organization (WHO) is a specialized United Nations agency which acts as a
coordinator and researcher for public health around the world. Established on 7 April 1948, and
headquartered in Geneva, Switzerland, the agency inherited the mandate and resources of its
predecessor, the Health Organization, which had been an agency of the League of Nations. The
WHO's constitution states that its mission "is the attainment by all peoples of the highest possible
level of health." Its major task is to combat disease, especially key infectious diseases, and to
promote the general health of the peoples of the world. Examples of its work include years of
fighting smallpox. In 1979 the WHO declared that the disease had been eradicated - the first
disease in history to be completely eliminated by deliberate human design. The WHO is nearing
success in developing vaccines against malaria and schistosomiasis and aims to eradicate polio
within the next few years. The organization has already endorsed the world's first official
HIV/AIDS Toolkit for Zimbabwe from October 3, 2006, making it an international standard.[9]
The WHO is financed by contributions from member states and from donors. In recent years the
WHO's work has involved more collaboration, currently around 80 such partnerships, with
NGOs and the pharmaceutical industry, as well as with foundations such as the Bill and Melinda
Gates Foundation and the Rockefeller Foundation. Voluntary contributions to the WHO from
national and local governments, foundations and NGOs, other UN organizations, and the private
sector (including pharmaceutical companies), now exceed that of assessed contributions (dues)
from its 193 member nations.[10]

Economics
Main article: Health economics

Health economics is a branch of economics concerned with issues related to scarcity in the
allocation of health and health care. Broadly, health economists study the functioning of the
health care system and the private and social causes of health-affecting behaviors such as
smoking.
A seminal 1963 article by Kenneth Arrow, often credited with giving rise to the health
economics as a discipline, drew conceptual distinctions between health and other goals.[11]
Factors that distinguish health economics from other areas include extensive government
intervention, intractable uncertainty in several dimensions, asymmetric information, and
externalities.[12] Governments tend to regulate the health care industry heavily and also tend to be
the largest payer within the market. Uncertainty is intrinsic to health, both in patient outcomes
and financial concerns. The knowledge gap that exists between a physician and a patient can
prevent the patient from accurately describing his symptoms or enable the physician to prescribe
unnecessary but profitable services; these imbalances lead to market failures resulting from
asymmetric information. Externalities arise frequently when considering health and health care,
notably in the context of infectious disease. For example, making an effort to avoid catching a
cold, or practising safer sex, affects people other than the decision maker.
The scope of health economics is neatly encapsulated by Alan William's "plumbing diagram"[13]
dividing the discipline into eight distinct topics:
• What influences health? (other than health care)
• What is health and what is its value
• The demand for health care
• The supply of health care
• Micro-economic evaluation at treatment level
• Market equilibrium
• Evaluation at whole system level; and,
• Planning, budgeting and monitoring mechanisms.
Consuming just under 10 percent of gross domestic product of most developed nations, health
care can form an enormous part of a country's economy. In 2001, health care consumed 8.4 per
cent of GDP across the OECD countries[14] with the United States (13.9%), Switzerland (10.9%),
and Germany (10.7%) being the top three.
The United States and Canada account for 48% of world pharmaceutical sales, while Europe,
Japan, and all other nations account for 30%, 9%, and 13%, respectively.[7] United States
accounts for the three quarters of the world’s biotechnology revenues.

Systems

A group of Chilean 'Damas de Rojo', volunteers on their local hospital.

Main article: Health care system

See also: Preventive medicine and Social medicine

Social health insurance is where a nation's entire population is eligible for health care coverage,
and this coverage and the services provided are regulated. In almost every country, state or
municipality with a government health care system a parallel private, and usually for-profit,
system is allowed to operate. This is sometimes referred to as two-tier health care. The scale,
extent, and funding of these private systems is variable.
A traditional view is that improvements in health result from advancements in medical science.
The medical model of health focuses on the eradication of illness through diagnosis and effective
treatment. In contrast, the social model of health places emphasis on changes that can be made in
society and in people's own lifestyles to make the population healthier. It defines illness from the
point of view of the individual's functioning within their society rather than by monitoring for
changes in biological or physiological signs.[15]
The United States currently operates under a mixed market health care system. Government
sources (federal, state, and local) account for 45% of U.S. health care expenditures.[16] Private
sources account for the remainder of costs, with 38% of people receiving health coverage
through their employers and 17% arising from other private payment such as private insurance
and out-of-pocket co-pays. Opponents of government intervention into the market generally
believe that such intervention distorts pricing as government agents would be operating outside
of the corporate model and the principles of market discipline; they have less short and medium-
term incentives than private agents to make purchases that can generate revenues and avoid
bankruptcy. Health system reform in the United States usually focuses around three suggested
systems, with proposals currently underway to integrate these systems in various ways to provide
a number of health care options. First is single payer, a term meant to describe a single agency
managing a single system, as found in most modernized countries as well as some states and
municipalities within the United States. Second are employer or individual insurance mandates,
with which the state of Massachusetts has experimented. Finally, there is consumer-driven
health, in which systems, consumers, and patients have more control of how they access care.
This is argued[by whom?] to provide a greater incentive to find cost-saving health care approaches.
Critics of consumer-driven health say that it would benefit the healthy but be insufficient for the
chronically sick, much as the current system operates. Over the past thirty years, most of the
nation's health care has moved from the second model operating with not-for-profit institutions
to the third model operating with for-profit institutions; the greater problems with this approach
have been the gradual deregulation of HMOs resulting in fewer of the promised choices for
consumers, and the steady increase in consumer cost that has marginalized consumers and
burdened states with excessive urgent health care costs that are avoided with consumers have
adequate access to preventive health care.
A few states have taken serious steps toward universal health care coverage, most notably
Minnesota, Massachusetts and Connecticut, with recent examples being the Massachusetts 2006
Health Reform Statute[17] and Connecticut's SustiNet plan to provide quality, affordable health
care to state residents.[18]

Politics
Main article: Health policy

The politics of health care depends largely on which country one is in. Current concerns in
England, for instance, revolve around the use of private finance initiatives to build hospitals
which it is argued costs taxpayers more in the long run.[19] In Germany and France, concerns are
more based on the rising cost of drugs to the governments. In Brazil, an important political issue
is the breach of intellectual property rights, or patents, for the domestic manufacture of
antiretroviral drugs used in the treatment of HIV/AIDS.
The South African government, whose population sets the record for HIV infections, came under
pressure for its refusal to admit there is any connection with AIDS[20] because of the cost it would
have involved. In the United States 12% to 16% of the citizens are still unable to afford health
insurance. State boards and the Department of Health regulate inpatient care to reduce the
national health care deficit. To tackle the problems of the perpetually increasing number of
uninsured, and costs associated with the US health care system, President Barack Obama says he
favors the creation of a universal health care system. [21] However, New York Times opinion
columnist Paul Krugman said that Obama's plan would not actually provide universal coverage.
[22]
(In contrast, Dennis Kucinich, an early candidate who did not get on the ballot, supported a
single-payer system.) Factcheck.org alleges that Obama's predicted savings were exaggerated. [23]
In contrast, the state of Oregon and the city of San Francisco are both examples of governments
that adopted universal healthcare systems for strictly fiscal reasons.

Health care by country

Health care systems are designed to meet the health care needs of target populations. There are a
wide variety of health care systems around the world. In some countries, the health care system
planning is distributed among market participants, whereas in others planning is made more
centrally among governments, trade unions, charities, religious, or other co-ordinated bodies to
deliver planned health care services targeted to the populations they serve. However, health care
planning has often been evolutionary rather than revolutionary.