A world of difference between health and healthcare

There may be only four letters distinguishing these two words, but there is a huge difference in how we design and implement our health systems and policies depending on which word we focus on.

IMAGINE that you have RM100 that must be spent on either a one-month gym subscription or a month’s supply of diabetes medication.

Or that you have RM1,000, which must be spent on either a short holiday to relax or therapy sessions to manage your anxiety attacks.

Or imagine that you’re the Health Minister with RM10mil that must be used either to fight air pollution in Kuantan or to buy faster ambulances so that asthmatic children can get to the hospital quickly.

Of course, these are over-simplified (and maybe even unfair) either-or questions that ignore modern realities and other decision criteria.

They are merely meant show the difference between “health” and “healthcare”.

The Oxford dictionary defines health as “the state of being free from illness or injury”, while healthcare is the “the organised provision of medical care to individuals or a community”.

In practical terms, we usually understand healthcare to mean hospitals, doctors, blood tests, MRI scans, medicines, dialysis, surgeries, etc. – all of which are tools to help us achieve health.

These two terms are used very interchangeably, but mean very different things.

Healthcare is merely the means to an end, and health is that end.

In fact, healthcare is only one of many tools to achieve health. Yet, our gargantuan system currently overly emphasises and incentivises healthcare.

Let’s consider one imperfect statistic that demonstrates this emphasis. In 2014, the Health Ministry (MOH) spent RM25.8bil (PDF), of which 69% was spent on curative care (e.g. hospital services and outpatient medicines) and only 7% on preventive care (e.g. public health services).

This is an imperfect statistic because other elements of government spending also promote health – e.g. housing, education, poverty eradication and clean water – but because it’s difficult to isolate the health effects of that spending from other positive effects, we may never know the true ratio.

We can all agree that curative care is an important ethical and moral imperative – no one is saying, “Let’s stop spending money on life-saving treatment”.

However, we should also agree that the 10-fold difference in allocation between curative and preventive care feels a bit unreasonable.

Healthcare is not health

It is very possible that healthcare is actually “sick-care”, as we put money into curing diseases and relieving suffering after people become ill.

Yet, there are still reasons why we still focus on healthcare, rather than health.

Firstly, healthcare (or sick-care) is urgent, immediate, dramatic, insistent and vote-pulling, and it will therefore demand and receive more attention, resources and political visibility.

Secondly, healthcare is a very big business, and there are inevitably vested interests resisting any change.

Thirdly, there is a vicious circle where hospital-based curative services consume lots of resources, and they are led by specialists who have more decision-making powers within the Health Ministry than public health or family physicians.

These problems are not unique to Malaysia, and we will examine them in future columns.

The moral imperative to care for all sick Malaysians must be restated.

Indeed, we must even increase our total healthcare expenditure (PDF) from our current 4.5% of GDP (gross domestic product) closer to the 6.6% average for a small peer group of middle-income countries like Brazil, Thailand and Turkey, the 9% developed country average or the 10% global average, to deliver more accessible and better quality healthcare to all Malaysians.

However, it is very possible to spend more money without getting more health.

While we should definitely increase healthcare spending, it is only one part of the solution, as mentioned before.

It might even lead to the unintended consequence of diverting attention or money away from other health-giving areas.

This is because many factors combine together to affect an individual’s health.

So, we must also aggressively address the social, economic and cultural determinants of health, such as early childhood development, education, poverty eradication, employment, housing, food security, sanitation, access to physical activity, and social services.

To improve health, lengthen lives and reduce suffering, these determinants are more powerful than hospitals and medicines.

Experts may disagree on how much these determinants contribute to health outcomes, but they all agree that medical care is not the only influence on health and that its effects are more limited than previously thought.

Prioritising health, not healthcare

I’ll make a strong statement here: at least 90% of health outcomes are reliant on the social, economic, cultural and biological determinants of health.

In other words, although healthcare is important, it is the most expensive determinant and contributes the least to health outcomes.

Now that we understand the importance of health (not healthcare), we can apply the World Health Organisation’s Health in All Policies principle.

In next week’s column, we will examine what I call an ideas-rich and solutions-rich environment, and how to achieve it.

In that environment, health will be a priority for all Malaysian ministries and agencies, alongside their main missions; and Health Impact Assessments will be adopted in all public policies and projects.

In such an environment, we can hopefully avoid the agony of budget dilemmas as health becomes naturally integrated into all government policies and projects.

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health, and has worked in five health sectors across three continents. He is currently specialising in health systems and policy in a public university and a local think tank. The views expressed here are entirely the writer’s own.

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