AROUND THE WORLD
Healthcare Around the World Editorial 4
Parul Sarwal, MD
President’s Message 5
Alwyn Rapose, MD
Socialized Medicine in Denmark 6
Thomas Emil Christensen, MD, PhD
South Korea's National Health Insurance System 8
Moonwon Hwang, MD and Yeoeun Lim, PhD
Healthcare Systems and its Challenges in Africa 10
Hawa Abu, MD, PhD, MPH, and Jafaru Samuel Abu, MBA, MSc, CNA
How the Healthcare System Works in the Biggest Country of South America: Brazil
Fernanda Furtado Sparrenberger, MD 11
Navigating Healthcare in India: A Story of Resilience and Optimism 12
Arunava Saha, MD
Healthcare Delivery in Malaysia 13
Yi Xiang Teo, MD
As I See It: An Outside View on African Healthcare 15
Rebecca Kowaloff, DO
The Healthcare System in Finland 16
Sunny Choi, PhD
Nursing in Armenia: Today and Tomorrow 16
Nancy A. Barsamian, DNP, MPH, RN
published by
Worcester District Medical Society
321 Main Street, Worcester, MA 01608 wdms.org | mwright@wdms.org | 508-753-1579
wdms officers
President Alwyn Rapose, MD
Vice President Michelle Hadley, DO
Secretary Justin Maykel, MD
Treasurer Adib Karam, MD
wdms administration
Martha Wright, MBA, Executive Director
wdms editorial board
Lisa Beittel, MBA
Sonia Chimenti, MD
Lloyd Fisher, MD
Larry Garber, MD
Rebecca Kowaloff, DO
Anna Morin, PharmD
developed by
Australian Medicare 17
Anne E. Wright
The Philippine Healthcare System 18
Phillip Ong
Curbside with Dr. Baker 21
Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com
In Memoriam
Dr. John Paul Lock 23
Frederic H. Schwartz, MD, FACP
Dr. James Ledwith Jr. 23
David Runyan, DNP, FNP-BC, NRP, President, Worcester Free Care Collaborative, Inc.
Dr. Robert Quinlan 24
Reprinted with permission from The Worcester Telegram and Gazette
Society Snippets
33rd Annual Women in Medicine Breakfast 25
3rd Annual Park Cleanup 25
WDMS Calendar of Events 26
References
For a complete listing of references from the articles in this issue, click or tap here.
Nancy Morris, PhD, NP
Thoru Pederson, PhD
Joel Popkin, MD
Alwyn Rapose, MD
Parul Sarwal, MD
Robert Sorrenti, MD
Parul Sarwal, MD, Editor-in-Chief
Sloane Perron, Copy Editor
Robert Howard, Designer
advertising Inquiries to Martha Wright mwright@wdms.org
508-753-1579
Martha Wright, MBA
Peter Zacharia, MD
Arunava Saha, MD, SVH, Medicine
Resident
Olivia Buckle, Student Representative
thanks to
The Reliant Medical Group, UMass Memorial Health
Music Worcester
Physicians Insurance
Hanover Theater
Mechanics Hall
UMass Chan Medical School
Beechwood Hotel
Editor-in-Chief
Parul Sarwal, MD
In this issue of Worcester Medicine, we take you on a global tour of healthcare systems. In a time when nations are increasingly turning inward, our editorial board set out to break down the walls and see what others are doing right—or wrong—in the healthcare space. Understanding how different countries address their respective issues promises to be a compelling study in contrasts, offering insights to improve healthcare delivery in our own communities.
Healthcare systems vary not only in structure and financing but also in the delivery of care, reflecting the unique needs and values of each society. Take, for instance, the United Kingdom’s National Health Service (NHS), a model of universal healthcare funded through taxation. The NHS ensures that every citizen has access to medical services without direct charges at the point of care, embodying a commitment to equity and accessibility. However, the system also faces significant challenges, particularly in terms of funding and resource allocation, which are critical areas of ongoing debate.
In contrast, the United States operates a mixed healthcare system, characterized by a combination of private and public funding. Despite boasting some of the most advanced medical technologies and highly skilled professionals in the world, the U.S. healthcare system struggles with issues of high costs and unequal access to care. The Affordable Care Act was a step towards bridging some of these gaps, yet disparities persist, highlighting the complexities of reforming such a vast and varied system.
“ …while the challenges of healthcare are universal, the solutions are as varied as the cultures that create them.
This issue of Worcester Medicine goes beyond these two well-known examples to examine a broader range of healthcare models. Denmark’s universally accessible, tax-funded healthcare system stands out for its efficiency and focus on preventive care, though it’s not immune to the challenges of an aging population and rising costs. Similarly, South Korea’s rapid implementation of universal health coverage has produced impressive outcomes despite, again, the ticking clock of an aging demographic.
The healthcare landscape in Sub-Saharan Africa presents a complex picture. While the region has made strides in combating HIV/AIDS,
recent crises like Ebola and COVID-19 have exposed significant weaknesses in its medical infrastructure. However, these hardships have not stifled creativity and progress, particularly in palliative care, as Dr. Rebecca Kowaloff highlights in her perspective piece in this issue. It’s proof that meaningful care can emerge even from scarcity.
Brazil’s Unified Health System, one of the largest public health systems globally, provides free universal care to millions while struggling with underfunding and regional disparities. Similarly, India’s ambitious Ayushman Bharat program, which aims to insure 500 million citizens, represents both a monumental challenge while being an opportunity for transformative change.
Our exploration also takes us to Southeast Asia, where Malaysia’s two-tier system has achieved nearuniversal coverage. The Philippines is working towards the same goal through its PhilHealth program. Australia’s Medicare system, which balances public and private healthcare, and Finland’s tax-funded universal healthcare, known for its high-quality and equitable care, round out our comparative study.
As we examine these diverse systems, we are reminded that while the challenges of healthcare are universal, the solutions are as varied as the cultures that create them. This issue of Worcester Medicine invites you to think globally and act locally, drawing on the lessons of others to enhance our own healthcare policies and practices. The ultimate goal remains the same: to improve health outcomes for all, both here in Worcester and beyond. +
President’s Message
Alwyn Rapose, MD
Dear friends,
Continuing from where I left off in my first President’s Message, I would like to encourage active participation from all WDMS members in the activities planned for this year. The Cottle Lecture is scheduled for October 23 and it will be a wonderful opportunity to meet one another again while hearing from a dynamic speaker. Bring someone along with you who has not been an active member. I also encourage you to sign up for Health Matters, the signature television program of the WDMS, which provides you with a wonderful opportunity to showcase your expertise on a local television station. Our delegation to the Massachusetts Medical Society House of Delegates also needs you. Please sign up if you have been a member of WDMS for more than one year.
This edition of Worcester Medicine features articles on healthcare systems in other countries. In our own world, we have seen tremendous advances with minimally invasive and robotic surgery, TAVR, and outpatient joint replacement procedures, all helping reduce hospital stay and post-op recovery times for surgical procedures. Our medical literature is flooded with information regarding breakthroughs in chemotherapy, immunotherapy, newer antimicrobials to target drug-resistant pathogens (I love it!), vaccines, and gene therapy (recently approved in December 2023 for sickle cell disease). However, there is another reality. A large part of the population lacks access to even a primary care physician and patients are assigned to non-physician clinicians as their PCP. Large medical corporations and hospital chains have edged out the family physician and compromised the personalized doctor-patient relationship. In most communities, group practice is the norm even though it is obvious that a patient would be so much happier to see a single physician committed to his or her healthcare rather than strangers at every different visit. Patients also face the challenges of receiving surprising bills, higher premium costs, lower benefits, and unexpected changes in coverage come January of each new year. As a result, “Healthcare is a Human Right” has become more of a slogan rather than a reality to common folks in Worcester. Interestingly, the world of concierge medicine has reached our doorsteps with a major Boston hospital providing personalized care for an annual fee of around $10,000 above regular health insurance policy premiums! This is despite the predicted shortfall of physicians and nurses to provide care in the general community.
In seeking a solution, we often look to the government to change laws that reduce profit-making by large hospital chains, insurance, and pharmaceutical companies. However, let me suggest we start making small changes ourselves. Encourage one another and lead by example providing the best care we can for our patients. Let’s remind ourselves why we entered medical practice. Mother Teresa said, “I alone cannot change the world, but I can cast a stone across the waters to create many ripples”. Let’s change our world one patient at a time.
May God bless you for all you do.
Sincerely,
Alwyn Rapose, MD, FACP alwyn.rapose@reliantmedicalgroup.org
ISocialized Medicine in Denmark
Thomas Emil Christensen, MD, PhD
n Denmark, medicine is socialized: all citizens have equal access to medical care, at an affordable price which costs about 7,700 USD per taxpayer per year. This covers everything from general practitioner visits to highly specialized care in the hospital, with nothing paid out of pocket by the patient. Many additional expenses are also subsidized, for example, medication, physiotherapy (also known as physical therapy), and psychiatric care. Patients are only responsible for a fraction of these costs.
How does socialized medicine work?
Consider “Mr. Hansen”, a wealthy lawyer living in a waterfront mansion just north of Copenhagen. He’s careful with his diet, doesn’t drink or smoke, and he’s training for his 15th marathon. Mr. Hansen has chest pain. On primary assessment in the ambulance, he appears to have a clogged coronary artery. This is considered urgent in Denmark, so he is transported by ambulance directly to the best hospital in the city where highly skilled specialists will do an acute coronary intervention to restore blood supply to the heart. Then he will be transferred to a local hospital for further care and followup assessments. After discharge, Mr. Hansen will receive cardiac rehabilitation via the hospital’s outpatient clinic. For all of this, Mr. Hansen is charged nothing. All costs are covered by the public health care system.
“
Consumer-driven health care is a very expensive way of ending up with the same outcome.
What happens if a lower-income citizen has a myocardial infarction? “Mrs. Jensen” lives in public housing just south of Copenhagen. She’s unemployed, smokes heavily, and eats poorly. The level of care provided to Mrs. Jensen is exactly the same as the care provided to Mr. Hansen, also at no additional cost to her.
In many ways, the system makes perfect sense. Most health-related issues are present in poor socioeconomic status groups so socialized medicine provides optimal care to patients who need it most.
But the system is also beneficial to wealthier patients because it keeps expenses low. There is a built-in incentive for rational spending because funding is fixed, decided in the yearly federal budget act.
In a consumer-driven healthcare system, like that in the USA, there is an incentive to offer medical services to a patient even with no documented research showing it improves patient mortality or morbidity. For example, in Denmark, preventative screening of healthy individuals is kept to a minimum. Only a few programs exist,
mainly screening for cervical and breast cancers. This is because very few screening programs have actually been documented to show improved patient outcomes. In addition, the Danish healthcare system is reactive, not proactive: no annual physicals – testing is kept to a minimum. This means no easy access to imaging tests (CT scan, MRI) and no colonoscopies in the absence of symptoms.
Most healthcare-related issues in Denmark are handled by general practitioners; seeing a specialist requires a referral. On average, every Dane is seen by his family doctor seven times a year, and most issues are handled in the office. Only a small fraction of visits lead to a specialist referral. Thus, specialists can focus on patients who actually need specialized care. This increases the rational use of resources, providing costly specialized care to patients who need it.
The Danish system avoids consumer-driven demand for services which increases testing and treatments even with no documented positive effect on outcomes.
”Mr. Olsen” from Aarhus schedules a visit with his GP because of a backache with no additional symptoms. The GP provides Mr. Olsen with a referral to a physiotherapist and a few weeks later Mr. Olsen’s back pain has markedly improved. In a consumer-driven healthcare system, Mr. Olsen –who is well-insured – may schedule an appointment with a rheumatologist. Mr. Olsen will receive a physical as well as a CT and MRI of the spine. The images are then scrutinized by a radiologist who finds a herniated disc. Next, Mr. Olsen sees a back surgeon to discuss surgical vs. conservative treatment. The surgeon recommends physiotherapy. A few weeks later Mr. Olsen’s back pain has markedly improved. Consumer-driven health care is a very expensive way of ending up with the same outcome. Also, while the specialists are attending to minor issues of the well-insured, access is reduced for the uninsured “Mrs. Sorensen” who has a spinal tumor requiring highly specialized care.
Even worse, in consumer-driven health care the doctors might recommend more advanced treatments than necessary and actually harm patients. The back surgeon might recommend surgery to a patient even though evidence shows similar improved outcomes with less risky physiotherapy.
In summation, the pros of socialized medicine are: a) better access to health care for patients needing it the most, b) cheaper overall health care services because of the incentive to minimize costs,
Socialized
Medicine in Denmark Continued
c) minimized overdiagnosis and overtreatment that pose threats to well-insured patients in private health care.
Are there downsides to this socialized system? Unfortunately, yes. It is subjected to political intervention that, contrary to its purpose, obstructs operations. This aside, the main problem is that there is no mechanism to balance supply and demand. When expenses increase, funding remains fixed, hence the system is subjected to constant budget cuts negatively impacting the quality of care. Furthermore, the load is not evenly distributed, but predominantly carried by patient groups with the least powerful lobbyists. In this, cancer and heart patients are at the top of the hierarchy, whereas psychiatric patients are at the bottom.
Also, recruitment and retention are difficult. Danish nurses and doctors are paid a fraction of their American counterparts. It’s becoming especially difficult to recruit and retain nurses. There is a large efflux of nurses to non-related professions where pay and working conditions are better.
This is also true for recruitment to less popular rural areas. It is difficult to offer any incentive to lure much-needed healthcare workers away from the major cities for a longer commute to work with multimorbid, non-resourceful patients in small, understaffed hospitals.
So, which is better? Socialized medicine or privatized health care? Each offers its own challenges and advantages. Socialized medicine is cheap, accessible for patients who need care the most, and has less over-diagnosing and overintervention. And for now, the system has overwhelming public support in Denmark. +
Thomas Emil Christensen, MD (Cardiology), PhD works at Hvidovre Hospital in Hvidovre, Denmark. Email: thomasemilchristensen@gmail.com
SSouth Korea’s National Health Insurance System: An Overview
Moonwon Hwang, MD and Yeoeun Lim PhD
outh Korea provides its citizens with a National Health Insurance (NHI) system established under the National Health Insurance Act. The legislation began in 1977, and by 1989, the entire population was enrolled in the NHI system. The Ministry of Health and Welfare supervises the operation of the NHI program through making and implementing policies. As a nonprofit institution, the National Health Insurance Service is a single insurer that provides health insurance to all citizens living in Korea. The Health Insurance Review & Assessment Service (HIRA) evaluates the medical service fee, quality of healthcare, and adequacy of medical service.
South Korea’s NHI differs significantly from private health insurance in several key aspects:
1) Universal Coverage: The National Health Insurance Act enforces the government’s constitutional duty to enhance social security and public health. The system covers employees, public officials, educators, and regional residents, ensuring universal coverage. As of 2023, 51.5 million individuals are insured under the NHI, with an additional 1.5 million covered by the Medical Aid program for low-income citizens.
2) Compulsory Insurance: Enrollment in the NHI is mandatory once legal requirements are met, regardless of individual preference. Insured individuals must pay premiums, with enforcement measures for non-payment.
3) Income Redistribution Function: Unlike private insurance, where premiums depend on coverage details and risk levels, NHI premiums are based on income, ensuring affordability. Benefits are equally distributed, performing an income redistribution function that reduces the economic burden during illness by pooling resources and providing uniform benefits.
4) Designated Medical Institutions: All healthcare facilities in South Korea must treat NHI-covered patients. Medical institutions cannot opt out of the NHI framework, ensuring comprehensive access to healthcare services.
Employees contribute to the NHI by paying a premium, calculated by multiplying their monthly salary by the premium rate (7.09% in 2023). Employers and employees each pay 50% of this premium. For the self-employed, premiums are determined based on income, property, and vehicle ownership. For example, the author, with an average monthly salary of 10,000 USD, shares the monthly NHI premium of approximately 769 USD with the employer.
When determining the scope of health benefits, the Ministry of Health and Welfare excludes treatments for conditions that do not interfere with daily activities. These exclusions are referred to as non-covered services. Generally, covered services are those eligible for health insurance benefits. In contrast, non-covered services include cosmetic surgery, vision correction surgeries (LASIK, LASEK), dental prosthetics (gold crowns), manual therapy, and general medical certificates. Additionally, some services like ultrasound exams, MRI diagnostics, and assisted reproductive technologies are considered non-covered based on specific criteria. New medical technologies are often initially classified as non-covered until their efficacy and cost-effectiveness are evaluated, potentially resulting in varying costs across medical institutions.
In the NHI system, the cost of medical services
is relatively low compared to other countries. For instance, the cost of hospital services in South Korea is 57 units compared to 100 units in the Organisation for Economic Co-operation and Development (OECD) countries on average and 130 units in the United States [1]. A concrete example is the initial consultation fee at primary care clinics in South Korea, which is approximately 13.08 USD as of 2024.
South Korea adopted the NHI system in 1977. At the time of its implementation, the national finances were poor, and the income levels of the population were very low. Therefore, to apply health insurance to the entire population, a system of “low insurance premiums, low fees, and low benefits” had to be adopted. This type of insurance system inevitably led doctors to see many patients through short consultations and relatively focused on income from non-covered services.
Under the NHI system, patients are less conscious of healthcare costs, potentially leading to overutilization of services. To curb excessive usage, a co-payment system is implemented. Patients pay 20% for inpatient care and varying rates for outpatient care depending on the type of hospital: 30% at clinics, 40% at hospitals, 50% at general hospitals, and 60% at tertiary hospitals. However, there are caps on out-of-pocket expenses to prevent excessive financial burden. Severe diseases like cancer have significantly reduced co-payment rates, and Medical Aid recipients pay only 0-10%.
To illustrate, a patient who underwent a liver transplant and was hospitalized for 26 days incurred a total medical cost of approximately 77,157 USD. The patient’s out-of-pocket expense was approximately 14,252 USD, including partial coverage for insured services (approximately 4,943 USD), full payment for non-covered services (approximately 2,995 USD), and non-covered items (approximately 6,314 USD). The NHI covered the remaining cost. Major non-covered and full-payment items included PET/ultrasound exams, non-covered treatment materials, drug costs, and private room fees.
Through this NHI system, South Korea has established a high-quality healthcare structure with easy access to physicians and very low insurance premiums. In 2020, South Koreans had the highest number of outpatient visits per capita among OECD countries, with an average of 14.7 visits annually, compared to approximately 3.2 visits per person per year in the United States [2]. Health outcomes are also favorable, as evidenced by a low avoidable mortality rate (99 per 100,000 people in South Korea compared to 238 per 100,000 in the USA) [3].
However, the NHI system currently faces challenges regarding financial sustainability and coverage. Changes in population structure due to aging and low birth rates increase the financial burden, and healthcare costs continue to rise. In 2022, national healthcare expenditures accounted for 9.7% of GDP, up from 6.0% in 2012. Continued cooperation between the government and healthcare providers is essential to maintain a sustainable health insurance system. +
Moonwon Hwang, MD, is an Assistant Professor of Ophthalmology at Inje University College of Medicine and Busan Paik Hospital.
Yeoeun Lim is a Ph.D. student in Cognitive Science at Indiana University Bloomington. She received her Bachelor of Music, Master of Music, and Doctor of Musical Arts degree in Musicology from Seoul National University.
Healthcare Systems and its Challenges in Africa
Hawa Abu, MD PhD MPH and Jafaru Samuel Abu, MBA, MSc, CNA
Landscape and Historical Background of Healthcare in Africa
Africa is the second largest continent in the world (after Asia) with an estimated population of 1.3 billion and a broad range of physical geography with four main regions: North, West, East, and South Africa. There are 54 African countries with their respective political systems, economic development trajectories, varying social practices, and cultural diversity with over 3,000 distinct ethnic groups.
Throughout African history, healthcare has largely evolved with complex and diverse perspectives shaped by a myriad of factors including indigenous healing practices, colonial influences, global health initiatives, and ongoing efforts to address deeply rooted systemic challenges, with the goal of providing affordable, accessible, and equitable healthcare for all. In the pre-colonial era, indigenous/traditional healing practices were well-established in African societies and rooted in spiritual beliefs, herbal medicine, and community-based care delivered by traditional healers. Although the Westerners had the belief that African traditional medicine was primitive and non-scientific, most parts of Africa have preserved their traditional healing practices to date. During the colonial era in the late 19th to mid-20th century, Western medicine was introduced by the ruling countries (Britain, Belgium, France, and Portugal), which mostly served their administrative and economic interests with very basic infrastructure and a focus on controlling the spread of infectious diseases among colonial masters and the African labor force. The advent of missionaries in Africa promoted healthcare development with the expansion of infrastructure including hospitals and medication dispensaries, training local healthcare workers, and executing disease control programs. In the post-colonial era (mid-20th century), many African countries had gained their independence, and efforts were geared towards developing national healthcare systems. However, systemic challenges including political instability, limited resources, and disparities in healthcare access have persisted across the continent. In 1978, the Alma Ata Declaration, by the World Health Organization (WHO) provided an important global initiative toward primary healthcare with an emphasis on communitybased participation, improved healthcare access, and integration of traditional and modern medical practices, which was widely accepted with varying implementation strategies across Africa.
Challenges of the Healthcare Systems in Africa
The obstacles to healthcare in Africa are multifaceted ranging from the limited workforce and health information systems to inadequate governance and insufficient healthcare budgetary, with varying extent across the respective African countries. However, common issues persist as follows:
The initial and most crucial challenge faced by the African healthcare system was the HIV/AIDS epidemic (1980s-1990s) which had a profound economic and social impact. Efforts made to address the epidemic included support from international aid and partnerships, NGOs, and donor countries to promptly develop infrastructure for early disease detection and initiation of antiretroviral therapy. Although there has been a remarkable decline in the incidence of HIV/AIDS, emerging health threats such as the Ebola crisis (2014-2016) and the COVID-19 pandemic
have emphasized the inadequacies of the healthcare systems in sub-Saharan Africa; such as inadequate emergency response plans and strategies, poor access to healthcare, lack of medical supplies and equipment, poor integration of traditional healing practices and modern medicine as many families seek help from African traditional healers before presenting to a clinic/hospital, and the overwhelming levels of poverty with lack of basic amenities. These issues still persist placing the African populace at a high risk of morbidity and mortality from poorly contained and managed infectious diseases.
Besides the burden of infectious diseases (such as malaria, HIV/AIDS, tuberculosis, emerging and reemerging neglected tropical diseases), most African countries are experiencing the epidemiologic transition of the high double burden of infectious diseases and non-communicable diseases (obesity, hypertension, diabetes, renal impairment, and cancers) with an increasing prevalence of multimorbidity and competing health priorities. In addition to these conditions, there are co-existing poor health indices including high infant and maternal mortality rates, putting an extra strain on the healthcare system which is already inadequately funded by the government and understaffed by healthcare providers.
Since most African countries are unable to sufficiently meet the requirements for a stable and functional healthcare system to manage the growing rates of multimorbidity, there is widespread and pervasive mistrust in the broken-down and overburdened healthcare system which has facilitated medical tourism. Sadly, this has cost Africa an estimated $1 billion loss annually according to the 2015 World Bank statistics. Those who propagate medical tourism include African leaders who divert the funds meant to build the healthcare system for their personal use at the continent’s detriment.
In the last three decades, there has been a dramatic rise in the number of healthcare professionals migrating from Africa to developed nations around the world resulting in “brain drain” in the African continent. Migrating healthcare workers have left their home countries due to: very poor working conditions, inadequate medical equipment and supplies, working long and extended hours, paucity of biomedical and clinical research funding, unfairly low and delayed remuneration, high cost of living, economic and political instability, disruption in medical training, and interrupted delivery of healthcare services. These delays
are caused by professional industrial action to get the attention of the government in order to address their unfavorable working conditions.
Recommendations to Overcome Healthcare Challenges in Africa
Although the challenges of the African healthcare system are complex and overwhelming, we seek solace in the African proverb, “The best way to solve a problem is to tackle it bit by bit, one step at a time”. Additionally, it is imperative that those who experience a given problem are included in the discussion, implementation, and evaluation of the proffered solutions. In April 2019, the African Epidemiological Association during their Annual Scientific (comprised of policymakers, program implementing partners, and healthcare researchers) identified strategies to mitigate these challenges of the African healthcare system. These proposed solutions included training and capacity building, providing health insurance for the African populace, advocacy and increased political engagement, increasing budgetary allocation to healthcare, improving healthcare infrastructure, and better recruitment and retention among healthcare workers. We hope these strategies are sustainable and that the African healthcare system is strengthened in the near future! +
Hawa Abu, MD, PhD, MPH
Assistant Professor, Geriatric Medicine Division
UMass Chan Medical School, Worcester MA
Jafaru Samuel Abu, MBA, MSc, CNA
Respiratory Therapy Student
Quinsigamond Community College, Worcester, MA
IHow the Healthcare System Works in the Biggest Country of South America: Brazil
Fernanda Furtado Sparrenberger, MD
t was my first day working as a physician, after six years of medical school. I always loved Family Medicine and had the privilege of working in one of the Family Health Strategy (ESF) clinics in my hometown where I’ve lived my whole life. So, I am going to talk about the healthcare system in Brazil, which is mainly composed of The Sistema Único de Saúde (SUS) – the Unified Health System in Brazil.
The SUS is Brazil’s public healthcare system which provides healthcare services to the entire population, regardless of their ability to pay. SUS operates under the principle of universal healthcare coverage, meaning that all Brazilian citizens and legal residents have the right to access healthcare services provided by the system.
ESF is a cornerstone of Brazil’s public healthcare system. It is a clinic system that aims to provide comprehensive primary healthcare services to individuals and families in their communities with a focus on prevention, health promotion, and disease management.
I was nervous and apprehensive on my first day, so I found it very helpful that the ESF operates through multidisciplinary teams composed of doctors, nurses, nurse assistants, dentists, and Community Health Workers (CHWs). As a team, we were responsible for providing care to a specific geographic area, usually covering a certain number of families, and the nurses knew their patients very well. These team members were responsible for the health care of about 4,000 people in this region of the city.
ESF also places a strong emphasis on preventive care and health promotion activities, such as immunizations, prenatal care, family planning, nutrition education, and screening for chronic diseases like diabetes and hypertension.
“
One of the most significant challenges facing the public health system in Brazil is the issue of underfunding and insufficient resources.
While ESF teams provide a wide range of primary care services, they also serve as the gateway to the broader healthcare system. They refer patients to secondary and tertiary care facilities when necessary for specialized treatment or procedures.
We also utilize electronic health records to facilitate communication and coordination of care among team members and other healthcare providers within the SUS network. If we need to refer a more critical patient to the hospital, we can use public hospitals.
Public hospitals play a central role in the SUS network, collaborating with primary care units, specialized clinics, and other healthcare providers. They ensure continuity of care for patients. They also participate in referral networks, where patients can be referred for specialized care or procedures not available at primary care facilities.
Although on paper, it is an amazing program, we have a lot of challenges in the day-to-day work with SUS. One of the most significant challenges facing the public health system in Brazil is the issue of underfunding and insufficient resources. Despite its universal coverage mandate and comprehensive scope of services, SUS often struggles to meet the healthcare needs of Brazil’s large and diverse population due to limited financial resources. SUS is funded primarily through government allocations from federal, state, and municipal budgets, as well as contributions from social security taxes.
How the Healthcare System Works in the Biggest Country of South America: Brazil Continued
Budget constraints and competing priorities often lead to insufficient funding for healthcare, limiting the availability of resources for essential services, infrastructure upgrades, and healthcare workforce development.
When patients need a specialist, primary care physicians face shortages of professionals. This is especially true in underserved regions. Additionally, some factors such as low salaries, inadequate working conditions, and few career advancement opportunities discourage specialists from public services in favor of private systems.
Similar to other healthcare systems worldwide, waiting times to see specialized doctors within SUS can sometimes be lengthy, particularly for nonemergency or elective procedures. This can be due to factors such as high demand, limited resources, and the prioritization of urgent cases.
The primary care system works well in our country. We can diagnose and manage a wide range of acute and chronic health conditions, as well as provide preventive care, health promotion, and wellness counseling. However, if a patient needs specialized care or exams, they wait a long time in the waiting list to be called, and this, depending on the disease we are talking about, can worsen the quality of life of the patient.
We also have the private health system in Brazil, that provides an alternative option for individuals and families seeking timely access to healthcare services, specialized care, and enhanced amenities beyond what is available through the public healthcare system. However, access to private healthcare services may be limited by factors such as affordability, geographic location, and the availability of health insurance coverage.
Another option in Brazil is private health insurance, with many individuals and families opting to purchase private health insurance plans to access private healthcare services. Health insurance companies offer a variety of plans with different coverage options, including individual plans, family plans, and employer-sponsored plans.
Overall, opinions about healthcare systems in Brazil, including SUS, are diverse and multifaceted, reflecting the complex realities of healthcare delivery, financing, and governance in the country. While I recognize the significant achievements and aspirations of SUS, there are also ongoing debates and efforts to address its shortcomings and improve the overall quality, accessibility, and sustainability of healthcare for all Brazilians. +
Fernanda Furtado Sparrenberger, MD General Practitioner, Postgraduate in Family Medicine fernanda.sparrenberger@yahoo.com
TNavigating Healthcare in India: A Story of Resilience and Optimism
Arunava Saha, MD
he high-pitched ringing of the ventilator pierced the night air, rising above the general cacophony of cries, shouts, and laughter—the usual amalgamation of sounds omnipresent in a medicine ward. It was admission day at the largest government hospital in a Tier-II city of India, catering to a population of eight million; and it was absolute pandemonium.
Being the second-most populated country in the world comes with its fair share of problems. Despite the recent economic boom, India continues to perform abysmally in the global health security index and the global hunger index. These statistics highlight the widespread disparity and longstanding healthcare accessibility gaps. Yet, with a meager 2.5% of GDP spent on healthcare, India has managed to develop and sustain one of the most unique healthcare models in the world, driven by the philosophy, "Leave no one behind”.
“
Whereas the U.S. spends about $8,500 per person annually on healthcare, India spends about $40.
While the rich have access to the best resources, the poor are not entirely forsaken thanks to government-funded hospitals. These institutions, although similar to the U.S. healthcare system, operate on a drastically different scale. Whereas the U.S. spends about $8,500 per person annually on healthcare, India spends about $40[1]. Consequently, public-funded government hospitals, low-cost nursing homes, or missionary-funded private hospitals are the go-to places. Despite this grim picture, which generates an image of a dilapidated building with people scattered around crying for help, the truth is starkly different. With donations through various NGOs, and occasionally from the private sector, and relief from international organizations, government hospitals continue to provide a beacon of hope for millions.
Medical training in India is rigorous, strenuous, and often formidable. A resident is expected to be responsible for the day-to-day workings: seeing more than 60 patients in an average outpatient day along with managing 80-100 admitted patients in the ward. All this means residents have almost no time to eat or sleep, let alone go home for a shower. They practically live in the ward, catching a few hours of sleep in the doctors' room or sometimes even on a gurney. Nursing staff is minimal, with one nurse catering to a ward of 80-100 patients, so patients’ relatives often take on most of the responsibility, including providing food and medications, helping the patient walk and use the restroom, and in some cases, even manually bagging their intubated loved ones for hours until a ventilator can be arranged.
Sometimes patients get angry, some bring their loved ones at the critical moment and create an uproar when nothing can be done—occasionally
even attacking junior doctors in the process. But, for most of the population, the physician still stands on a pedestal. Traveling to a hospital is like a pilgrimage, where they leave their homes and families behind and travel long distances with the belief that they will have someone to help in their plight. Despite the hardships, the beauty lies in the fact that if instructed to do something, they try their best to follow it. This is where the sense of satisfaction in practicing medicine comes from—knowing that patients are willing to listen to you as you try to make a difference.
Obviously, in such a scenario, the healthcare system also has several lacunae. We lag behind in preventive healthcare; easy access to over-thecounter medications and antibiotics without prescriptions leads to worsening antibiotic resistance; inadequate data integration, issues of privacy and confidentiality of health data, and insufficient data sharing mechanisms affect continuity of care. There is also a stark disparity when it comes to access to basic sanitation and healthcare in remote rural areas; lack of access to essential vaccines, and extremely poor public communications infrastructure.
It is often said that India lacks “social solidarity”—a sense that people should take care of each other—and this has resulted in a health system rife with inequities. On the contrary, you will notice a strong sense of cohesion, camaraderie, and accomplishment when you enter one of these hospitals. Rooted deep in our culture is a unified consensus to do our best with what we have and not complain. As stated in the Bhagavad Gita: Do not worry about the results; keep performing your karma with due diligence. One would be amazed to see this practiced all around, where every single person—from doctors and nurses; cleaning staff and attendants; to scientists and researchers—is just doing their best to stay afloat and somehow doing a great job in the process. The approval of the country’s first natively developed chimeric antigen receptor (CAR) T-cell therapy, priced at a fraction of the cost in the U.S., is a testament to the same.
So, when the ventilator rang out at 3 a.m., connected to an intubated young gentleman with organophosphorus poisoning who was drowning in his secretion, the wheels in my head started turning despite the commotion. I dropped the urinary catheter I was inserting, my colleague left her first meal of the day, and my senior ran back after just exiting the ward a few seconds earlier. In a few moments, we had suctioned him, given him another dose of atropine, and reintubated him. As his vitals stabilized and the ventilator returned to its rhythmic beeping, we sighed and went back to our tasks.
In those few seconds of respite, the phone rang. A young patient with leptospirosis, liver failure, and septic shock was making his way up to the medical floors due to a lack of ICU beds. We looked at each other, grimaced, and went back to work. This is not just my story—it is the story of every medical resident who has pursued residency training in India.
As an internal medicine resident who has completed further training in the U.S., I feel privileged to have experienced both healthcare systems at close quarters. The differences and similarities between the two are striking. While it may not make sense for India to take lessons from the U.S., given its own struggles to fashion an effective healthcare system; I believe we have a lot to learn from both its mistakes and its successes. +
Arunava Saha, MD
Pulmonary and Critical Care Fellow
Tulane University School of Medicine saha.arunava100@gmail.com
THealthcare Delivery in Malaysia
Yi Xiang Teo, MD
he healthcare system in Malaysia consists of both private and government (public) hospitals. Public hospitals also serve as teaching hospitals where medical graduates complete their two-year housemanships (like sub-internship rotations). These hospitals are heavily subsidized by the government, making cost a significant differentiating factor between the two tiers.
Malaysia provides universal healthcare for all citizens. Instead of providing a public or government health insurance policy, the government heavily subsidizes the cost of treatment through public facilities. For instance, the consultation fee per office visit for a general practitioner in a public hospital is RM1 (approximately $0.20) and RM5 (approximately $1.20) for specialist consultations. In contrast, private healthcare costs range from RM30-RM125 for a general practitioner and RM80-RM235 for a specialist visit. This is demonstrated by Table 1: Examples of healthcare cost comparison between public and private sector[1]. This subsidized practice was established in the 1970s, and it aims to ensure affordable healthcare for all Malaysian citizens. Moreover, there are several health safety nets for low-income citizens.
“
Instead of providing a public or government health insurance policy, the government heavily subsidizes the cost of treatment through public facilities.
However, the affordability of public healthcare leads to overcrowded hospitals, which in turn affects the quality of care and results in a lack of individualized attention for patients. This overcrowding is a major drawback, contributing to longer waiting times and reduced patient satisfaction. Many physicians are concerned about the sustainability of this model. Despite heavy subsidies, rising operational costs are straining the public sector, making it difficult to
Healthcare Around the World
Healthcare Delivery in Malaysia Continued
maintain adequate compensation for physicians. This situation has led to physician burnout and challenges in retaining talent within the public sector.
Hence, with their ability to afford out-of-pocket costs, citizens with higher household incomes often opt for private healthcare. This is where private health insurance (PHI), sold under Medical and Health Insurance (MHI) policies, comes into play. These policies, available since the 1970s, can be purchased voluntarily either by individuals or through employer-sponsored health insurance (ESHI) schemes.
Most private health insurance policies in Malaysia primarily cover inpatient treatment. A significant aspect of these policies is that patients are usually required to pay their medical bills upfront and then seek reimbursement from the insurance company. This protocol can deter individuals with lower household incomes from purchasing private health insurance, as the initial medical expenses may be prohibitive, despite eventual reimbursement.
The MHI market in Malaysia saw significant growth in the 1990s following the introduction of personal income tax relief in 1996. This tax relief made private health insurance more financially attractive, leading to a decrease in the uninsured rate from 85% in 2005 to 57% in 2011. The likelihood of being uninsured in Malaysia is strongly linked to factors such as income and education, with higher income and education levels correlating with higher insurance coverage rates [2,3].
General practitioner (GP) clinics are widely accessible and accept walk-in patients and are available in both public and private sectors. In the private sector, specialists accept patients without a GP referral, offering more direct access to specialized care. Conversely, the public sector requires a referral from a GP for specialist consultations. These primary care services include preventive care, treatment for common illnesses, maternal and child health services, immunizations, and health education.
Healthcare disparity remains a challenge in the Malaysian healthcare system. For instance, the LGBTQ community continues to suffer from discrimination and stigmatization both socially and medically. There is a growing recognition of the need for inclusive healthcare services that respect the identities and experiences of LGBTQ individuals. Training healthcare professionals on LGBTQ issues and reducing discriminatory practices are essential steps in this direction, but much remains to be done.
Malaysians have increasingly embraced traditional Chinese medicine (TCM) as part of their healthcare regimen, evident in the proliferation of TCM clinics and practitioners across the nation. These establishments cater not only to the Chinese Malaysian community but also to individuals from diverse ethnic backgrounds seeking alternative or complementary healthcare solutions, including acupuncture and herbal medicine. While TCM offers additional support for conditions like chronic back pain, its growing popularity also raises concerns about potential misinformation and biases that could affect patients' understanding and decisionmaking regarding healthcare, with rural and low socioeconomic status communities being the most vulnerable population for such negative impact.
In conclusion, healthcare accessibility and affordability in Malaysia are commendable. However, sustaining this progress and enhancing care quality requires continuous reforms and targeted initiatives. Addressing existing challenges is key to the success of healthcare in Malaysia such as including the healthcare needs of marginalized communities like the LGBTQ population and enhancing the overall health literacy of the populace. +
t able 1: c omparison of medical fees between public and private healthcare systems
Yi Xiang Teo, MD, born and raised in Malaysia, completed his medical education in Shanghai, China. He is currently a fellow in Pulmonary and Critical Care at UMass Baystate, after having completed his chief residency at St. Vincent Hospital.
HAs I See It: An Outside View on African Healthcare
Rebecca Kowaloff, DO
ospice Africa (HA) is more than Uganda’s national hospice, it is a leader for the continent. From three sites spread across this Central African country, nurses, social workers, chaplains, and doctors serve patients in their homes at hospice clinics, and at community mobile clinics providing physical, emotional, and spiritual comfort for patients and their caregivers, relieving as much suffering as they can. Teams travel across bumpy dirt roads to visit cachectic patients curled on foam mattresses on the floor. They check vital signs and bring the most revolutionary of their interventions: oral liquid morphine.
I had watched the green liquid mixed from water and vats of powdered morphine at the Hospice’s main site in the capital city of Kampala. It is decanted into brown water bottles, prescribed, and distributed by HA’s trained nurses. Uganda was the first country in the world to legislate that nurses could prescribe morphine, a necessary measure given the country’s physician shortage. Opioid addiction has not become a problem in Uganda since the oral morphine program, a public-private partnership funded by the government, began in the mid-1990s. Now, morphine is provided for free through government funding. HA trains palliative care clinicians from across sub-Saharan Africa in all aspects of supportive care for seriously ill patients. Their services are vital in a country whose life expectancy just 30 years ago was under 40 due to HIV/AIDS and cancers not seen in the United States. Screening protocols in Africa are unfortunately not as common as they are stateside. In cancer “wards” that were open-sided pavilions with mattresses on the floor, to cement block shacks with dirt floors, and for caregivers juggling enormous family and financial burdens, the ability to provide real relief of suffering, not just from a brown bottle, but from a support team arriving in an old van, has made an enormous difference on a continent where global health disparities are most prominent. +
Rebecca Kowaloff, DO
RThe Healthcare System in Finland
Sunny Choi, PhD
egardless of one’s socioeconomic status, Finland’s publicly funded system – such as education and healthcare to name a few – allows its residents to access these fundamental services for free. With a relatively low population of 5.5 million (geographically similar in size to Germany with a population of over 80 million), Finland’s free healthcare system is supported through taxes. Private healthcare options through private medical providers are also available (through employment for example) as an additional source of access. With private care, patients have access to easier booking with preferred physicians and minimal waiting appointment periods. Private care visits are still partially covered by the Finnish social network.
Primary care in Finland provides services to visit general practitioners, in addition to dental care, child health care, mental health care, and maternity care. Visiting specialists normally require referrals from primary care practitioners. Maternity care and ‘baby box’
Finland at one point carried a high infant mortality. As an effort to improve the health of both mothers and babies, the Finnish government introduced a special maternity package called the “baby box” in the 1930s. This box is provided by the Finnish social security system (also known as Kela) to all expecting mothers to prepare both mothers and babies for their early days, regardless of the family’s financial situation. The box is filled with essential items such as clothing, bedding, bathing items, and diapers that are needed for newborns and their mothers. The box itself can even serve as the baby’s bed.
Access to patient’s health records
All Finnish residents have the right to access their full health records from a secure online platform called Kanta. Healthcare providers as well as patients have full access to their patient records as a source of a two-way consent system. Finland's electronic health records (EHR) system is considered one of the most advanced and comprehensive EHR infrastructures in the world. Its electronic system enhances continuity of care and patient empowerment through its transparent and accessible system. It also increases efficiency by removing paperwork in a secure system that follows strict data protection regulations. This centralized and anonymized health data can then be used for improving public health research purposes.
Conclusion
Finland's universal health coverage model highlights many fundamental rights such as equity, transparency, and accessibility for its residents, but the system may also face sustainability challenges with an accelerating aging population and decreasing birth rate. Nonetheless, Finland’s healthcare system boasts valuable insights as an excellent model for countries such as the U.S. as the country navigates potential improvements for its current healthcare system. +
Sunny Choi, PhD developed her career over the years in the field of edtech. Currently based in Finland, Sunny is now pursuing her own startup with a mission to foster digital inclusion between people from multigenerations. Email: choi.sunnys@gmail.com
Nursing in Armenia: Today and Tomorrow
Nancy A. Barsamian, DNP, MPH, RN
As an experienced Armenian American nurse, assistant professor, and a recent graduate of the Tan Chingfen Graduate School of Nursing at UMass Chan Medical School, I have had the opportunity to teach nursing students in the U.S. and in Armenia. Over the last three decades, I observed firsthand how the healthcare system in Armenia has attempted to evolve from its foundations of the Soviet Union healthcare system. The current healthcare system in Armenia is still developing. They do not have universal healthcare, and many non-governmental organizations have stepped in to support the healthcare system, leaving a healthcare patchwork. The main access points to healthcare for the average citizen in Armenia are outpatient polyclinics, much like the Community Health Center models in the U.S. In addition, there are several large specialty hospitals in the capital city of Yerevan. The average person pays for their healthcare out of pocket and usually seeks care only when it is an emergency or significantly impacts activities of daily living. In addition, fifty percent of the population lives in rural areas with no access to acute care hospitals. Patients in these areas need to travel for hours to access care.
“
As in most parts of the world, nurses are the largest part of the healthcare workforce in Armenia…
In many ways, the family structure serves as the safety net for healthcare support. The prominent feature of a traditional Armenian household is the extended family, several generations under one household. Many of the day-to-day health issues are managed with homeopathic remedies, passed down by generations, such as using different types of teas for digestive issues. Nurses realize the importance of patient education in primary prevention and chronic disease management and work to infuse needed health education into Armenian families.
As in most parts of the world, nurses are the
largest part of the healthcare workforce in Armenia where there are 16,700 practicing nurses (56.5/10,000 population) [1]. The hospital nurses in Armenia function much like licensed practical nurses in the U.S. They receive a certificate or a diploma, not a college degree, after completing their nursing education. They work as healthcare generalists, inserting intravenous catheters, giving injections, and administering medications. The average caseload of patients on a medical-surgical unit is 6-10 patients. In rural Armenia, there is a shortage of medical doctors, and nurses function independently providing primary medical care, often treating patients in their homes under the ongoing shortage of medicines and supplies.
Country-wide, nursing salaries are very low with a slight variation if the medical facility has private or public ownership and if financial support to the institution is supplemented by the diaspora. The salaries of intensive care unit nurses are among the highest nursing salaries. Most nurses work 24-hour shifts and earn 25,000 drams equivalent to 65 U.S. dollars per 24 hours. Nursing position descriptions are written in very general terms such that nurses often perform tasks typically done by different disciplines in addition to their work, especially if the requests come from their supervisor or the medical director of the hospital.
A 2020 qualitative study of nursing in Armenia revealed nurses believe that the general public does not respect nurses and that nurses' roles are much more restricted than they are in the U.S. [2]. Participants noted that nursing roles focus on providing support to physicians and administration, there is no platform for advancement or professional development, and nursing is not considered an autonomous healthcare profession [2]. Armenia faces a nursing shortage with high turnover, especially among new graduate nurses. Once new nurses realize how difficult the work is and how low the salaries are, they quickly make a career change.
There is hope that the nursing profession will advance its efforts to meet the needs of Armenians. In the Fall of 2022, the American University of Armenia began the first Bachelor of Science in Nursing program in the country. The program is designed for nurses with proficiency in the English language, who have a diploma in nursing or midwifery and want to advance their education. The program is based upon the American Association of College of Nursing standards. The American University of Armenia nursing faculty are introducing nursing students to advanced assessment skills, critical thinking, evidencebased practices, the use of informatics, quality improvement, and ethics. These nurses have taken the initiative to advance their knowledge and recognize the importance of becoming competent professionals who work as part of the healthcare team. Graduates from the BSN program will be future leaders of the nursing profession in Armenia. They strive to move the nursing profession forward and at the same time improve the quality and access to health care in Armenia. +
Nancy A. Barsamian, DNP, MPH, RN, serves as Assistant Professor at the UMass Chan Medical School, Tan Chingfen Graduate School of Nursing. She also holds an Adjunct Professorship at the American University of Armenia's Turpanjian College of Health Sciences. For inquiries, reach out to nancy.barsamian@umassmed.edu
IAustralian Medicare
Anne E. Wright
n 2019, when my partner and I downsized for our retirement, we settled in Australia, my partner’s native homeland. The Australian national health care system was an important factor in our decision after having witnessed the compassionate and supportive care my partner’s brother and sister received while undergoing treatment for cancer in Australia, versus my own arduous and disheartening cancer journey in the United States. In the five years we’ve been here, we’ve had to utilize just about every facet of Australian Medicare and have so far found it to be superior to the American system.
“ …no one is tied to an employer for their health care.
Medicare is premium-free for Australian citizens and permanent residents. Visits to general practitioners (GPs) that “bulk bill” - meaning the doctor is compensated directly from Medicare - are also free of charge for patients. MRIs, CT scans, EEGs, blood tests, etc. are usually also free of charge if a doctor deems them necessary. Net out-of-pocket costs for specialist consultations generally run about $100 after a Medicare reimbursement is deposited directly into the patient’s account (usually within hours of the appointment).
Remarkably, hospitalizations, for the most part, are also free of charge within the Medicare system. We never received a single bill for my partner’s weeklong hospitalization two years ago. Not only that, before he was discharged, I was contacted by a hospital representative to ascertain the accessibility of our home. Based on that conversation, the hospital requested an in-home safety evaluation by an Occupational Therapist (OT). The OT recommended multiple grab bars, safety railings, an easy-access sliding door entry to the bathroom, and easy-turn water taps. All were installed at no cost to us by a government program called Short-Term Restorative Care. We were thrilled and astounded. From the government’s standpoint, it is more cost-effective to pay several thousand dollars on home safety equipment than to spend potentially tens
Australian Medicare Continued
of thousands of dollars for a hospitalization resulting from a serious fall. But still, it was a huge relief for us.
My next-door neighbor recently had knee replacement surgery. Her surgery, hospitalization, and follow-up physical therapy were all essentially free. Her one out-of-pocket cost was the specialist’s approximately $100 consultation fee. That being said, there is a drawback with a national healthcare system when it comes to surgeries for joint replacements which in Australia are considered elective in that they are non-urgent. Cancer and other life-saving surgeries are performed without delay but wait times for elective surgeries have blown out since COVID, sometimes in excess of six months. Private insurance, for those who can afford it, can reduce wait times, cover the cost of private hospitals, private rooms, extra physical therapy, and the like. The cost of private premiums varies from insurer to insurer and depends upon the specific extras the patient selects.
Seniors are particularly well looked after under the Australian system. There are dedicated aged care programs, prescription medications are capped at the equivalent of $5 U.S. dollars, higher Medicare rebates for specialist consults, and ambulance services are free of charge (in Queensland, ambulance services are free for everyone). When a pensioner’s out-of-pocket expenditure for specialists reaches a certain level (currently about $500 U.S. dollars) in a calendar year, Medicare reimbursements to the patient increase. The same is true for out-of-pocket costs for prescriptions. Once a patient spends a certain amount on medications in a given year, a program called Safety Net kicks in, and prescriptions are free for the rest of the year. Similar provisions are available to non-pension-age patients, but the out-of-pocket expenditure requirements are much higher before Safety Net benefits are granted.
One of the best benefits of universal Medicare is that no one is tied to an employer for their health care. In Australia, you can move from job to job and state to state freely without ever having to worry about losing your health care. And since the government has always been one’s healthcare provider, pre-existing conditions are not an issue.
We’ve personally found that because doctors in Australia determine the appropriate health care plan for each patient rather than for-profit insurance companies like in the United States, patient outcomes are better. The care here is proactive and preventative. If a doctor wants a scan to confirm or exclude say a tumor, they order one. It’s far easier and less expensive to remove a small tumor than waiting until it spreads. Since there is no battling an insurance company for coverage, procedures, and treatments are done in a timely manner. If a patient is in the emergency room and requires hospital admission, they don’t have to wait for insurance pre-authorizationor have the added stress of wondering if the hospital they are in even accepts their insurance. If they need the treatment they get it.
No healthcare system is perfect. Here in Australia, there are the aforementioned wait times for elective surgeries, there is a need for more urgent care facilities to fill the gap between general practices and busy hospital emergency departments, and rural communities often lack easy access to comprehensive medical services. Overall though, Medicare is a system that strives to achieve the best possible outcome for patients. +
Anne E. Wright, a former journalist, received her BA from Tufts University.
Introduction
The Philippine Healthcare System
Phillip Ong
The Universal Health Care Act (Republic Act No. 11223) was signed into law in February 2019. It aims to broaden the coverage to provide healthcare services. The law mandates the expansion of PhilHealth coverage to include all Filipinos which currently stands at 93%. The planned implementation in January 2020 was disrupted by the COVID-19 pandemic. It was only in February 2024 that PhilHealth announced a 30% increase in health benefits alongside the suspension of premium payments.
Healthcare Infrastructure
The Philippine public healthcare system operates on a devolved model where healthcare is managed by local government units.
The Philippines has 42,000 barangays (or neighborhoods, the smallest political unit). Of these, there are approximately 25,000 (60%) that have public health units called barangay health stations (BHS). Many of these, especially in remote areas, are but a one-desk affair with a clerk who refers cases to government hospitals in the municipal centers.
There are 2,300 such municipal health units which also range from undermanned, underequipped, and underfunded to being adequate for addressing local needs. Many low-income municipalities are visited by doctors only once a month.
Of the 1,400 hospitals nationwide, serving a population of over 110 million, only 500 are public.
Barriers to Access
The primary barriers to the availability of healthcare are:
A. Lack of Mobility
For an archipelagic country with limited road and port connectivity, transportation is a major challenge in the delivery of healthcare. In our work with poor pregnant women, the main reason for their nonavailability of prenatal examinations is the high cost of transportation to their barangay health center. They complain that the time and cost of transport exceed the benefits they receive from consultations. As such, even government-funded health care is not voluntarily accessed. This has resulted in infant malnutrition and mortality three times higher than neighboring Thailand and Malaysia.
B. Lack of
Funds
High out-of-pocket expenses deter individuals
Healthcare Around the World
The Philippine Healthcare System Continued
from seeking timely medical care, resulting in delayed diagnosis and treatment. On average, Filipino households have to shell out 44.4% of their treatment cost, according to the Philippine Statistics Authority [1].
Currently, The Philippine Health Insurance Corporation (PhilHealth) provides access to subsidized healthcare services to most Filipinos. Funded by contributions from some 65 million paying members (62%) of our population, it relies on the government budget to fill up the gap. In 2021, it disbursed P89 billion ($1.5 billion) in benefits [2]. In addition, the Department of Social Welfare (DSWD) coordinating through Malasakit Centers channeled around P450 million ($7.76 million) from the Philippine Charity Sweepstakes (PCSO) and the Medical Assistance for Indigent Patients (MAIP) [3].
The new Universal Health Care Act promises to allocate 50% of the Philippine Gaming and Amusement Corporation’s (PAGCOR) income for healthcare, but this legislative act is still far from implementation.
C. Lack of health workers
One of the most significant challenges facing healthcare delivery at all levels is the lack of qualified personnel. During the pandemic, various countries with higher incomes have been able to attract health workers by easing visa restrictions. It has triggered a substantial migration of experienced health staff from private and public hospitals.
The Philippine College of Physicians (PCP) estimates that there are only 2.3 healthcare workers per 10,000 population. Public health facilities are served by only 4.5% out of the 66,000 doctors and about 1% of the 500,000 nurses.
Compounding this is the suspension of nursing examinations during the COVID period. This reduced the pipeline of replacements for the industry. Some new hospitals and care facilities could not start operations due to a lack of personnel.
Conclusion
In my personal involvement in helping a poor teenage patient suffering from acute myelogenous leukemia (AML), I experienced the many faults of the system as narrated by her:
I was on this battlefield for three years, from 2016 to 2019. I saw countless fallen warriors. I experienced taking my chemo drugs for one week while we were three patients in the same bed. The insufficiency of hospital beds and rooms for infectious diseases. The lack of nurses and doctors that led to patients’ deaths because of not having proper care. The delayed chemo because of the drug shortage. Patients bleeding because of the inadequacy of blood bags in the hospital blood bank. The painful part is the scarcity. You died not just because of cancer, but you died because of not having money or any support from the government for the whole treatment. The treatment should not be only for wealthy people, but also for the people who are fighting for their everyday needs.
Having enumerated major problems in the Philippine Health Care system does not mean that improvements have not been implemented. Plagued by corruption and inefficiency, the system managed to provide adequate protection to the population during the COVID-19 pandemic. With well-informed public officials, it is hoped that the Universal Health Care Act will bring improvements at least in infant mortality. + i nfant mortality rates , 2000 and 2020 ( or nearest year )
Phillip Ong, Chairman, Santeh Group, Philippines
Curbside with Dr. Baker
Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com
Dr. John Paul Lock
August 1, 1946 - July 21, 2024
WDMS member since May 28, 1978
Paul Lock, MD passed away on July 21, 2024, at his home in Paxton surrounded by his family including his three children. His wife, Gail, had predeceased him in 2022. Paul was born in Worcester and graduated from David Prouty High School in Spencer in 1968 and was awarded the School’s Distinguished Alumni Award in 2018. Following high school, he matriculated at Assumption College from which he graduated in 1968 followed by completion of medical school at St. Louis University School of Medicine in 1972. His training in internal medicine at St. Vincent Hospital in Worcester was followed by a fellowship in endocrinology at the University of Colorado School of Medicine. Following the completion of his medical training, he returned to Worcester, Massachusetts to become an Assistant Professor of Medicine in the division of Endocrinology at the University of Massachusetts School of Medicine. In addition to his teaching and patient care responsibilities, he authored more than 60 medical publications and participated in more than 75 clinical research studies related to the evaluation and management of diabetes.
I was privileged and fortunate enough to have Paul invite me to join his private medical practice located in the old City Hospital building in 2000. It was an exciting time for clinical research in diabetes. Down the hall from our office, Charlie Birbara, MD was performing his own research in rheumatology. Our practice relocated to the Park View Tower Building on Park Avenue where we continued until 2010 when Paul accepted a full-time position at the University of Massachusetts School of Medicine in the division of Endocrinology.
I remember Paul fondly as a mentor, teacher, and friend. Paul was generous with his time and I was a welcome recipient of his knowledge. Our office was a hotbed of activity for clinical research with multiple pharmaceutical companies. One of Paul’s most exciting projects was the non-invasive measurement of serum glucose via the Glucowatch which was later featured in the movie Panic Room starring Jody Foster. The Glucowatch never achieved commercial success but was a critical step in the path to today’s non-invasive glucose monitors.
Paul had a voracious appetite for hard work but, when he was not in the office or hospital, he enjoyed his vacation home on Martha’s Vineyard with his family and friends. His zest for life was complemented by his love of good food and wine as well as classical literature. He will be missed.
Frederic H. Schwartz, MD, FACP
Dr. James Ledwith, Jr.
August 13, 1957- July 9, 2024
Worcester (North) member since March 28, 2008
It is with profound sadness and deep regret that I inform you of the passing of our esteemed colleague and friend, Dr. James (Jim) Ledwith, on July 9, 2024, following a tragic bicycle accident in Arizona on June 19th. Dr. Ledwith was an integral part of our community, serving as the medical director for the Epworth Free Medical Program and as the UMass faculty advisor for the WFCC student organization for many years. He was also a dedicated physician with the UMass Department of Family Medicine at the Benedict outpatient clinic. Jim’s unwavering passion for providing care to our community’s most vulnerable populations was evident in every aspect of his work.
For two weeks, Jim fought valiantly in the ICU, showing encouraging signs of improvement after suffering a traumatic brain injury. Unfortunately, on July 7th, he experienced a secondary cerebral hemorrhage, leading to severe increased intracranial pressure. Despite an emergency surgery to relieve the pressure, the damage to his brain was too extensive. With immense courage, Jim’s family made the difficult decision to make end-of-life arrangements.
In his final act of kindness, at 7pm EST this evening, a walk of honor was held as Jim was transported to the operating room for organ donation. This selfless act granted newfound hope to numerous families affected by devastating illnesses, continuing Jim's lifelong commitment to helping others.
Details regarding arrangements are not yet available. Please keep Jim’s family, friends, and colleagues in your thoughts during this incredibly difficult time. If you are inclined, please pray for their peace and comfort as they come to terms with this tremendous loss and the impact Jim had on his community.
David Runyan, DNP, FNP-BC, NRP
President, Worcester Free Care Collaborative, Inc.
Dr. Robert Quinlan
April 21, 1944 – June 23, 2024
WDMS member April 1, 1985 to February 1, 1989
Robert (“Bob”) Quinlan died peacefully on June 23, 2024, at his home in North Grafton, Massachusetts with his loving wife Diane by his side. He was 80 years old. He will be remembered for his dedication to battling cancer as a surgeon, professor, researcher, and champion to many who sought his care and, ultimately, as a patient himself.
Bob was the youngest of three children of Jeremiah and Madeline Quinlan. He was born in Boston, Massachusetts, and graduated from Cambridge Matignon School, College of the Holy Cross, and Cornell University Medical College. He completed his surgical training and formed lasting friendships in the residency program at the Peter Bent Brigham Hospital in Boston. Following his residency, he served as a Lieutenant Commander in the United States Navy Medical Corps before accepting a surgical oncology fellowship at the Johns Hopkins Hospital in Baltimore. In 1980, he was named Chief of Surgery at Memorial Hospital in Worcester, Massachusetts (now UMass Memorial Health). He practiced surgery until age 70, at which time he was named the hospital system’s first Chief Patient Experience Officer. Widely recognized for his contributions and compassion in breast cancer care, Bob made a tremendous difference in the lives of thousands of patients and families. Patients admired him for his clinical and surgical excellence, but most notably, deeply appreciated his bedside manner and personal commitment to their care. He was instrumental in establishing the hospital’s Comprehensive Breast Cancer Center, where he served as Director from 1997 until 2014. The Center was renamed in his honor in 2023. He also served as Professor of Surgery at the UMass Medical School. Bob was honored to serve as president of the Massachusetts Chapter of the American College of Surgeons, the New England Cancer Society, and the New England Surgical Society. He also served in leadership roles at the American College of Surgeons, the American Society of Breast Surgeons, and the Society of Surgical Oncology.
Beyond surgery, he was drawn to experimental biology and served as a trustee for the Worcester Foundation for Biomedical Research. He authored dozens of articles for peer-reviewed journals and numerous book chapters. He played golf through high school and college before discovering a life-long passion for sailing in his thirties. He cruised coastal waters from the Chesapeake Bay to Labrador, Canada, with a particular fondness for Downeast Maine. In his fifties, Bob developed a love for blue water sailing, beginning with a Bermuda to Newport return followed by several North Atlantic passages. He sailed the Baltic Sea, the North Sea, the coast of Scotland and the Faroe Islands, and the coast of Iceland, north of the Arctic Circle among icebergs off the coast of Greenland, and completed a circumnavigation of Ireland. He found happiness and balance aboard any sailboat with friends and family.
Bob was a member of the New Bedford Yacht Club for over 30 years. He was inducted into the Cruising Club of America in recognition of his North Atlantic adventures. Bob grew up skiing in New England and found great pleasure in powder turns. He gave the gift of skiing to his children and instilled in them a deep appreciation for the majestic beauty of the Colorado Rockies. In the final years of his life, he enjoyed spending time with his family and new friends in the beautiful mountains of western Maine.
Bob is survived by his wife, Diane Quinlan; his step-daughter Lauren B. Connors and her husband Jake and his granddaughter Cassidy of Douglas, MA; and his children, from a previous marriage to Judith S. Quinlan, Sarah E. Quinlan of Boston and Mark R. Quinlan and his wife Dara of New York City and grandchildren, Cameron and Haden of New York City. He is also survived by his brother, Paul Quinlan, and his wife, Pauline of Morristown, New Jersey, and his sister, Janice Brown of Framingham, Massachusetts, and many nieces and nephews.
In lieu of flowers, the family requests contributions be made to the SEA Education Association, the Memorial Sloan Kettering Cancer Center and the Bob M. Quinlan, MD Breast Center at UMass Memorial.
A memorial service will be held in the Fall of 2024.
Reprinted with permission from The Worcester Telegram and Gazette. Originally published 7/2/24.
33rd Annual Women in Medicine Breakfast
September 27, 2024
Judith Sumner, PhD, Ethnobotanist and Author
Guest Speaker: Judith Sumner, PhD, Ethnobotanist and Author Title: “Medicinal Plants in Wartime”
3rd Annual Park Cleanup - Bell Hill (Chandler) Park
September 28, 2024
Thank you to the Medical Student Committee for organizing another successful park clean-up, and to the volunteers who helped. Together, we collected 22 bags of trash and one tire, rim and all .
Testimonial from one of our student parti cipants, Lillian Cain, MS1 :
“I recently participated in the Bell Hill Park Clean up with my fellow UMass Chan medical students. It was nice to take some time to experience nature while at the same time helping to clean up a communal space. I had never taken the time to explore Bell Hi ll Park so experiencing such a beautiful park in Worcester for the first time was a pleasure. I was happy to spend time with my fellow students while at the same time giving back to the Worcester community. Thank you for this opportunity! ”
CALENDAR OF EVENTS
18th Annual Louis A. Cottle Medical Education Conference
October 23, 2024, 5:30 pm, Beechwood Hotel, Worcester
Speaker: Dr. Kerry-Ann Williams, Child and Adolescent Psychiatrist and CMO at Justice Resource Institute
Title: “Are You Called?” - We will hear Dr. Williams reflect on the "why" behind the work that we do in medicine, to learn more about how purpose and meaning influences our careers in medicine, and to plan for how to restore what might be missing in our professional lives
Fall District Meeting and Awards Ceremony
November 13, 2024, 5:30 pm, Beechwood Hotel, Worcester
Meeting includes Voting/Approval of the 2024 Bylaws, 2025 Budget, and presentation of the Dr. A. Jane Fitzpatrick Community Service Award, the WDMS Career Achievement Award, the WML Medical Student Achievement Award, Medical Student Scholarship Awards , and WDMSA Nursing Scholarship Award
HOD Opening Session, I-24 – Via Zoom
All WDMS members are invited to attend as guests and may submit a resolution to MMS WDMS has Delegate seats available (call the WDMS Office to inquire 508-753-1579.)
HOD First Session and Online Hearings: 11/18
Virtual Reference Committee Hearings A, B and C: 11/19
Ref Com Deliberations: 11/25
HOD Second Session and Closing: 12/7
Movie Night and Reception and WCFB Drive
December 19, 2024, 6:00 pm, Mechanics Hall
“Forgotten Love” is a story taking place during the period between WWI and WWII about surgeon Rafal Wilczur who is at the peak of his medical career when his wife leaves him, taking with her his daughter Marysia. Abandoned by his wife, he falls victim to a mugging and as a result of head injuries loses his memory. Following the mugging he is presumed dead, but resurfaces 15 years later in the countryside with amnesia December 2024, 5:30 pm, Mechanics Hall
Please bring a non-perishable food donation for the Worcester County Food Bank
229th Annual Oration
February 12, 2025, 5:30 pm, Beechwood Hotel
Orator: Lisa Sanders, MD - is the Medical Director of Yale's Long Covid Multidisciplinary Care Center. In addition to her work as a physician and teacher, she writes the popular Diagnosis column for the New York Times Magazine and the Think Like a Doctor column featured in the New York Times blog, The Well. In 2019 she collaborated with the New York Times on an eight-hour documentary series on the process of diagnosis for Netflix.
Title: Diagnosis
Other 2025 events include the Annual Business Meeting, Women in Medicine Leadership Forum, Medical Student Educational Forum and Meet the Author Series. Please visit www.wdms.org to view past events. www.wdms.org
