Global Health Delivery: An Introspective look Global Health Delivery: How Did we Get to where we Are [Series 02]

Gathline Etienne, MD

*Correspondence to: Gathline Etienne, MD,

Copyright

© 2023 Gathline Etienne. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 June 2023

Published: 01 July 2023

Module 2: Why ideas matter: Social theory in global health

Apply three of the social theories to your identified health challenge

Apply the theory of social suffering and two other theories of your choice to your identified health challenge. Social suffering has four components; please limit your description to a single component of your choosing.

Be sure to do the following:

• Describe each theory (in your own words) and remember to acknowledge the authors.
• Explain how each theory helps you to better understand your health challenge. For example, how does the use of the social theories help you to refine or restate your problem, or understand its limitations in a more concrete way?

In developing projects to tackle global health, especially mental health, one must heed the caution of Paul Farmer et al in their book Reimagining Global Health. They described several theories that demonstrate how well-intentioned global health and development projects can have unintended and at times, undesirable consequences.[1] A microscopic view on the biopower Medicare and Medicaid, which was signed into law on July 30, 1965, by President Lyndon B. Johnson as basic insurance programs for Americans who didn’t have health insurance.[2] Through legislation they have introduce various payment models to improve the quality of healthcare and make it affordable. The outcome, however of this purposive action led to some unintended consequences. Take for example, the main payment model of Fee-for-service (FFS), where services provided by healthcare providers in various establishments are unbundled and paid for separately. That has led to increasing cost of medicine, disparities and inequities in services; where some patients receive too much care, while others do not get enough and some get the wrong care.[3] One study showed that from the viewpoint of physicians, 20% of medical care is unnecessary, including 22% of prescribed medication, 25% of tests, and 11% of procedures.[4] The system can also be punitive such that if a doctor tries to become more efficient and curb overuse, then reimbursements go down.[3] This was magnified during the lockdown phase of the Covid19 pandemic. Several hospitals were forced to closed in March 2020 due to a sharp decline in patient volumes and hence billable services. Furthermore, 43,000 health care workers were laid off which ballooned in April to 1.4 million.

At the same time, insurance companies contest these fees with denials of coverage and requirements like prior authorization. Each year, this trillion- dollar tug of war leaves too many patients and their families with unexpected bills for unexpected treatment.[5] Such overuse leads to unnecessary procedures, duplication of care, medication overuse, which ultimately hurts the patients financially, physically, mentally: their well-being. This outcome is in direct conflict to the local morals of physicians who swore the Hippocrates oath to “first do no harm”.

We see that the very institutions or constructs designed to address a problem can in fact create more problems for society, leading to pain and suffering. This was the premise of Social Suffering1, which was developed by Arthur Kleinman, Veena Das, and Margaret Lock to account for the forms of social violence that constitute inequity. It is an anthology of four interlinked concepts as follows: One, the sources of suffering can come from larger, common social forces. Two, structural violence constrains agency and prevents groups from reaching their full potential. For example, Medicare FFS causes a shift from patient centered care to procedures, which drives the cost of medicine and transform doctors into diagnosticians rather than caregivers. They have little time at bedside to connect with their patients to provide empathy, eventually leading to higher burnout rates, depression and even suicide. Their absence creates a domino effect affecting an entire microcosm of healthcare delivery. Hence, we see the consequence of the third concept; health challenges rarely affect individuals alone. Lastly, society and its institutions can worsen social and health problems as illustrated above.

Max Weber, a German sociologist was wise in his prediction that power in the 20^th century would shift from families and communities to institutions and their associated bureaucracies and as such can be resistant to change or new ideas.[1] However, to avoid such practices from becoming the standardization of care or the social construct of reality in health care delivery, an in depth evaluation of the current system is imperative to help practitioners design better programs and cultivate a habit of self-reflection to global health..[1] A particular approach could be “The theory U” model developed by Otto Scharmer[1], which is a creative change management model that enables an individual or systems to let go of the past and embrace new ideas for better, fulfilling outcomes.

References

1. Paul Farmer et al. Reimagining global health
2. https://www.cms.gov/About-CMS/Agency-Information/History
3. https://www.thirdway.org/report/the-case-against-fee-for-service-health-care
4. Lyu, Heather et al. “Overtreatment in the United States.” PLOS ONE, 24 Mar. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/.

https://www.statnews.com/2020/06/12/fee-for-service-is-a-terrible-way-to-pay- for-health-care-try-a-subscription-model-instead