The global health-care collapse
The imposition of lockdowns during the Covid-19 pandemic had one overarching goal: to prevent hospitals from becoming overwhelmed. Governments hoped to contain infections and buy time to build capacity. In the end, however, much of this extra capacity went unused. England’s seven “Nightingale” hospitals closed after accepting few patients, as did many of America’s field hospitals. A study of Europe’s experience in public health, a journal found just one example where there were more Covid patients than ICU beds: in Italy’s Lombardy region on April 3, 2020. Though there are now stories of overwhelmed Chinese hospitals like that As the country faces a large wave of exits, it is too early to know whether these are isolated examples or a broader, systematic failure.
Outside of China, Covid weighs less in people’s minds these days. But health systems in rich countries are closer to collapse than at any time since the disease began spreading. Unlike unemployment or GDP, there are few comparable up-to-date figures on health care across countries. That’s why The Economist has trawled through statistics compiled by country, region and even individual hospitals to paint a picture of what’s going on. The results suggest that patients, doctors and nurses have not escaped the worst effects of the pandemic. Instead, the effects appear to have been delayed.
Start with the UK, which has excellent data. The National Health Service (nhs), the country’s state provider, is in dire straits. Just before the pandemic, someone with a medical problem that needed urgent but not immediate attention, a category that includes strokes and heart attacks, was waiting an average of 20 minutes for an ambulance. Now they wait longer than an hour and a half (see graphic). The number of long “trolley waits” – the time between the admission decision and the arrival of a patient at a hospital ward – has skyrocketed.
Other countries have less comprehensive statistics but equally miserable patients. In September, the polling company Ipsos published a global survey that included a question on the quality of healthcare. In almost all of the roughly 20 rich countries, people said that the services offered were “good” or “very good” less than in 2021. In the UK, the corresponding share fell by five percentage points. In Canada it fell by ten. In Italy until 12.
Italian hospitals, swamped by Covid patients in early 2020, are struggling again. We have data from Pope John XXIII’s hospital. analyzed in Bergamo, the place where some of the harrowing images of people on ventilators were seen almost three years ago. In the year that Covid hit Italy, the hospital’s waiting lists rose slightly for some measures. They then fell slightly the next year. But in 2022 they dropped out. Someone in town looking for a non-urgent breast ultrasound may have to wait up to two years. Officials in Emilia-Romagna, another region hit hard in 2020, have launched a plan to bring waiting lists back to pre-pandemic levels.
Newspapers across the Anglosphere are full of horror stories. In New South Wales, Australia, about 25% of patients had to wait more than half an hour before being transferred from paramedic to emergency department staff in the third quarter of 2022, up from 11% two years earlier. In Canada, waiting times are at an all-time high, with a median delay of six months between referral and treatment.
Even the richest and most competent countries are feeling the strain. In Switzerland there are fewer free intensive care beds than at most times of the pandemic. Germany faces similar problems, with an increase in patients reducing critical care capacity (see chart). In Singapore, at the end of 2021, patients waited about nine hours for a visit to the polyclinic. By October 2022, they were waiting 13 hours.
America is doing better than most countries thanks to the vast sums of money it spends on health care. But it’s not going well. The average occupancy rate of hospitals recently exceeded 80% for the first time. Even in the darkest days of the pandemic, few states reported pediatric wards under stress (what we define as beds occupied at 90% or more). As of early November, all 17 states were in this position, owing to a rise in all manner of bugs among children.
The collapse in the quality of health care is contributing to a staggering increase in “excess deaths” – beyond what would be expected in a normal year. In many rich-world countries, 2022 proved even deadlier than 2021, a year with multiple major Covid waves. Monthly deaths across Europe are currently around 10% higher than expected. Germany is in the midst of a huge mortality wave: Since September, weekly deaths have been more than 10% above normal. At the beginning of December they were 23% higher.
What’s wrong? Politicians, both national and regional, take the blame—and sometimes deserve it. But the forces causing the chaos are common to all countries and linked to a shared experience of the pandemic. They can also be difficult for governments to cope with, at least in the short term.
In the oecd club of mostly rich countries, healthcare spending is now just under 10% of GDP, having been below 9% before the pandemic (see chart). Of the 20 countries with 2021 data, 18 spent more per person than ever before. Almost all spent more as a percentage of GDP than in 2019. Adjusting these figures for the aging population does not change these results significantly.
So the problems in health systems are not due to a lack of money. Much of the increased spending has been on programs to combat Covid, including testing and tracing and buying vaccines. But funding is now increasing across systems on a broader basis. In almost every rich country, more people are working in healthcare than ever before. Overall employment in hospitals was 9% higher in 2021 than in the pre-pandemic year across the six oecd countries we surveyed. The latest data suggests 1.6 million people are now working in healthcare in Canada, an all-time high. In the EU, more than 12 million people work in ‘human health’ activities, a record. American hospitals employ 5.3 million people, another record.
Perhaps the real problem isn’t the number of employees, but how efficiently they work. Real output in America’s hospital and ambulatory healthcare sector, which effectively measures the amount of care provided, is just 3.9% above pre-pandemic levels, while output across the economy is 6.4% higher. Elective care activity (i.e. pre-planned surgeries) is slightly lower in England than before the Covid hit. In Western Australia, the proportion of delayed elective surgeries increased from 11% to 24% in the two years to November.
In other words, hospitals are doing less with more. Although declining productivity is a macroeconomic phenomenon, healthcare is currently suffering from additional pressures. A recent paper by Cambridge University’s Diane Coyle and colleagues looks at the impact of the UK’s handling of Covid. “Don’ts and don’ts” protocols to replace protective equipment and cleaning requirements after handling Covid patients, still in place today in many countries, slow everything down. The segregation of Covid and non-Covid patients limits bed allocation.
Meanwhile, after three grueling years, many employees feel miserable. A report in Mayo Clinic Proceedings notes that quantitative measures of burnout among American physicians have skyrocketed (see chart). When healthcare workers are demotivated, they may be doing less of the things that once kept the show going — like staying longer to make sure the patient registry is in order, or treating another medical professional’s patient to help.
But while productivity has fallen, it hasn’t fallen far enough to fully explain the health care collapse. This suggests that the real explanation for the collapse lies on the other side of the coin: exploding demand.
Post lockdown, people seem to need more medical help than ever. Some of this has to do with immunity. People went two years without being exposed to various failures. Since then, endemic pathogens like respiratory syncytial virus have flourished. Everyone you know has – or has recently had – the flu.
But the pandemic has also blocked other conditions that are only now being diagnosed. In 2020-21, many people delayed seeking treatment for fear of contracting Covid or because hospitals were closed due to non-Covid conditions. In Italy, cancer diagnoses decreased by 39% in 2020 compared to 2018-19. A study of American patients found that, over a similar period of time, there was a notable reduction in diagnoses of cancers that are typically detected during screening or routine screening.
In England, the nhs waiting list has grown by more than 60% since the pandemic was declared. Many of the people on the list and on similar lists in other countries are likely to be sicker and therefore require more resources than if they had been treated in 2020. A recent paper published in the Lancet Public Health, another journal, estimates that colon cancer deaths in Australia could be almost 10% higher than pre-pandemic trends over the next two decades, partly due to delays in treatment .
Covid continues to increase demand. A recent paper from the Institute for Fiscal Studies, a think tank in London, estimates that the disease is reducing the available number of beds in the nhs by 2-7%. As Covid-positive patients take up resources, providers are providing inferior care to all. Research by Warwick University’s Thiemo Fetzer and Cambridge University’s Christopher Rauh suggests that for about 30 additional Covid deaths, one non-Covid patient dies, “caused by the deterioration in the quality of care”.
The effects of poorly functioning health systems go beyond unnecessary deaths. People feel their country is falling apart. If you live in a rich country and you get sick, expect someone to help. And someone should definitely help when the tax burden is at or near an all-time high, as it is in many places.
The good news is that the backlog created by the pandemic will disappear. The rise in respiratory viruses in adults and children has probably peaked. Admins have made strides in tackling enormous waitlists. But with an aging population and an ever-present threat, pre-pandemic healthcare could seem like it was from a golden age.
© 2023 The Economist Newspaper Limited. All rights reserved.
From The Economist, published under license. For the original content, see https://www.economist.com/finance-and-economics/2023/01/15/the-global-health-care-collapse