In this segment of the lecture, we'll review the three remaining World Health Organization building blocks, pharmaceuticals and medical devices, workforce, and information. The coverage of each of these building blocks will not be as detailed as that for leadership and governance, finance and service delivery. They are no less essential to the operation of an effective health care system, but for the purposes of this course only a brief overview of their operation is necessary. The World Health Organization defines the contributions of the pharmaceuticals and medical products building block to a well-functioning health system as one that ensures equitable access to essential medical products and vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use. In this part of the lecture, we'll concentrate on the importance of ensuring access to essential medicines to satisfy the priority healthcare needs of populations. Essential medicine policies are crucial to promoting health and achieving sustainable development as we'll see in module four. The pharmaceuticals building block has at least two components. The first component relates to the actual pharmaceutical product. They must be of assured quality, safety, efficacy and cost-effective. The second component refers to the scientifically sound and cost-effective use, that is that pharmaceuticals need to be used in the right way at the right time. This component requires that requires scientifically sound use of pharmaceuticals shows the tight set of linkages between pharmaceuticals and service delivery building blocks. But in addition, there's a separate system of production for pharmaceuticals and medical devices that is has its own industry and its own rationale. And in the United States, the pharmaceutical industry is big. The US pharmaceutical market is the world's most important national market. Together with Canada and Mexico, it represents the largest continental pharma market worldwide. The US United States alone holds over 45% of the global pharmaceutical market in 2016. In 2016, this global market was valued at around 446 billion US dollars. Many of the top global companies are from the United States. In 2016, six out of the top 10 companies were from the US when based upon measures of pure revenue. In other words, it's a very significant industry that has a very significant impact on the health system. The operation of the pharmaceuticals building block in the United States provides an important contrast with the role of this building block in health systems in other high-income countries. Access to pharmaceuticals in the United States is covered by nearly all forms of health insurance. But the system of coverage is complex and is separate from coverage of other health services. The process by which pharmaceutical companies market pharmaceuticals to and through insurance companies and health care providers is complex. Finally, the prices paid for pharmaceuticals in the United States are higher, often much higher than in other high-income countries. The following three graphs provide an overview for this. The first slide from the OECD is Pharmaceuticals as a proportion of health spending. This is the amount of money spent on pharmaceuticals in the health system as a proportion of national health spending. The significant feature here is that Germany had 14.3% of national health spending is much greater than the United States and the United Kingdom at 12.3% and 11.4% respectively. However, when we look at pharmaceuticals as a proportion of GDP, we see a different pattern. The United States spending on pharmaceuticals as a proportion of GDP is around 2.1% while it is 1.59% in Germany and 1.11% in the United Kingdom. The final graph shows an even greater divergence between the US, Germany, and the United Kingdom. In 2017, spending per capita in the United States in US dollars is around $1,210 per capita while in Germany, it's around $780. In England, it is $480 per capita. These lower levels of expenditure on pharmaceuticals reflect different systems for delivery of pharmaceuticals and different systems for sourcing and paying for those pharmaceuticals. In summary, the pharmaceutical industry is a large and important one in the United States, is a relatively smaller part of the health system in the United States than countries such as Germany, but it has very objectively high levels of expenditure. And finally, the pharmaceuticals building block is a further node in the polycentric complex US health system. The next building block that I want to analyze is the workforce. The World Health Organization describes a well-performing health workforce as one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances, that is that there are sufficient staff, fairly distributed. They are competent, responsive and productive. The health workforce includes all of those professions required to deliver healthcare services, but it also includes managers and administrators and others. This slide refers to the numbers of physicians and nurses in a number of countries per 1,000 of population. What's significant about this graph is again, the relatively small number of doctors per 1,000 people in the United States compared with the OECD median and compared with other high-income countries. In this graph, you'll see that in 2016, the United States, there are around 2.6 doctors per 1,000 of population in contrast to the OECD median of 3.1 doctors per 1,000 of population. By contrast, the figure in Germany is 4.2. This is indicative of and parallels the lower levels of capacity, that is the lower numbers of acute care hospital beds and the lower levels of usage of both hospitals and lower numbers of consultations with doctors in the United States. The relatively small numbers of doctors is significant when we refer again to the levels of spending on doctors in medical practice in the US health system. That is doctors account for around 16.4% of total health spending in the United States where the OECD median is around 7.9% of total health spending. This reflects the significance and the central role of doctors in the US health system. The graph on the right-hand side shows the number of nurses per 1,000 of population and here nearly all high-income countries fall above the OECD median. And the United States is around 12 per 1,000 of population, which is well above the OECD median with only some high-income European countries having significantly larger numbers of nurses. The relatively high number of nurses in the United States is important because there's been a widespread movement to enable nurse practitioners and advanced nurse practitioners to practice to the full extent of their scope of practice. This map shows the numbers of states in which nurse practitioners have full practice authority. This has enabled nurse practitioners and advanced nurse practitioners to become primary care practitioners providing a broad range of primary care services. This is a particular significance in rural and other areas where there is a shortage of primary care physicians. So in relation to the workforce, we'd summarized in the following way the numbers of practicing physicians is low below the OECD median. Spending on practicing physicians is above the OECD median. And this is significant because it highlights the central role of doctors as a stakeholder in the US health system. Finally, there's been a sustained effort to authorize nurse practitioners to have full practice authority. In practice, this has provided an extra source of supplier primary care services where there are shortages of those services. But the addition of nurse practitioners working as primary care practitioners has further added to the complexity of relationships between health care providers, healthcare payers, and patients. The final building block is information building block. This is central to all healthcare systems. The World Health Organization suggests that a well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health system status. As this definition of the role of information suggests, information is a central component of payment systems, of systems to improve the quality of health care, of relationships between patients and and health care providers, and of relationships between health care providers and the populations of people that they serve. Information is important to all stakeholders in the health system. As to leading researchers in this field suggest, health and health research data are vital resources for clinical care, informed clinical choice, quality improvement, drug and device safety, effectiveness assessment, and scientific discovery. Health-related data refers to four major determinants of health, personal, social, economic, and environmental. Such data are the reagents with which we can produce information to support personal choices about health care, system choices about optimizing medical and public health strategies, and policy choices about rules and regulations that have the ingredients necessary for medical breakthroughs. The information building block is generally regarded as an important leverage point in influencing systems of health care. By this we mean that changing information flows to ensure that stakeholders receive feedback on their performance in relevant and timely ways is a very important tool for influencing health systems to improve quality, control costs, and improve population health. So access to timely, reliable, and relevant information is a means of improving healthcare systems. There are, however, challenges in making relevant information accessible to the right people at the right time in the right form. There is much missing information and there's unreliable information. This is particularly relevant in the United States as the United States is a polycentric healthcare system. Here it's useful to remember the interactions between the service delivery building block and the finance building block. First, its service delivery systems and healthcare providers have to integrate the various forms of insurance and secondly that there need to be information flowing between patients, insurers, and providers in ways that improve the outcomes produced by those systems of care. This is proven difficult and complex in the United States because of the range of different systems of insurance and the numbers of providers and the complex interaction between those providers. In this section of the lecture, we've reviewed the workforce, pharmaceuticals, and information building blocks. Each of these building blocks reflects the commitment to health made by institutions and citizens in the United States and to the large and complex US health system that these commitments have produced. There are pragmatic efforts to make best use of the workforce. The pharmaceutical industry and market is enormous and is a source of innovation for the world and not just the United States. Finally, there are many initiatives aimed at improving information flows in the health system to improve the quality of health care and population health. But the impact of these if it's on the health system are modulated by the unbounded and polycentric nature of the US health system. In the final segment of the lecture, well review the interactions between the building blocks and some of the outcomes produced by the US health system.
