If you live in Bali where do you go when you have a life-threatening medical condition requiring cutting edge medical treatment to survive? Immediately you ask the question some obvious questions arise.
What is the condition and where do they treat it best?
What are my chances of a successful outcome?
If I am insured, will my insurance cover the cost whole or in part and, if not, what do I do?
Should I go back to my country of origin, where I have a right to medical treatment?
If I do, can they perform the procedure I need and do it successfully?
For Australians living in Bali the answer is simple. Most procedures are obtainable in Australia and it makes sense to be treated there where the cost is covered by what is commonly regarded as one of the best national medical systems in the world. Same would broadly apply to New Zealanders, though not all the most complex procedures may be on offer there. Unless we have residency in Singapore or Hong Kong let’s say, the rest of us would be looking at a longer haul journey back to our respective countries in Europe or North America. Others of us would be checking out the possibilities of Thailand, India & Malaysia.
In my own experience of this, when my wife – who is French – was diagnosed with critical aortic stenosis, a condition which is invevitably terminal without an immediate aortic valve replacement, we went to France. Given that she was entitled to medical treatment in France, whose state medical system is also highly regarded, and the fact that her condition precluded open heart surgery, combined with the fact that the French were the first to introduce the aortic valve replacement via arterial cathetarisation (TAVI) back in 2000, the decision was pretty much a given.
The TAVI procedure was successfully performed in an Australian-owned private hospital just South of Paris in the first week of September this year by one of the foremost exponents of the procedure. Unfortunately, my wife who also suffers from atrial fibrilation, required a subsequent procedure to install a pacemaker. This operation is relatively routine and was performed by one of the hospitals other cardiologists. Now, five procedures later and as many months on, she is finally out of hospital and we are contemplating our return home.
In short, we had a very up-close and personal experience of the strengths and failings of the medical system in France. Unquestionably the TAVI procedure saved her life. However the follow-up treatment and cardiac rehabilitation was botched. In France private hospitals cannot pick and choose their patients, they have to treat everyone – and then… make a buck for their shareholders. That can lead to some very conflicted and unhappy hospitals. On the other hand, medicine in France tends toward the authoritarian and the public sector can be rigid and uncaring in application. Couple that with major cuts in social spending introduced by France’s new president Macron, overworked and underpaid nurses, and you can see why patients are being discharged from hospitals too soon in order to free up beds and the bad results that ensue.
Along with making a living, healthcare and housing are the two most important social needs any society faces and in the developed world things are not going well. When it comes to health, at whatever age – we need to inform ourselves and act accordingly. For increasing numbers of us adequate medical cover is now too expensive and, if we can, we must look to effective state cover for the basics, topped up with an additional policy to take care of the rest. That done we need to inform ourselves as to where to go to get effective treatment? What hospitals get good results and those that don’t? Which doctors or surgeons to seek out and which to avoid? What your entitlements and rights to treatment are and how you can expect to be treated when hospitalised? Given the way the medical world is headed you need to know these things.
In France, and probably elswhere, one of the best sources I know to find out how things really are is to ask the paramedics and ambulance companies serving hospitals. These men and women see it all. They know which doctors save lives and which kill people, the nurses who brutalise and demean and those who succour and sustain.
There is also a lot of published research data. So much so, that it can confuse rather than elucidate.
One of the best of these for general purposes is the annual survey comparing the medical systems in eleven of the leading developed nations published by the Commonwealth Fund, an independent US foundation established in 1918 to promote health internationally. The survey ranks five key aspects: the Care Process (preventative, safe care, co-ordination & patient involvement); Access (affordability & timeliness); Administrative Efficiency (coverage restrictions, insurance liaison, records & tests); Equity (treatment of low & high income patients, timeliness & barriers to care) and Health Outcomes, which speaks for itself. The countries and their overall rankings were: (1) UK, (2) Australia, (3) Nederlands, (4) New Zealand & Norway, (6) Sweden & Switzerland, (8) Germany, (9) Canada, (10) France, (11) USA.
The USA was the clear outlier, trailing substantially in almost all categories, except the Care Process. The UK was in the top three in all categories except Health Care Outcomes, where it was second last. However it should be noted that the UK still had the biggest reduction in fatalities for 2 years running, whereas the US, who came in last, had the least. Australia is impressive: top in Healthcare Outcomes and Administrative Efficiency, interestingly trailing only in the Equity sector, where it came in seventh.
All the European countries surveyed delivered results above the 11-country average with the exception of France, joined by Canada and the USA. France did not score well in any of the categories with the significant exception of Healthcare Outcomes, where it came in 5th. It does however have the highest ratio of doctors per population.
Back in 2000 the World Health Organisation (WHO) published its survey of the best medical systems over 190 countries. Though interesting its results make sense only when you understand the main criteria was what their health experts considered “what is achievable in that country”. Not necessarily the information you’re looking for. Here France comes No.1, while the other European countries in the Commonwealth Foundation report come in the 17-25 bracket, with the US at 37 and NZ at 41. Singapore weighed in at No. 6, Japan (10th), Malaysia (49), Thailand (47), Malaysia (49), Indonesia (92), India (112) & China (141).
There were other surveys through 2017, usually by organisations or publications dealing with wealth or expat living, which variously rank highly such countries as Singapore, Malaysia, Israel, Columbia, Costa Rica, Qatar and Oman.
While other factors than strictly medical are involved another metric to look at might be the countries whose citizens live the longest, which measured by WHO in 2015 shows (1) Japan 83.7, (2) Switzerland 83.4, (3) Singapore 83.1, (4) Australia 82.8, (9) Sweden & France 82.4 ,(12) Canada 82.2, (14) Nederlands 81.4, 9200 UK 81.2, (24) Germany 81.0, (31) USA 79.3.
Of course much depends on the cost and complexity of what needs to be done. I have been told by various people in Bali and elswhere in Asia how they have been successfully treated and very affordably so, in Bankok, in Penang and in India. For this good judgement and referrals from someone who knows are strongly indicated. From my own experience, Singapore is excellent and particularly good value diagnostically. However when it comes to costs of operations for non-residents it is a lot more expensive than Europe and Australia but less so than the US or Hong Kong.
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