In his 2012 state-of-the-nation address, President Nursultan Nazarbayev identified the development of preventive medicine as a key priority that “should become a major tool in preventing disease.” President of the Kazakh Academy of Preventive Medicine Almaz Sharman spoke to The Astana Times about the value of preventive medicine.
How would you describe the main components of quality of life and what is the role of health in it?
We all want to be healthy, physically strong, enthusiastic and smart; to look attractive and young and to have peace of mind. In other words, we all would like to enjoy good quality of life. In many ways this can be achieved through healthy behaviour, in-person communication, spiritual enrichment and respect for the environment.
In today’s world, quality of life has become a key priority. It is a broad concept defined by mental and physical well-being, the main criterion of which is health.
We began to realise that it is quite possible to manage our own health by adhering to healthy behaviour, ensuring early detection of signs of diseases and using modern medical technologies to treat them. By following these rules, people can prevent many diseases and, therefore, enjoy long and active life.
What in your opinion should be the role of the state in providing health services?
Health care in Russian is zdravookhranenie, which can literally be translated as protection of health. It primarily mean measures aimed at disease prevention. In most countries of the world, the governments take responsibility for that. Health protection is fundamentally different from medicine in a sense of intellectual and creative work, a craft and a complex profession dedicated to treatment of diseases. It’s a craft because treatment of most diseases can be standardized. It’s creative because each patient is unique and requires an individual approach with unlimited opportunities for technological innovations.
The governments are able to effectively mobilize human and material resources to prevent epidemics, ensure health and food security and to promote healthy behaviour. However, the governments are rarely successful in dealing with functions that require professionalism and individual creativity, which is a characteristic of patient care and treatment of diseases. This is especially true at a time when medicine is becoming more technological.
A sanitary inspector, for instance, can prevent food poisoning, but he cannot create delicious and healthy food. The same is with a health care officials who is able to effectively monitor compliance with safety standards. However, government bureaucrats intervening with professional work performed by doctors and the creative process in patient care may turn out to be counterproductive. Physicians are primarily responsible for the professional execution of their duties. Their performance should be judged by their peers and their patients. The level of financial compensation and demand, as in any labour market, should be determined by consumers of medical care.
In your opinion, what are the main parameters to be achieved in the national health care?
Current trends in health care can be characterized by a shift from disease-centric paradigm to a new paradigm that focuses on disease prevention and health promotion.
This can be achieved through strengthening primary health care that deserves priority funding. Unfortunately, while such priority is often declared it has rarely been effectively executed. Modern primary health care is not just sanitation and the work of doctor’s assistants. The primary health care is a gateway that is supposed to be central in communicating with the other parts of the healthcare system. Primary care doctors are the ones who protect consumers from getting ill and help them navigate in the ocean of medical knowledge. For a layman, a non-medical person it is difficult to distinguish a good medical practice from incompetence and ignorance. In such environment, primary care is a bottleneck or a gateway that helps to identify islands of competence and to communicate with the other parts of healthcare system. Such a role requires that a primary care doctor is an efficient, engaged, well-educated and empowered expert.
International experience demonstrates that hospital admissions may be reduced by 40 percent and health care costs by 30 percent if a country’s primary health care system is strong. Around 70 to 80 percent of health care episodes in an individual’s life can be identified by general practitioners equipped with basic instruments.
It is important to strengthen the role of primary care physicians by providing them with in-depth knowledge and modern technologies. Internet, social networks, portable echocardiography, medical applications for smart phones and other modern devices make medical technology available not only to doctors, but also to ordinary consumers of healthcare.
Close interaction, continuity and cohesiveness in health care can be provided by a relatively small group of managers through an effective and dynamic administration system. I believe it is necessary to provide doctors and practitioners with key levers of administrative and financial management and unlimited opportunities to innovate freely and to introduce modern methods for disease prevention, diagnosis and treatment according to the principles of evidence-based medicine.
Finally, a key condition is the joint responsibility of citizens. According to the World Health Organisation, about 40 percent of Kazakhstan’s health care expenditures come from private sources. This means that citizens today are actively investing in their own health. It is important to mobilize and rationalize the resources of private medicine in order to create an effective and harmonized health care system based to professional motivation for the interests of patients.
What do you think about public versus private medicine?
I think we should not demonize the right to pay for one’s own health, and physicians’ right to be properly compensated for their hard work.
In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet.
What is called the government guaranteed health care benefit package which is perceived as “free healthcare” has a specific source of funding – the state budget, which is made of taxpayers’ money. The question is what portion of healthcare expenditures should be guaranteed by the government? Very often unlimited expansion of guaranteed benefit package is not affordable to the public healthcare system. In addition, the public funded model in its essence is a monopoly with intention of controlling the taxpayers’ money in providing healthcare services. And monopolies, as we all know, tend to suppress innovation and raise prices.
Kazakhstan’s Constitution does not preclude public funding of private healthcare organizations. Mobilizing such resources has great potential in motivating healthcare workers, introducing innovations and providing quality medicine.
Patient care, like any other complex intellectual and creative work, deserved being well rewarded morally and financially.
What about the ideals of altruism and self-sacrifice of doctors?
The word “altruism” came from Latin and is literally translated as “other people.” It was introduced by Auguste Comte, a French philosopher, who believed that individuals had a moral obligation to renounce self-interest and live for others. Frankly, I do not agree with this concept. I prefer the term of professional altruism which implies an opportunity for professional self-enrichment through servicing the others.
This concept is reflected in many cultures. In Hebrew, one says tikkun olam, a sort of taking the world in for repairs. In Hindi, they say paropakari sewa which is not selfless service but includes benefit for the one who gives. Regardless, what matters is that you own your own motives completely.
It is unreasonable to be altruistic by rejecting the fundamental principles of existence, the desire for personal success and happiness. A doctor is not able to fully take care of patients without caring for himself. The success of his or her service always involves a critical condition: satisfaction of internal needs in well-being, balance and harmony. Only through understanding what those internal needs are one can rationalize the conditions for their realization and dedicate himself to professional services. To be a truly moral human being one must act upon one’s own rational self-interests.
