The issue raised is very important; it revolves around health spending as a condition for improving health status. The researcher who asked the question also poses a dilemma; who spends more will not guarantee the improvement of the state of health, and Cuba gives us the proof to that effect.

The American society has several problems that affect the state of health in addition to the fairness and efficiency of the distribution of care: poverty and marginalization of minority populations, dependence on hard drugs and alcohol, social non-coverage of millions of Americans, education is not available for all, low prevention of the mother and her new born baby, the malnutrition that characterizes the dishes of Americans, etc. These points clearly show the work awaiting US officials in the years to come, to achieve what was done by less powerful countries like Cuba.

If you take the US as an example you can see why there is no absolute 1 to 1 correlation between health spend and health outcomes. However, the US has a staggering degree of inequality in accesss - also an important factor. It is also quite inefficient if you look at it on a system level. However, I think if you take a more global view you will find an overall correlation between spend and outcomes - likely quite weak. There is also the possibility that any correlation you observe is not causal because general wealth and basic issues such as sanitation and access to food and clean water are also important - wealthier countries coincidentally also spend more on health services. However, the relationship is bidirectional and there is evidence that spend on health care has net economic benefits...

This is very important issues interm of public health point of view. Ofcourse there are little evidence on causal relation of increase public spending and positive impact. Analysis interm of poor and rich countries settings:

In terms of magnitude, the estimated contemporaneous impact among high-income counties is smaller than for low- or middle-income counties in a majority of the outcomes. This may imply that low- and middle-income counties respond to increases in public health spending with reductions in private health spending (which would be a form of moral hazard). Another possible explanation is that high-income counties are somehow better able to harness increased public health spending to improve their health outcomes in a way that other counties cannot.

As well as the salient points made above there is another point to consider: that of government regulation. Take the case of prescription medicines (one of the major drivers of excess US spending): the US allows market competition to dictate pricing (that is, the pharmaceutical companies & insurers negotiate) however countries with lower expenditure on health as a proportion of GDP typically have government intervention which controls costs, either directly or indirectly.

Lamia and Griffiths have pointed out the importance of the question posed and indeed it is one that needs collaboration of researchers to find solutions to the health problem that do not involve expenditure increases. The health disparities in the US (inequality) are among the worst in the world compared with other developed nations and I believe that spending more will not really solve their problem. The findings of the study I conducted recently for South Africa are aligned with Griffith's opening statement. Also, it was discovered that all this increased expenditure is rather misused and does not cater for the improved health status.

I believe that as researchers, we have a challenge to really take this question seriously until there can be change with the way in which operations are being carried out, especially around health.

So we agree that spending more will not guarantee a fair and efficient health system.

New question: To achieve a US fair health system like that of France in the first place, and secondly an effective health system like that of Spain in recent years; should we start by dismantling financial barriers or organizational barriers?

I think you have answered your own question. The United States far outspends any other country and yet has poor overall population-based results. The question is why is health spending so high in the US, and it isn't because of the amount of hospitalization or physician visits or tests or drug use. Rather it is due to the prices.

I think you all have made the point clearer that more spending does not always in the same fold equate improved health. However, it will not be fair to compare the US and the Cuban health system. US has one of the most competitive and complex health system. If all things remain equal, more spending will generally improve health services and thus better health.

Osas Asemota is correct - the U.S. is an outlier in health spending; and its spending does not achieve comparable health outcome benefits. If one looks at other countries, excluding the U.S., then there does tend to be a positive correlation between health spending and outcomes such as life expectancy.

I do think it is important to remember that not all spending is “good.” One has to work continuously to eliminate waste. And, one needs to keep searching for ways of achieving good outcomes at lower cost (i.e., more cost-effective approaches).

All the researchers who answered on this question agree that: “more spending in a health system does not necessarily mean an improvement in public health at the same level of these expenses”.

Thus, I do not completely agree with Osas Asemota and Stephen C Schoenbaum regarding the possibility of comparison between the American and Cuban health systems.

In my opinion, the performance of a health system can be measured by the expected results. Otherwise: if citizens do not fully benefit from care services through demographic, financial and organizational accessibility; and if the state of health does not reflect the good image of the world's leading power …so the name or reputation of a country cannot hide the shortcomings of a system!

Aissaoui Nasreddine - Thank you for your question. State of health improves by spending more on programs that we know from the evidence they can make a difference in health outcomes. Therefore, it is not a matter of quantity of budget but how these funds were used, what are the priorities, the percentages allocated to each area, and how such allocation is linked with evidence, studies and health outcomes.

I do not think there is no place for comparing countries, and each state has its system, economic factors, quality of care, standards of living, and social status.

Clearly, in equal conditions more spending means in general better health system. The problem is that the conditions are not the same. Spending in health is not necessary what the patient receives as a return. The first problem is how the prices are formed.

In USA, the prices are dictated by close circle of medical professionals that can limit the number of doctors. Therefore, it those are monopoly prices. Further, it is monopoly on essential, sometimes personalized, and sometimes vital product. Well, what is the price of a bottle of water – well, say a dollar. So what is the price of the medicine when one is dying? For example a bottle of water in the desert for a man to die of lacking water? What is the price of a hepatitis C antiviral therapy? Well, if the doctors dictate the price and the medical health is business as usual -- it is exactly so much as the patient possess. In USA mutualizes, e.g. in average it is 80000, in Spain it is about 60000 for the health provider. In India, that do not follow that model of forming the price, it is $130. Clearly, one and the same therapy and in most of the cases from exactly the same producer (in India or China).

There is one more moment – the goal of the medical health. In USA – provide service according to the money spend.

In Spain, where the doctors are mainly civil servants, employed by the government, and paid badly, but with an absolute guarantee that they cannot be laid off without severe error (and Spain has always double-digit unemployment) the goal is other. The goal is not to have severe error according to the rules. So the rules are written and the goal is simplified as following the written rules. Most frequently, the rules are some OMS best practice recommendation. The goal is not to heal at all. Follow the instruction () and you are ok as a civil servant even a doctor. Well, looks not so ideal, but the system is so successful that the Spaniards has one of the longest lives with health insurance of about $100 per person and universal coverage. The problem is that the system is not sustainable and is not just. Moreover, once in crisis the system become obsolete. I live in Spain, can explain exactly what happens if somebody is interested.

Well, do not know exactly how it is in Cuba. Supposing that it is like in the ex-eastern Europe the goal is to provide healthy enough people to work for the totalitarian one party regime. Although the words are exact and seem to be “bad guys” words, I am far away for the idea to categorize it as bad or good, at least because it is far from bad health system.

Clearly, if one wants for some reason to make the system in the USA cheaper and better for the patient, and has power to do it, one must break the doctors’ monopoly, that is actually very similar to totalitarian regime in politics. How to break monopoly in closed market? It cannot be broken within the system. The easiest way is to open it. Outsource the medical health and you will have better health system for the patient (but much poorer for the doctors).

Good analysis Kostadin Koroutchev, especially the situation of the American health system, as well as the problem of the prices of the provision of care in the USA and Spain.

What I liked the most is your comparison on the closed health system even the US system or that of Cuba: "the US health system is actually very similar to totalitarian regime in politics".