Christopher Kerns: From Advisory Board, we're bringing you a radio advisory. My name is Christopher Kerns. You can call me Christopher. I'm filling in for Ray Woods, who has recently been elected prime minister of Denmark. Christopher Kerns: If there is one question that I get asked more often than any other as an Advisory Board expert is which healthcare system around the world is best? I get asked it all the time and I usually reply that it is one of the most frequently asked and most tedious questions that I ever get. And the reason why it's so tedious is because there are so many different reasons why healthcare systems might be different and they're very difficult to compare on an apples to apples basis, mostly because the cultures are different, the circumstances are different, the geographies are different, the nature of the healthcare needs are extremely different from place to place. That said the COVID 19 pandemic has afforded us an opportunity to actually compare healthcare systems around the world on an apples to apples basis. Christopher Kerns: In fact, we would say that it's the first true international stress test of the healthcare delivery system that the world has ever really known in the modern era. And so since the start of the pandemic, we've been tracking how different countries of combated the COVID surges, how they've managed lockdowns, how they have managed the vaccine development and then deployment and then handling the misinformation that goes along with that deployment. We have now a lot more insight into the benefits and disadvantages of each nation's healthcare [inaudible 00:01:26]. Christopher Kerns: So the question that I get asked now is, well, given that information, which country performed the best during COVID? It's a very difficult question to answer, obviously, but to help me answer it, I've actually asked a long time colleague of mine Vidal Seegobin, who oversees our international research division to join us today. Hey Vidal. Vidal Seegobin: Hi Christopher. Good talk to you. Christopher Kerns: Where in Canada are you from Vidal? Vidal Seegobin: Born and raised in Toronto and then did a short stint in the nation's capital of Ottawa. Christopher Kerns: And you were the only person I've ever known from Toronto to pronounce that second T. Vidal Seegobin: I know. Christopher Kerns: Almost everyone I know always says Toronto. Vidal Seegobin: I know and that's in fact the right way to pronounce it. And I get a lot of ribbing for it when I head back there. Christopher Kerns: Vidal, you research healthcare on an international level, which can be tricky because every nation of course, has a very different healthcare delivery system. How difficult did that make it to understand the global impact of COVID-19? Vidal Seegobin: And it remains to be incredibly difficult to compare different health systems, even if you're picking single metrics, because what qualifies for a metric that we use to measure performance can be different across countries. And under normal circumstances, I would say that there are certain narrower elements that are easier to compare than others, but the pandemic that we are currently experiencing, as you mentioned, is one of a unique situations where we've all went through the same experience with the same level of information and largely with the same tools in the toolbox to leverage against. And so it's afforded us kind of a as close as we can get to an apples to apples comparison about what works or what's strength and weakness when it comes to how you configure your health system and how it responds to a novel pandemic. Christopher Kerns: I think one way we can look at this is how did we handle the beginning of the pandemic? And then how did we handle the vaccine rollout? At the very beginning of the pandemic Vidal, you and I often worked together in the weekly updates that I started providing that eventually became the webcast, Stay up to Date, which I host on a regular basis. And we started comparing a number of different metrics, but at the beginning of the pandemic, we really looked at three things. We looked at case rates. We looked at hospitalization rates and we looked at mortality rates. Any lessons that you were able to learn by looking at that and looking at that from a country by country basis, because I know you were tracking all of those across a multitude of OECD countries? Vidal Seegobin: There's a couple of key attributes that made the early pandemic response in some of the more successful countries that were able to keep their case rates low, somewhat difficult to replicate. The first is that you might have the ability to close down your borders and even in some cases close down interstate or inter-provincial borders, which reduce the number of people moving and of course the number of people you are interacting with and spreading the virus. Christopher Kerns: And that of course explains the ability during lockdowns to minimize the virus spread among countries such as Australia, New Zealand, Japan, Korea. Yes? Vidal Seegobin: That's correct. And then if you look at South Korea and Japan in particular, the second key element is the ability for the government and I think the acquiescence of the public to allow for the government to step in with very, very stringent restrictions and requirements, which can include everything from requiring people to stay in their homes, to report through apps, to report through phone systems and to share that information across different healthcare providers or even agencies, that would feel a little bit more difficult to do in more western oriented democratic systems. Vidal Seegobin: And then the last element that I would say is a critical ingredient to success is the experience of having had to respond to a respiratory coronavirus. As you look at again, South Korea, their experience in 2016 with MERS was the theater by which they were able to develop some of the key protocols, data sharing, privacy relaxation policies that I think contributed to their early success and suppression before there was ever a vaccine that we could roll out. Christopher Kerns: When I think back to the beginning of the crisis, there was an almost competitive view of the international response. There was a lot of my country is different, or at least we're not as bad as they are, or why can't we be more like them in a lot of different ways? Is that the right to think about the international response? Vidal Seegobin: No, I think there's one general tendency that we all have when it comes to healthcare, particularly when we are healthcare experts, if you understand the health system that you're operating in, you see all shades of gray and you are pretty aware of all the warts and then when you look at another health system, it's very easy to fall into the grass is always greener at the other side of the fence. And the truth of the matter is, is that every health system is configured in ways that strengthen certain areas, but have associated drawbacks that are actually in many cases connected to those strengths. And so I think it's more a decision about what do we as a society, as those running health systems, want to weigh as a strength and what are we willing to tolerate as a drawback? Vidal Seegobin: If I connect to some of the points I made earlier, you're thinking about here in the United States, I don't think we in our society would tolerate the level of government intervention and government restrictions that were imposed in some of those countries, South Korea, being an example. And I think to pick up an earlier point that you made, even to compare a more closely aligned Anglophone country, Melbourne, which is the largest city in Australia, went through a restriction of 110 days that limited mobility to about two kilometers or less. I can't imagine that happening in any city or jurisdiction United States, but they were willing to accept that as part of the social contract that they have established in their country. So I think you have to be very clear about what are those benefits that they're willing to over invest in and what are the trade offs that they're willing to pallet for that? Christopher Kerns: So I think it's fair to say that no country performed perfectly. One of the things that was often noted is that countries that were most successful at being able to lock down their economies as quickly as they were, were not necessarily those that were able to distribute vaccines as quickly as other countries might have. And I know we're probably going to get to that soon. So let's get to some of those trade offs then. I don't think we have time to talk about every single nation here, but what countries did you want to focus on for this conversation? I know that you have recently written a piece in which you limited your analysis to just a few nations. Maybe you can explain a little bit, what was your thinking behind that? Vidal Seegobin: Yeah, so I wanted to pick countries where you could at least control for some of the cultural variables that always influence and percolate through health system design and the priorities that they picked. What I settled on for three comparator countries were the United States, which is a much more market oriented system where we expose healthcare to market forces, to some extent, to some greater extent, in some cases. England, with its National Health Service, which is a government run and publicly tax funded health system. Christopher Kerns: And that's important to keep in mind that you're talking about England in particular because each of the healthcare systems in the UK are slightly different. So we're just going to be focusing on the English system, yes? Vidal Seegobin: That's correct. And then the last, so if you're going to create a continuum where United States is more exposed to market forces, not in totality, but more exposed to market forces, and England, which is on the polar opposite, which is mostly government managed, controlled and publicly funded, Australia is the middle ground here. So you're looking at a tandem public and private model where people are encouraged to take out supplementary private insurance cover, about 60% of planned care goes through private systems, but in some ways they operate in tandem and in some cases they compete with each other. So there's a hybrid model that I think is interesting to compare and contrast, and in some cases, be the tiebreaker. Christopher Kerns: What are some of the big differences between these systems that are relevant for our analysis of the pandemic response? Vidal Seegobin: The first key difference is where we are able to find slack or excess capacity in the system. Now, if you're thinking about February or March in 2020, when we were really worried about our ability to find beds, to find ventilators, and to have staff, to perhaps be prepared for some of the worst case scenarios, what we tended to find was the health systems that exposed their healthcare providers at hospitals in particular to market forces, either be profitability metrics, or market share metrics, or in generally encouraging growth through a mix of those incentives had a better time at finding and placing patients in that extra capacity. Christopher Kerns: I think that's fascinating because when we think about the excess capacity in the United States, which I think is what you're referring to here is the low occupancy rates that we've historically had, for a very long time that was thought of as a weakness, that was thought of as a costly aspect of the US delivery system, because we had so much excess capacity and yet given the US's relative inability to control the spread of the virus, in our case the excess capacity is really what saved us in many cases at the beginning of the pandemic, because we had the beds. Is that fair to say? Vidal Seegobin: That is definitely fair to say. I think generally speaking, we all struggled in some of the more narrower, localized cases. So if you're talking about New York, it probably still felt like it was a very, very stressful period of time. But I think over a six to eight month period, England continued to struggle with its inability to find some of that excess capacity because all capital decisions about when beds are built or where hospitals are built are all centralized decisions made by the government, which are then weighed by political decisions, whether the appetite for spending more money from the government is a good thing or a bad thing at the time, versus some of the more regionalized or localized decisions that can be made by individual actors or groups that are perhaps trying to maximize or minimize other market related indicators. Christopher Kerns: But that centralized decision making authorities also provided them a number of benefits too, especially relative to countries that were far more exposed to market forces, such as the US. Vidal Seegobin: That is definitely a fair point. So if you're going to say there are clear benefits that the National Health Service of England can unlock because of its size and its ability to move in lockstep, I would point to the poster child of that being the genomic testing network that they were able to stand up relatively quickly based on national laboratories and reference sites that were already put in place for other reasons before the pandemic. And what you saw was a country much smaller than the United States testing and providing a national intelligence on variance, way above their weight class when it comes to the size of the country. So when we were prepared for or talking about the Delta variant, some of those early signals were coming out of the scaled single move to create a national spine of genomic testing that came out of England's work here. So if I was to point to something that's been a clear benefit from size and scale that England shows as a benefit, it would definitely be that one. Christopher Kerns: So when I think about the course of the pandemic, I often like to think of things in three acts. There is the initial phase of infection and transmission. There is the second phase of vaccine development, so what do we do once we have gotten to a level of stability in overall infection rates, but we still don't have a vaccine. And then last vaccine deployment. And I'd like to know how each of these different systems and their structural factors impacted performance on each of these. So let's start at the very beginning. When we think about infection rates, what structures enabled certain countries in your analysis, to do better than others? Vidal Seegobin: On the first kind of infection and transmission spread phase, I think Australia showed that closing borders, putting tight restrictions on people's freedoms and ability to move within the economy and society definitely did have a clear benefit of keeping the transmission and spread of the virus particularly low. And I would also note pretty early on in the transmission phase Australia, because it had both a public and private health system, were able to structure their approach such that the first line of defense, in case we lost control of community spread, would go to public systems where we had public beds to provide care. A backstop was the private systems. So the government said, "We will keep you as backup and in case we are overrun on our public side, too many people and not enough beds, we will then sequester private hospital beds to provide additional capacity." They never really needed that, but I think it afforded them a level of comfort to know that if they had to, they could ramp up additional bed capacity pretty quickly. Christopher Kerns: And it's probably fair to say that the federalized system of the US really prevented the ability to control that spread. There was really no chance that we were ever going to be able to do that, given the inability to restrict people across state borders. Vidal Seegobin: Yeah. And I think that's another major point that's important, that's perhaps not replicable if an American is looking to Australia. So when the community spread was pretty pronounced in Victoria in and around Melbourne in particular, Queensland, New South Wales restricted access from anyone coming from that state into their state, which we know could not happen here in the United States. Christopher Kerns: And that strong and focus on civil liberties is also a factor in the UK as well. I think that's fair to say. Vidal Seegobin: That's true. That's very true. Christopher Kerns: What about vaccine development? Vidal Seegobin: So I think we clearly have to say that US investment in R and D and exposure to market forces where a lot of pharmaceutical companies do recoup a lot of their R and D costs by selling directly to consumers or to many different providers, creates a virtuous cycle by which we saw rapid development of the vaccine, for which I think the world benefited from. So if I was to give a gold star to one health system or one country for the vaccine side, in terms of its development and quick rollout, particularly to healthcare workers, we're talking about December and January, I definitely have to give that to the United States. Christopher Kerns: And then finally, what about the vaccine deployment? Vidal Seegobin: So there are two elements that kind of underpin the vaccine deployment. The first is the friction that is either created or removed when I want to access the vaccine. And I'd have to give top marks to England for having very clearly used its primary care doctor or in their terms, general practitioner network, as the first line defense for the public. And so what that looked like if I was a senior citizen, I got a letter from my GP to tell me what time and what date to show up for my vaccination and that's all I had to do. They took care of all of the scheduling, of all of the ramping up of the and the distribution. And I think when we're thinking about January, February, or even earlier than that, that was a clear win for England. Christopher Kerns: What about the US, which also had a generally successful vaccine rollout. Now we can argue about whether or not it stalled, but I think most would argue that at the very beginning of the vaccine rollout US was making pretty strong progress. Vidal Seegobin: Yes, I think that that's true. Part of the issue, and this is my own heuristic, is that about 50% of the population of any country is really wanting the vaccine as soon as possible. The benefit that the United States had was a very diffused distribution model, where there were multiple openings for you to get your vaccine and that could vary depending on which state. So for me, I was able to get my vaccine at the Walmart that was really close by. So you're thinking very easy to find, I know exactly what to expect, I got that pretty quickly and pretty easily. So that part of the equation works pretty well. Vidal Seegobin: The second part is how you get past that 50%. So how you start to message to other people who might be reticent for a whole host of reasons, the vaccine is safe, the vaccine works in terms of it's reducing your risk of hospitalization. And I don't think any one country has perfected that communication strategy where I do think it has worked, comes to that point that I mentioned earlier, which are countries that have or maintain a higher level of faith or trust in their governments, that may not be the same across any two, three countries and are harder to replicate or to improve with any one tactic or policy. Christopher Kerns: Now Australia, from what I understand has a relatively high level of trust in its government, it has centralized decision making, but it also has some distribution diversity as well, but they seemed to struggle a bit with their vaccination rollout. What accounts for that in your view? Vidal Seegobin: There's a couple of factors that I think contribute to why Australia, if I was to be a little bit hard on them, dropped the ball from being one of the early leaders here in terms of very low case rates and pretty few deaths compared to their population size. So they made a bet that the one vaccine that they were going to dedicate national infrastructure behind was going to be the AstraZeneca vaccine. And when there started to be, or percolate concerns about risks for people around 50, that started to cause a lot more friction in terms of people accessing the vaccine. Vidal Seegobin: The second is that for a lot of people, particularly if you are not in Victoria, where the Melbourne issue was pretty front and center, very little of your life felt different and so there didn't really feel like a lot of pressure to race to get to the vaccine. And when it felt like AstraZeneca might be a little dodgy, they would wait. And then unfortunately what that required then was Australia to get back onto the market, to purchase Pfizer and Australia as a country while wealthy is not the wealthiest country in the world, and it's not the largest. And so you start to move into the queue when it comes to getting inventory, that of course is limited, and that of course caused additional delays in their ability to access the vaccine. Christopher Kerns: So there are a number of areas in which one system might have performed better than another. Are there any aspects of this pandemic response where really no one performed very well? Vidal Seegobin: Yes. So I would point to contact tracing as something that regardless of how you designed your contact tracing system, the respiratory virus quickly overwhelmed your base contact tracing operations. So if you were in England, you probably chose to try to do it digitally and that not only struggled technically, but also got overwhelmed in terms of it not being able to capture all of the people you were in contact with. Then if you looked at a contact tracing system that was manned by individuals, again, very quickly, people forgot who they spoke to, didn't give you a full list of who they might have contacted and very easily also got overwhelmed, even if you were using human beings to try to contact people on the phone. Christopher Kerns: Yeah. From what I understand, the issue of contact tracing is helpful for a disease such as Ebola or syphilis, but it's not really all that helpful when you've got something as communicable as the chicken pox or COVID-19. Vidal Seegobin: Exactly, exactly that. Christopher Kerns: So put it all together for me Vidal, we've looked at three different phases of the pandemic infection, development, deployment of the vaccine, when you add it all up, who won, who did the best? Vidal Seegobin: I don't want to kind of continue on that question for very long, because I don't think it's actually the right way to think about the problem. What I am comfortable saying from looking at multiple countries' response to the vaccine and to suppression and to management of COVID 19 is all of these health systems basically performed exactly as you would expect them to. The strengths that you might note that are laudable and that we can tout as being great parts of our health system are oftentimes associated with some drawbacks that are the negative effects or the mirror opposites of what we have designed into our health system. And so what I think about the strengths, they are things that we put priority on and they are also associated with some drawbacks. And so if there are things that did not work in your health system, they're probably by design and not because somewhat had ill intention or dropped the ball. It's in fact, the downside of the way that we have designed and decided that we are going to run and organize our health systems. Christopher Kerns: I think it's fair to say that you're only as good as your last pandemic. Vidal Seegobin: That's definitely true. Christopher Kerns: So, given what you just said, is there anything that our listeners may have thought was an obvious advantage in one country, but turned out to be a downside for them or had downsides that they didn't anticipate? Vidal Seegobin: The one thing that we've all been chasing, not even talking about infectious disease, when we're talking about the health system, a lot of us have been saying the chronic disease issue has overwhelmed our health systems and we are really worried about sustainability. And I think when we look at what health system configuration might be helpful here, I think we talk about a primary care forward, a primary care gate keeping model. And England and Australia do have that as an attribute of their health system, they require you to come to a general practitioner or a PCP if you're talking about it in the US context, before you're able, even to access hospitals or a specialist. And the thought was that that connection, that relationship that you would have, that's actually outside of the hospital, is a real benefit in a pandemic when we are singularly focused on protecting hospital bed capacity and the clinicians that are practicing or providing care in the acute care setting. Vidal Seegobin: And so on paper you would've said while those health systems for which you have a gate keeping model are probably going to be really well situated to manage non COVID disease more effectively because we have those relationships and those access points, I think the jury's still out clinically about whether or not that worked, because we do know that there is a lot of delayed care in those jurisdictions because people just stayed away from everything related to healthcare, whether it was a hospital or a physician's office or a clinic. Vidal Seegobin: And I think the second thing that is important to realize is that primary care offices, primary care practices can as easily or perhaps even more easily be overwhelmed by demand as a hospital. And so in some cases, particularly in England, we did see primary care practices, doctors completely burn out by the kinds of demand that they were absorbing, both for recurrent issues that they should have been treating in the primary care setting to begin with, as well as shunting or absorbing some of the things that might have been treated in the hospital but we just couldn't do that at that time. Christopher Kerns: So we've talked about a number of different phases of the pandemic. What's the next phase that people aren't talking about that that you're watching for, Vidal? Vidal Seegobin: So I'm watching for the hidden effects that have been caused by the pandemic that are healthcare related that are not currently being addressed, but are going to manifest within a two to three year timeframe after COVID 19 becomes endemic. And what I mean by that is the associated behavioral health issues that I know have become part and parcel of societies that have had to go through this incredible stressful time. And that is going to have associated effects both with people's behavioral health and mental health, but also their ability to maintain stability in their traditional clinical issues. Vidal Seegobin: The second thing I am tracking pretty closely is how we decide we are going to dig ourselves out of the financial implications of what we've done. Most of the countries that I'm describing have put to some extent and to some many cases, large extents, major restrictions on the economic activity that either forms the backbone of the tax base that funds the health system or the economic activity that allows for people to be employed, to make money, to be able to afford healthcare. And so I think that that is also going to create two factors, first and foremost, where's the money going to come from to both fund healthcare going forward, given we are going to decide that there's probably a lot of things that are going to want to improve about performance going forward, and that's going to cost money? And then second, what are going to be all of the demographic epidemiological impacts of this pandemic on people, patient habits, and how are we going to treat that, identify it earlier and manage that over time? Christopher Kerns: It's a pretty sobering assessment overall because when people start to talk about the various aspects of performance during the pandemic in their own country that they disliked, I think what you're saying is that many of the trade offs that they would have to make to rectify some of those problems might actually cause problems on some of the things that they actually liked very much about their country's performance. Vidal Seegobin: Yes, that is definitely true. And I won't even use the US example because it can be pretty fraught with people's personal perspectives, but in Australia, one of the premiums that they build into their health system is choice. It is really, really important that I have choice. If I can afford to have access to a doctor that I know by name, then I should have the ability to pay for that and to have access to it and to get there quicker. That is a key feature of the health system, but then that of course creates associated questions around if I cannot afford to pay for it, then do I deserve or should I have less access to care? Vidal Seegobin: Then if you think about issues around vulnerable populations, we talk about that, the terms we tend to use in the United States context is health equity, but you might be talking about it in the Australian context from Aboriginal or indigenous populations, which traditionally have had very poor outcomes. So these are a balancing trade offs that you want to have. And then if you have to move emphasis from one side to another, are you willing to give up on some key benefits that you've taken advantage of historically? Christopher Kerns: So I'm going to give you one final question then. What should our listeners in the US and across the globe who are listening to us take away from all of this? Vidal Seegobin: There's three things that I think are really, really important. One that's very self-serving as someone who's a very much an evangelist of looking across different health systems for understanding and intelligence, my hope is that even outside of COVID 19, we come to recognize that there are so many shared problems in healthcare that if you're looking for answers and solutions, either structural in nature or individual performance, cast your eye more broadly to the rest of the world, because there are a lot of really great examples of things that are replicable, even in your local context, that are worthy of consideration and note. And clearly, Christopher, you and I were spending time in the very early stages of the pandemic to try to do some of this sorting and connecting as we were all experiencing problems or just lack of information in COVID 19. So I think this has again been a, hopefully a testing bed for that theory that although healthcare is local, I think we need to start to look more globally when it comes to answers and solutions. Vidal Seegobin: This second element is that there are key features of the health system that were a challenge in all configurations, that I think are going to occupy healthcare leaders going forward. So I would be disinclined to judge or to blame the health system itself, its configuration, is the reason why we are struggling with things like staff burnout, with recruitment, with retention, with poor patient experience. I can talk to four different countries and basically tell the same story when it comes to that. So don't be so inclined to blame the incentives, to blame the structure, when it comes to some of these problems because they are shared regardless of configuration. Vidal Seegobin: And then the last is I think the point that I made earlier about health systems basically performing as they were designed to. If you want a different health system to do different things, then I think it's really important for us to be clear about what are the trade offs that we're going to have to make if we want to get that new thing, because it might require for us to give up on an old benefit. And that's not easy to say because we all want things to be better, faster, cheaper, more effective, more frictionless, but many times the reason why that is the case is because it's a function of the trade offs or balancing act that we've made around the premiums that we've put into our healthcare system and its configuration. Christopher Kerns: Thank you, Vidal. It's very rare that we've been able to see these sorts of comparisons made on such a level playing ground, where we can actually look at different healthcare systems around the world and really compare them in apples to apples comparison. We have that now because of this international stress test. And I want to thank you for your analysis on this topic and coming onto the podcast today. Vidal Seegobin: Thank you, Christopher. Christopher Kerns: One of the things that became very clear to me as we started doing this research at Advisory Board on the international stress test was the idea of how easy it is to complain about your own healthcare delivery system. And believe me, there's much to complain about. In fact, it is one of the reasons why I have a living here at Advisory Board, is being able to talk about the greatest problems in the system. But it's an almost calming realization to understand that most of our healthcare delivery systems around the world performed as designed and that if we don't like what we got, we have to figure out the ways in which we can change the aspects that we didn't like while maintaining all of the aspects that we do. That's what Advisory Board is really here to do each and every day.