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This is a long reply. I prefer to support my answers rather than giving my opinion in the form of: “Yes/No because I say so,” or “Yes/No because other people do it and I believe it works well/poorly.” Hopefully, someone interested in the concept of sustainability has a sustainable attention span.Any discussion of healthcare sustainability needs to examine systematic weakness. There is no perfect system. All systems have compromises. All systems can improve different metrics. Since this is all true, no healthcare system on the planet is sustainable in its current form.Many other answers support their point of view by saying that it is sustainable elsewhere. But is it?The first things to disappear in a “single-payer” government run system are competition and price transparency. Almost every economist agrees that competition has been shown to reduce costs by increasing efficiency. Competition disappears when government has a monopoly on healthcare delivery.The Inefficiency of Monopolyhttps://courses.lumenlearning.com/wmopen-microeconomics/chapter/the-inefficiency-of-monopoly/Most people criticize monopolies because they charge too high a price, but what economists object to is that monopolies do not supply enough output to be allocatively efficient. To understand why a monopoly is inefficient, it is helpful to compare it with the benchmark model of perfect competition.Markets and Priceshttps://www.econlib.org/library/Topics/HighSchool/MarketsandPrices.htmlSupply and Demand: Prices play a central role in the efficiency story. Producers and consumers rely on prices as signals of the cost of making substitution decisions at the margin. How are prices determined?A work that still holds today is this one showing that economic calculation (price transparency) is impossible under government run systems. Price transparency disappears in a government run system because true prices (for both goods and services) cannot be determined despite claims purporting to know how much is spent:Economic Calculation in the Socialist Commonwealthhttps://www.goodreads.com/book/show/1714576.Economic_Calculation_in_the_Socialist_CommonwealthMises argued that no prices for capital goods could be obtained in a socialist economy if the government owned the means of production, since all exchanges would merely be internal transfers rather than "objects of exchange", setting the price mechanism out of order.Socialized Medicine: An Accounting Perspectivehttps://mises.org/wire/socialized-medicine-accounting-perspectiveJust like any language, financial accounting is not perfect. One limit of accounting must be stressed repeatedly in the debate over socialized medicine: financial accounting cannot exist without money prices. Financial accounting is impossible if buyers do not pay money prices for goods and services. In a socialized healthcare system, consumers (or patients) do not exchange money for their medical services. Therefore, there are no money prices for medical treatment in a socialized healthcare system. This means financial accounting is impossible under socialized medicine. …… However, socializing medicine makes financial accounting impossible in the healthcare system. This means socialized medicine has no language, no system to verify whether the most urgent needs of the patients are being satisfied in the best possible way. It impossible for the directors of the system to determine whether scarce medical resources are satisfying the most urgent needs of the patients, or whether those precious resources are being wasted. Without financial accounting, production decisions in socialized healthcare systems are always irrational. Consequently, a socialized healthcare system will be arbitrary, chaotic, and inefficient.Sometimes there is a difference between “universal” healthcare (government mandates that everyone has healthcare insurance) and “single-payer” healthcare (government is the one source for healthcare payments). Many other countries have mixed public/private systems:The new public/ private mix in health: exploring the changing landscapehttps://www.who.int/alliance-hpsr/resources/New_Public_Private_Mix_FULL_English.pdf?ua=1Universal Health Coverage Around the Worldhttps://axenehp.com/international-healthcare-systems-us-versus-world/So if most other countries don’t have single payer or socialized medicine, what do they have? Other systems fall in one of two broad categories:1. Insurance Mandates – Government mandates that all citizens purchase health insurance from private or public health insurers. Often includes a requirement for a standard minimum coverage across all insurers, subsidies for low income individuals, and forbids underwriting and for-profit insurance. Some countries with insurance mandates include Germany, Japan, the Netherlands, and Switzerland.2. Hybrid systems – Combines elements of single payer systems with private insurance mandates. Government provides a standard set of care for all citizens, with options to supplement with private insurance. Some countries with hybrid systems include Australia, France, Singapore, Sweden, and the UK.The Commonwealth Fund regularly publishes an excellent resource that summarizes the health care systems of many countries. The most recent report in May 2017 examined the systems in 19 countries. The following draws heavily from that report, and I highly recommend reading it if you would like more detail on the systems that I touch on here.Perspectives on the European Health Care Systems: Some Lessons for AmericaAmericans will probably be surprised to learn from the remarks that follow that Switzerland's health care system relies almost entirely on a system of private insurance. They might be surprised to learn that there is a growing reliance on the private sector in the financing and delivery of health care in Europe, particularly in the Netherlands, Germany, and Sweden. Even the Labor government in Britain has entered into an agreement with representatives of the private health care industry to improve health care delivery in certain vital areas…GermanyGermany's system is the prototype of the European sickness fund health care system. The most interesting aspect of the German system, however, is that Germany allows people whose income is above a certain level to opt out of that system. They are no longer obliged to pay a percentage of their wages to the sickness fund; however, they must use that money to buy private health insurance.The NetherlandsLike the Germans, the Dutch also can leave the sickness fund system once they earn more than a certain income. The financial threshold is lower in the Netherlands than in Germany, and as a result, one-third of the population is privately insured.SwitzerlandSwitzerland has the least paternalistic health care system in Europe. It is the only country in Europe with a health care system that is based totally on private insurance.Government run systems rely on price controls. Government sets the price of services and prescription drugs. That is why prescription drug prices are cheaper in most government run systems. Almost every economist agrees that price controls have been shown to reduce innovation. The sustainability of any system is determined by adaptation and innovation. The sustainability of most government run systems depends on the innovation provided by the U.S. system. Although not free market, it is more so than most other systems. Do supporters of government run systems consider lack of innovation as a condition for sustainability?Price-Control Failures, Then and Nowhttps://mises.org/wire/price-control-failures-then-and-nowPrice Controlshttps://www.econlib.org/library/Enc/PriceControls.htmlDespite the frequent use of price controls, however, and despite their appeal, economists are generally opposed to them, except perhaps for very brief periods during emergencies. In a survey published in 1992, 76.3 percent of the economists surveyed agreed with the statement: “A ceiling on rents reduces the quality and quantity of housing available.” A further 16.6 percent agreed with qualifications, and only 6.5 percent disagreed. The results were similar when the economists were asked about general controls: only 8.4 percent agreed with the statement: “Wage-price controls are a useful policy option in the control of inflation.” An additional 17.7 percent agreed with qualifications, but a sizable majority, 73.9 percent, disagreed (Alston et al. 1992, p. 204).Though The U.S. Is Healthcare's World Leader, Its Innovative Culture Is Threatenedhttps://www.forbes.com/sites/gracemarieturner/2012/05/23/though-the-u-s-is-healthcares-world-leader-its-innovative-culture-is-threatened/#38151a5c77ebThe United States remains the world leader in medical innovation, having produced more than half of the world’s new medicines over the last decade. But our edge is slipping away because of crippling domestic regulatory and tax policies.U.S. Medical Research Spending Drops While Asia Makes Gainshttps://www.usnews.com/news/articles/2014/01/02/us-medical-research-spending-drops-while-asia-makes-gainsALTHOUGH THE UNITED States once accounted for more than three-quarters of the world's research spending, its share has continued to drop in recent years, while countries in Asia saw a dramatic increase.In a study published Wednesday in the New England Journal of Medicine, researchers found the United States comprised 51 percent of global research spending, at $131 billion in 2007. But by 2012, that number dropped to $119 billion, or 45 percent of the world's biomedical research spending. By comparison, Japan and China increased their spending by $9 billion and $6.4 billion, respectively, during the same time. In 2012, Japan and China accounted for 13.8 percent and 3.1 percent of the world's total research spending.List of Nobel laureates in Physiology or Medicinehttps://en.wikipedia.org/wiki/List_of_Nobel_laureates_in_Physiology_or_Medicine7 Countries that Produce the Best Doctors in the Worldhttps://forum.facmedicine.com/threads/7-countries-that-produce-the-best-doctors-in-the-world.24520/1. U.S.A.Our 7 countries that produce the best doctors in the world list has come to an end with truly the greatest source of exceptional minds in the field of medicine. American doctors made the most lifesaving discoveries and groundbreaking treatments than any other country in the world.International comparison of health care systems using resource profileshttp://www.who.int/bulletin/archives/78(6)770.pdf… On the other hand, access to advanced medical technology was far greater in the USA than WHO 00198 Fig. 1a–f. Spider-web diagrams for the six study countries showing selected health care expenditures and resource measures for 1986, 1991, and 1996, normalized by the group maximum (% GDP = % gross domestic product; Exp/cap = expenditures per capita; Drugs/cap = drug expenditures per capita; MRIs = MRI units per capita; CT Scanners = CT scanners per capita; Beds/cap = no. of hospital beds per capita; Emp/cap = health care employment per capita; Phys/cap = No. of physicians per capita; Nurses/cap = no. of nurses pers capita; % Emp = health care employment as % of total employment) International comparison of health care systems Bulletin of the World Health Organization, 2000, 78 (6) 775 in the other countries, and this gap appears to be increasing in absolute terms. It would appear that relative differences in staff wages and access to medical technology may explain a substantial part of the difference between US and European expenditures.Government run systems are also susceptible to rising costs. Economics 101 tells us, in order to keep the system afloat, this means either raising taxes, increasing efficiencies and/or reducing services. Efficiency will account for a small percentage since efficiency can only be improved to a point. Taxes in most countries with government run systems are already much higher than in the U.S. Do supporters of government run systems consider the sustainability of rising tax burdens and reductions in services?A Comparison of the Tax Burden on Labor in the OECD, 2019https://taxfoundation.org/tax-burden-on-labor-in-the-oecd-2019/OECD Better Life Index- United Stateshttp://www.oecdbetterlifeindex.org/countries/united-states/The United States performs very well in many measures of well-being relative to most other countries in the Better Life Index. The United States ranks at the top in housing . and ranks above the average in income and wealth, health status, jobs and earnings, education and skills, personal security, subjective well-being, environmental quality, social connections, and civic engagement. It ranks below average in work-life balance . These rankings are based on available selected data.Money, while it cannot buy happiness, is an important means to achieving higher living standards. In the United States, the average household net-adjusted disposable income per capita is USD 45 284 a year, much higher than the OECD average of USD 33 604 a year, and the highest figure in the OECD.Reductions in services are already happening:Is U.S. Health Care Less Efficient than Other Countries’ Systems?https://object.cato.org/sites/cato.org/files/serials/files/regulation/2012/8/v35n2-8.pdf… Hidden costsIn most other developed countries, health care prices are controlled below the level necessary to clear the markets. This is especially common in single-payer systems like those of Canada and Japan. The result is a great deal of nonprice rationing. Some of the nonprice rationing is based on professional judgment, roughly similar to that occurring in competing managed care plans in the United States. It is probably reasonably efficient. But much of the rationing is accomplished by consumers waiting for services, which leads to large hidden costs of health care…… Unlike Medicaid, the nonprice rationing problem is system-wide in some other counties. Atlas shows that for many different diagnoses, Americans obtain appropriate care more often than those in many other countries. The delay and poor access to care resulting from rationing by waiting harms health outcomes, but delay and poor access tend to be concentrated on issues that are not life threatening; therefore, they do not…Perspectives on the European Health Care Systems: Some Lessons for Americahttp://www.heritage.org/health-care-reform/report/perspectives-the-european-health-care-systems-some-lessons-america… If you insist, with a straight face, that in a government-run health care system, all of your fellow citizens will be treated equally -- regardless of their class, station in life, or disease condition -- you are not merely enthusiastic or well intentioned. You are lying…… A British PerspectiveDavid G. Green, Ph.D... Lesson #1: Aim to make the market serve everyone, whether they are self-supporting through work or not. Governments should confine themselves to what they can do best and leave the rest to civil society. This implies that:-- Governments should not try to be the single payer, because this will result in rationing; and-- Governments should not impose a single provider, because this would mean that consumers could not escape bad service and incentives to raise standards would be diminished……A Belgian ViewPaul Belien… Denial or Restriction of TreatmentAnother method currently used to cut costs is to restrict the access of patients to costly health care services. Sometimes these services are denied to all patients; sometimes, only to certain categories -- for example, the elderly.I have experienced the impact of this policy in my own family when, several years ago, my grandfather needed an operation. Because he was over 80 years old, my grandfather was given an old antibiotic that has drastic side effects: It causes deafness. Though there were other, but costlier, treatments available, the hospital gave the old drug to my grandfather because of his age. They knew about the side effects, but it did not strike them as unreasonable or unjust to reserve the modern treatments for people of a younger age group and to give old rubbish to the elderly.A recent study shows that while over 50 percent of patients in the United States receive the latest, most effective pharmaceuticals for arthritis, they are available to only 15 percent of patients in Germany and the United Kingdom. The same trend is revealed with regard to cardiovascular medicine. In Italy and Belgium, the threshold condition for receiving the most innovative and effective therapy is having a cholesterol level of about 290 as well as proof of a family history of heart trouble, even though established medical opinion holds that a cholesterol level of 190 is the appropriate threshold for treatment.New medications are a critical component of health care, yet patients in many European Union countries have to wait years before they become available. In most European countries, pharmaceutical companies must not only get approval from the national departments of health, but must also obtain pricing and reimbursement approvals before they can introduce a new drug into the market. Because this can result in delays averaging 18 months, many breakthrough medications are simply unavailable for extended periods of time. A study conducted by Europe Economics revealed that, from 1995 to 1997, more than half of the new medications surveyed were unavailable through pharmacies in Portugal, Italy, and Greece. More than one-third were unavailable in Belgium, France, and the Netherlands.The delays serve an economic purpose: Because the new products are more expensive than the old ones, by delaying access to the new drugs, the governments save money. Though European politicians try to save money by cutting services across the health care sector, pharmaceuticals are frequently targeted because cutting drug expenditures is relatively easy.Access to healthcare in Europe in times of crisis and rising xenophobiahttps://www.uems.eu/__data/assets/pdf_file/0009/1530/MdM_Report_access_healthcare_in_times_of_crisis_and_rising_xenophobia.pdf… In its 2012 report Health policy responses to the financial crisis in Europe, the WHO classified the global financial crisis that began in 2007 as a health system shock or “an unexpected occurrence originating outside the health system that has a large negative effect on the availability of health system resources or a large positive effect on the demand for health services”. The WHO further warned that “cuts to public spending on health made in response to an economic shock typically come at a time when health systems may require more, not fewer, resources – for example, to address the adverse health effects of unemployment”. Measures such as reducing the scope of essential services covered, reducing population coverage, increasing user charges for services and reducing the number of health providers were specifically identified as policy tools that undermine health system goals.Here is what is being proposed in the U.S.:Considering “Single Payer” Proposals in the U.S.: Lessons from Abroadhttps://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad… Policy ImplicationsCurrently, single-payer bills in the U.S. tend to share the same key goals: centralizing the financial and regulatory structure of the system, expanding the public benefits package, and eliminating private health insurance entirely. However, these three features are not the norm across countries that have achieved universal coverage for health care.In contrast to single-payer proposals in the U.S., many universal health systems delegate significant financial and operational responsibilities to regional authorities, as long as they comply with federal regulations. In addition, the comprehensiveness of the universal public benefits package varies greatly by country. Finally, virtually every country with universal health coverage offers complementary, supplementary, or substitute private health insurance, which is purchased to ease the burden of cost-sharing, expand access to hospitals and providers, and cover benefits excluded under the public insurance scheme.Although all “single-payer” systems are “universal” healthcare systems, not all “universal healthcare” systems are “single payer.” Here is a list of countries considered to have “single-payer” systems:Single-payer healthcarehttps://en.wikipedia.org/wiki/Single-payer_healthcareCanada, Taiwan, South Korea, Nordic countries, United KingdomIt's Surprising How Few Countries Have National, Single Payer, Health Care Systemshttps://www.forbes.com/sites/timworstall/2017/03/26/its-surprising-how-few-countries-have-national-single-payer-health-care-systems/#3090cc5c5a65There are indeed national and single payer systems out there, most notably the National Health Service in Britain. That's very fair, very equitable, but performs horribly on "mortality amenable to health care" which is otherwise known as curing people of what ails them. That's not a recommendation.Let’s look at some sustainability issues in Canada:Cost of public health care for Canadian families soared by 70% over two decades: reporthttps://globalnews.ca/news/4364344/cost-health-care-canadian-families/Canadians' health-care costs have skyrocketed: Studyhttps://torontosun.com/2017/08/01/canadians-health-care-costs-have-skyrocketed-study/wcm/495190a8-ff3e-4016-aea2-43c61b4e6d3dDrug costs rising fast in Canadian health-care spending, report findshttps://www.cbc.ca/news/health/cihi-health-costs-canada-report-prescriptions-pharmacare-1.4390945Universal Health Care in Canada: A Colossal Government Failurehttps://mises.org/wire/universal-health-care-canada-colossal-government-failureTom Kent was the senior government policy person in Canada when the Medical Care Act was passed in 1966The aim of public policy was quite clearly and simply ... to make sure that people could get care when it was needed without regard to other considerations.After half a century, the government has still not honoured its commitment, and its performance declines with each passing year, despite increased spending. Furthermore, the government made it illegal for citizens to pay private parties for the health care which the government fails to provide.Waiting, Waiting, Waiting for a DoctorAccording to a Fraser Institute survey, for medically necessary treatment, the median waiting time for patients in Canada from referral by a general practitioner to consultation with a specialist, and then to the date of actual treatment, was 21.2 weeks in 2017.This year’s [2017] wait time — the longest ever recorded in this survey’s history — is 128% longer than in 1993, when it was just 9.3 weeks.Research has repeatedly indicated that wait times for medically necessary treatment are not benign inconveniences. Wait times can, and do, have serious consequences such as increased pain, suffering, and mental anguish. In certain instances, they can also result in poorer medical outcomes — transforming potentially reversible illnesses or injuries into chronic, irreversible conditions, or even permanent disabilities.Or even death! From a 2014 study by the Fraser Institute:The Ugly Truth About Canadian Health Carehttps://www.city-journal.org/html/ugly-truth-about-canadian-health-care-13032.htmlI was once a believer in socialized medicine. I don’t want to overstate my case: growing up in Canada, I didn’t spend much time contemplating the nuances of health economics. I wanted to get into medical school—my mind brimmed with statistics on MCAT scores and admissions rates, not health spending. But as a Canadian, I had soaked up three things from my environment: a love of ice hockey; an ability to convert Celsius into Fahrenheit in my head; and the belief that government-run health care was truly compassionate. What I knew about American health care was unappealing: high expenses and lots of uninsured people. When HillaryCare shook Washington, I remember thinking that the Clintonistas were right.My health-care prejudices crumbled not in the classroom but on the way to one. On a subzero Winnipeg morning in 1997, I cut across the hospital emergency room to shave a few minutes off my frigid commute. Swinging open the door, I stepped into a nightmare: the ER overflowed with elderly people on stretchers, waiting for admission. Some, it turned out, had waited five days. The air stank with sweat and urine. Right then, I began to reconsider everything that I thought I knew about Canadian health care. I soon discovered that the problems went well beyond overcrowded ERs. Patients had to wait for practically any diagnostic test or procedure, such as the man with persistent pain from a hernia operation whom we referred to a pain clinic—with a three-year wait list; or the woman needing a sleep study to diagnose what seemed like sleep apnea, who faced a two-year delay; or the woman with breast cancer who needed to wait four months for radiation therapy, when the standard of care was four weeks…… My book’s thesis was simple: to contain rising costs, government-run health-care systems invariably restrict the health-care supply. Thus, at a time when Canada’s population was aging and needed more care, not less, cost-crunching bureaucrats had reduced the size of medical school classes, shuttered hospitals, and capped physician fees, resulting in hundreds of thousands of patients waiting for needed treatment—patients who suffered and, in some cases, died from the delays. The only solution, I concluded, was to move away from government command-and-control structures and toward a more market-oriented system. To capture Canadian health care’s growing crisis, I called my book Code Blue, the term used when a patient’s heart stops and hospital staff must leap into action to save him. Though I had a hard time finding a Canadian publisher, the book eventually came out in 1999 from a small imprint; it struck a nerve, going through five printings.Nor were the problems I identified unique to Canada—they characterized all government-run health-care systems. Consider the recent British controversy over a cancer patient who tried to get an appointment with a specialist, only to have it canceled—48 times. More than 1 million Britons must wait for some type of care, with 200,000 in line for longer than six months. A while back, I toured a public hospital in Washington, D.C., with Tim Evans, a senior fellow at the Centre for the New Europe. The hospital was dark and dingy, but Evans observed that it was cleaner than anything in his native England. In France, the supply of doctors is so limited that during an August 2003 heat wave—when many doctors were on vacation and hospitals were stretched beyond capacity— 15,000 elderly citizens died. Across Europe, state-of-the-art drugs aren’t available. And so on.Let’s look at sustainability issues in Taiwan:Health Care for All: The Good & Not-So-Great of Taiwan's Universal Coveragehttps://international.thenewslens.com/article/108032… Is NHI sustainable?However, the system is far from perfect.A budget deficit, an aging population, a rise in chronic diseases, questionable quality of care, disgruntled doctors and incessant public demand on Taiwan’s medical services are just some of the challenges detailed by Princeton University Health Policy Research Analyst Cheng Tsung-mei’s (鄭宗美) report on the country’s health care system…… NHI’s annual expenditure currently grows by 4.83 percent while funding grows by 4.35 percent annually. “Fortunately, we have NT$200 billion (US$6.48 billion) in safety reserves,” says NHIA Director General Lee. “But the 2016 decrease in premium has resulted in a NT$10 billion (US$323.9 million) deficit and possibly the deficit could double this year to NT$24 billion (US$777 million).”…… But instead of blaming the public on wasting resources, the system itself is designed to be open to abuse, Lin Chao-yin (林昭吟), an associate professor at National Taipei University Department of Social Work and an adviser to the Taiwan Health Care Reform Foundation (THRF, 台灣醫療改革基金會), points out.“Sometimes a patient is required by the doctor or hospital to return for follow-up visits or repeat medical exams. What should the patient do?” says Lin. An NGO that protects patients’ welfare, THRF also acts as a watchdog for the country’s health care system.“We have to look at the issues from different perspectives,” says Lin, “and work together to figure out how to educate the public and make the system more effective.”Aging populationAs of March 2018, Taiwan has officially crossed the “aged society” threshold – which World Health Organization (WHO) guidelines define as a society in which over 14 percent of the population is aged 65 or older.Taiwan is currently on track to become a “super-aged society” in 2026, or a society in which one out of five people is 65 or older.Overworked, underpaidSo how does Taiwan continue to lift its health care standards despite the tight purse strings?“At the huge expense of health professionals,” argues Chiang Kuan-yu (姜冠宇) of the Taiwan Medical Alliance for Labor Justice and Patient Safety (TMAL; 醫勞盟). Founded in 2012 by a group of physicians and nurses across Taiwan, TMAL has been plugging for all physicians to be covered under the Labor Standards Act (LSA, 勞動基準法) since its early years.“We are tired and burnt out,” says Chiang.In 2016, resident doctors clocked an average of 80 to 100 hours a week. Neurosurgery residents’ duty hours topped the chart at an average of 90.9 hours, followed by doctors in orthopedics, surgery, obstetrics, neurology and internal medicine.Doctors are falling ill or suffering from exhaustion due to occupational hazards, Chiang added. One high profile case in 2009 involved a former resident doctor who suffered a stroke and subsequent brain damage after working 84 hours a week for six months. After a lengthy three-year legal battle, his family was able to claim a retirement pension and compensation. However, the doctor’s mental capacity has regressed to that of a six-year-old…… “We don’t have statistics for the number of doctors who have left the country, but the situation is bad enough that MOHW [Ministry of Health and Welfare], at one point, considered banning young doctors from practicing overseas,” says Chiang.Taiwan’s health care system: The next 20 yearshttps://www.brookings.edu/opinions/taiwans-health-care-system-the-next-20-years/… Except for the first three years since implementation (1995-1998), annual growth in expenditures in Taiwan’s NHI had typically outstripped revenues. In the period 1996-2008, for example, NHI revenues increased at an annual rate of 4.43 percent while expenditures increased at an annual rate of 5.33 percent…… A main reason for NHI’s high performance is the ability of the government, as the single payer, to set and regulate fees, and impose a global budget system that caps total NHI expenditure. For 2015, for example, NHI expenditure is budgeted to increase 3 percent from its 2014 levels. The NHI Administration (NHIA), the government agency that administers the NHI under the Ministry of Health and Welfare (MOHW), wields near monopsonistic power as the single buyer of and payer for health care services including drugs vis a vis health care providers. This power enables the NHIA to control costs and provide Taiwan’s public with affordable health care services, in sharp contrast to the United States where private health insurers often have limited power to set fees, especially in markets dominated by large provider organizations…… While it is important to remove financial barriers to needed medical care, in the longer term the question of sustainability of the current generous copayment exemption policy must be raisedLet’s look at some sustainability issues in South Korea:First, we look at WHO rankings. Many people who discuss healthcare cite the WHO data without knowing where the information comes from or how it is generated. WHO methodology is biased toward “universal” healthcare systems.The Worst Study Ever?Exposing the scandalous methods behind an extraordinarily influential ‘World Heath Report'https://www.commentarymagazine.com/articles/the-worst-study-ever/… At its most egregious, the report abandoned the very pretense of assessing health care. WHO ranked the U.S. 42nd in life expectancy. In their book, The Business of Health, Robert L. Ohsfeldt and John E. Schneider of the University of Iowa demonstrated that this finding was a gross misrepresentation. WHO actually included immediate deaths from murder or fatal high-speed motor-vehicle accidents in their assessment, as if an ideal health-care system could turn back time to undo car crashes and prevent homicides. Ohsfeldt and Schneider did their own life-expectancy calculations using nations of the Organisation for Economic Co-operation and Development (OECD). With fatal car crashes and murders included, the U.S. ranked 19 out of 29 in life expectancy; with both removed, the U.S. had the world’s best life-expectancy numbers (see table above)…… What we have here is a prime example of the misuse of social science and the conversion of statistics from pseudo-data into propaganda. The basic principle, casually referred to as “garbage in, garbage out,” is widely accepted by all researchers as a cautionary dictum. To the authors of World Health Report 2000, it functioned as its opposite—a method to justify a preconceived agenda. The shame is that so many people, including leaders in whom we must repose our trust and whom we expect to make informed decisions based on the best and most complete data, made such blatant use of its patently false and overtly politicized claims.Scott W. Atlas is a senior fellow at the Hoover Institution and professor of radiology and chief of neuro-radiology at the Stanford University Medical Center.If we are to use a study that is biased towards “universal” healthcare systems, it would be important that a country’s “universal” healthcare system be ranked higher than the U.S. South Korea is ranked 21 spots lower than the U.S. Yikes! That does not instill confidence for sustainability.World Health Organization’s Ranking of the World’s Health Systemshttp://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/Health Care Reform in South Korea: Success or Failure?https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447690/… Everything went smoothly in both administration and financing in the first half of the 1990s. However, with the advent of the economic crisis of 1997 throughout southeast Asia, Korean NHI began to run a financial deficit. At the end of 1997, despite some Korean resistance, the International Monetary Fund (IMF) intervened in Korean financial affairs, causing a dramatic increase in the NHI’s deficit, which then grew each year until 2002….… THE FINANCIAL CRISIS IN KOREAN HEALTH CAREAfter 1996, Korean NHI began to develop significant deficits (Figure 1). From 1996 to the present, total health expenditures have exceeded total income. During the economic crisis of 1997, when the Korean economy was controlled by the IMF, NHI’s financial deficit grew worse. In addition, the financial structure of Korean NHI was disrupted by the separation of reimbursement for medical care and reimbursement for pharmaceutical services in July 2000. Although government continually raised the mandatory insurance premiums to make up for the deficit, many health policy experts predicted that increased governmental funding would not solve the problem.Let’s look at some sustainability issues in Nordic countries:‘Socialist’ Nordic Countries Are Actually Moving Toward Private Health Carehttps://www.dailysignal.com/2019/06/13/socialist-nordic-countries-are-actually-moving-toward-private-health-care/Never mind that these are not true socialist countries, but highly taxed market economies with large welfare states. That aside, they do offer a government-guaranteed health service that many in America wish to emulate.FinlandWhy is Finland’s healthcare system failing my family?https://www.theguardian.com/society/2016/feb/23/finland-health-system-failing-welfare-state-high-taxesImagine going to your nearest doctors’ surgery at 9am on a weekday with your sick six-year-old daughter because you cannot make an appointment over the phone. After your drive to another part of the city, you can’t simply book a time with the receptionist. There isn’t one. Instead, you must swipe your daughter’s national insurance card through a machine, which gives you a number. Then you and your feverish child simply sit and wait. Or rather, you stand, because the room is so crowded that people are sitting on the floor, on steps, or leaning against walls. The numbers come up on a screen every 10 minutes or so, in no particular order so you’ve no idea how long your wait will be as your daughter complains of feeling cold then hot and then cold again.By 10.45, another patient’s dad exclaims he’s been there since 8.15, he’s had enough, and he’s going to go to a private GP. “You used to just be able to make an appointment with a doctor!” he says angrily.You see, you are not even waiting to see a GP. You’re waiting to a see a nurse in order to justify to her how quickly your child needs to see a GP or whether she needs to see one at all. At 11.30, you give up and take your daughter to see a private doctor as well, forking out £50 for the privilege.This isn’t some nightmare vision of the NHS after 10 years of Tory cuts. This happened to me recently in a country I have moved to from Britain that is normally lauded as the shining example of a successful welfare state.Finland receives such a positive press in Britain. Its schools consistently have the best international student assessment results in the western world; there’s high social equality; all its teachers have master’s degrees. But it has one of the worst health services in Europe.Finland’s health service has been in a parlous state for decades and it is getting worse.According to an OECD report published in 2013, the Finnish health system is chronically underfunded. The Nordic nation of five million people spent only 7% of GDP on its public health system in 2012, compared with 8% in the UK. In 2012, the report found, 80% of the Finnish population had to wait more than two weeks to see a GP. Finland’s high taxes go on education and daycare…… In Helsinki there are reports of huge queues at health centres (GP surgeries), waits for appointments of many weeks, and greater and greater demands with less and less funding. In south-eastern Finland it takes about a month to see a GP. Back in December 2013, it was reported that Finns were increasingly using private doctors in neighbouring Estonia to save time and money.I live in Oulu, Finland’s northern technology hub, famed for its annual Air Guitar Festival. Jani Saarinen (not his real name), an Oulu doctor in his 30s, who has worked in both the state and private sectors in different parts of the country, explained to me that the municipal health system was plagued by “cost pressures” and “long waiting times”.“There used to be an outsourced health centre in Oulu, so it was private, but it was the public service that the city offered,” says Saarinen. “Using a different system from the municipality, they managed to get waiting times down to two weeks and see emergency appointments on the same day. Outsourcing was a much more efficient way of working, but it was closed down.”Saarinen explains that the system essentially forces people to go private or rely on friends who are doctors.Finland's cabinet quits over failure to deliver healthcare reformhttps://www.reuters.com/article/us-finland-government/finlands-cabinet-quits-over-failure-to-deliver-healthcare-reform-idUSKCN1QP0R6.. Healthcare systems across much of the developed world have come under increasing stress in recent years as treatment costs soar and people live longer, meaning fewer workers are supporting more pensioners.Nordic countries, where comprehensive welfare is the cornerstone of the social model, have been among the most affected. But reform has been controversial and, in Finland, plans to cut costs and boost efficiency have stalled for years.The 'dark side' of Finland's famous free health carehttps://www.cnn.com/2019/08/15/world/finland-health-care-intl/index.html… Of course, it's not all rosy. In March, the Finnish government resigned because it failed to get its health care reform through Parliament -- becoming the second government in a row to fail to do so.Finnish's decentralized health care system is often managed by local municipalities with populations ranging from hundreds of thousands of people to fewer than 100. And that decentralized nature is not only very expensive to maintain but also can produce vast disparities in the quality of care.Municipalities receive funding for health care services based on the size of the taxable population, which can make it more difficult to provide services in remote and larger areas -- where those services are also more expensive to begin with.In March, just after Juha Sipila's government resigned, the governor of the bank of Finland, Ollie Rehn, warned that reform remained urgent "from the point of view of fiscal sustainability."As the country's population ages and birth rates fall, the number of taxpayers paying into the system is diminishing—while the overall population is living longer and putting greater strain on resources. In 2018, the average single Finn faced a net average tax rate of 30%, compared to 23.8% in the United States….…"So if you think of sustainability, either we get more people to Finland or we have to cut the cost," he adds.To make Finland's health care system financially sustainable, one of the aims of the last government's reform proposal was to cut costs by centralizing services and introducing more private options. But centralization is proving tricky in a country that is sparsely populated in some areas, and where the health care system was designed to serve even the most remote parts of a country that stretches all the way up to the Arctic Circle…… "People outside of Finland tend to see only the good sides of the system," says Hiilamo."Normally, we show people the sunny side of the street, but there is a dark side of the street. And health care is on the dark side, and for many years we have had a problem."NorwayNorway: health system review.https://www.ncbi.nlm.nih.gov/pubmed/24434287Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments. The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. However, long waiting times for elective care continue to be a problem and are cause of dissatisfaction among the patients. The focus of health care reforms has seen shifts over the past four decades. During the 1970s the focus was on equality and increasing geographical access to health care services; during the 1980s reforms aimed at achieving cost containment and decentralizing health care services; during the 1990s the focus was on efficiency. Since the beginning of the millennium the emphasis has been given to structural changes in the delivery and organization of health care and to policies intended to empower patients and users. The past few years have seen efforts to improve coordination between health care providers, as well as an increased attention towards quality of care and patient safety issues.Illusions of Paradise? Health Inequalities in Norwayhttps://www.europenowjournal.org/2016/10/31/illusions-of-paradise-health-inequalities-in-norway/How can inequalities in health possibly exist in such a society? For many years, it was believed that health inequalities could not exist in the most egalitarian societies. At least, that is what we thought in Norway. We did not even bother to collect information on educational attainment in our health surveys. When the Black Report became available to us, revealing substantial health inequalities in the United Kingdom, which shared many of our principles related to the national health system (actually, we copied and pasted this system), we started to question whether health inequalities could exist in our society as well. But the real shock would come later: Health inequalities really emerged as a topic in the Norwegian public debate in the aftermath of a cross-country study published in The Lancet in 1997. The study documented the existence of considerable socio-economic health inequalities, above all in Norway and other Scandinavian countries.Health Care Around the World: Norwayhttps://www.healthcare-economist.com/2008/04/18/health-care-around-the-world-norway/… Waiting Times. There are significant waiting times for many procedures. Many Norwegians go abroad for medical treatments. The average weight for a hip replacement is more than 4 months. “Approximately 23 percent of all patients referred for hospital admission have to wait longer than three months for admission.” Also, care can be denied if it is not deemed to be cost-effective.Let’s look at some sustainability issues in SwedenPerspectives on the European Health Care Systems: Some Lessons for America… A View from SwedenJohan Hjertqvist… Changing Mindsets in EuropeAll of the above factors will influence the future of health care in Sweden and many other countries in Europe. It can safely be said that the old welfare state is on the run. There is word from all sides that confusion reigns. Conflicts have emerged with trade unions as signs of future changes and present realities confront old thinking about pensions, health care, and the labor market. A new brand of welfare society is emerging, leaving the traditional European welfare state behind. In Sweden, the Social Democrat government is beginning to accept this development as a tool to engender public efficiency, improve the quality of services, and meet the expectations of the middle class -- if not officially in party manifestos, in reality in its response to changes.Last year, the Swedish Parliament passed a bill welcoming private providers in primary care and nearly all other kinds of health care services with the exception of emergency care.What's most important is for Europe to change its perspective regarding the economics of health care. Traditionally, European politicians frown on any move toward the free market and declare that health care must be strictly rationed. They are afraid of over-consumption. They're afraid of new expensive drug therapies.From the perspective of most European governments, a successful year is one in which there was a zero increase in health care costs. Very seldom do these politicians relate costs with outcome, as any business would.The service-delivery market reform in Stockholm builds on a purchaser-provider relationship. All 2,200 producers in the system -- public and privately owned -- are paid by the same mechanism, which rewards productivity. (Even if Sweden officially denounces every American influence, many of the technical aspects of this system, such as the payment structure, have been imported from the United States.)As a result of this competition and the number of private service providers, services have increased dramatically in the Stockholm area while long waiting lists continue to plague health care in most other parts of Sweden. In fact, there is a direct correlation between a monopoly of old-style health care and long waiting lists. Outside the metropolitan region, patients must wait for up to one year for cataract surgery and two years for hip surgery.The Truth About SwedenCarehttps://mises.org/library/truth-about-swedencare… It is impossible to put a number on it, but it is obvious that the level of energy in the medical professions in Sweden is low compared to America. It can be seen on several levels, from doctors and even down to students. An American medical student and friend of mine spent a year at a major Swedish hospital. He was shocked when he realized that students never spent any of their spare time in the operating room; there was no drive to become the best. There are of course enthusiasts who love their work regardless, and do a fantastic job, but the system is not conducive to this attitude.Planning always fails. The planners come to realize that the market is superior but they will not back off. Rather they will try to mimic a market, using trendy techniques such as “New Public Management,” voucher systems, or healthcare exchanges. The results of these solutions are usually even more disastrous than outright planning. In order to work, they will have to reduce every medical condition to a code, every patient to an ID number, and every procedure to planned (arbitrary) cost and income numbers.It was recently revealed in one of the major newspapers that doctors were told to prioritize patients based on their value as future taxpayers. Old people naturally have a low future-taxpayer-value, so they naturally became low priority in the machine and less likely to receive proper treatment. In a private healthcare system you can make your own priorities, you can for example sell your house and spend the proceeds on becoming well. In a socialized system somebody else sets the priorities. …… When I moved to the U.S., our family health insurance took three months to kick in. One of my family members broke a leg in this period. We found a “five-minute clinic” half an hour away, had the leg X-rayed, straightened and casted, with no waiting time — all for $200 cash. That kind of service is non-existent in Sweden. It is an example of how a market, not yet totally destroyed by the state, can create affordable and high quality services.The reason American insurance-based healthcare is so expensive is that it is heavily regulated and legally connected to the equally-regulated insurance industry. Both are well protected from competition by regulation. Obamacare will make them even more expensive, bureaucratic, and inaccessible. The way to fix U.S. healthcare is by excising the central planners and regulators from it, not by implanting droves more of them.I have seen (and lived in) the future of American health care, and it does not work.Crisis situation at Swedish hospitalshttps://www.eurotopics.net/en/178879/crisis-situation-at-swedish-hospitalsSo Long, Swedish Welfare State?https://foreignpolicy.com/2018/09/05/so-long-swedish-welfare-state/… Sweden’s welfare problems affect people’s daily lives. Average earners in Sweden pay half their income in direct and indirect taxes. Yet, the famous Swedish welfare state is plagued by difficulties in accessing health care. Some individuals and companies are therefore turning toward private health insurance. At the end of 2017, 643,000 individuals in Sweden were fully covered by private health insurance. This is an increase of over half a million users compared to 2000.Swedes enjoy world-class healthcare—when they get ithttps://medicalxpress.com/news/2018-09-swedes-world-class-healthcarewhen.htmlAsia Nader didn't know whether to worry more about being diagnosed with a hole in her heart at the age of 21, or having to wait a year for Swedish doctors to fix it. …… Swedish law stipulates patients should wait no more than 90 days to undergo surgery or see a specialist. Yet every third patient waits longer, according to government figures.Patients must also see a general practitioner within seven days, the second-longest deadline in Europe after Portugal (15 days).Yet waiting times vary dramatically across Sweden's 21 counties responsible for financing hospitals.One dental patient in central Dalarna county told AFP six months passed before his check-up, while emergency room queues at Stockholm's largest hospitals average four hours.The 2016 nationwide median wait for prostate cancer surgery was 120 days, but 271 days in the northern county of Vasterbotten, official figures show.Let’s look at some sustainability issues in DenmarkFree Healthcare in Denmark: My First-Hand Experiencehttp://www.sageandsimple.com/2016/02/free-healthcare-in-denmark/First, let’s get one thing straight. Free healthcare in Denmark is not free. Danish healthcare is an 8% line item deduction of gross pay. Free healthcare in Denmark does not cover physicals, vision or dental care, and mental health services are only partially covered and only in certain situations. Prescriptions are full price until a personal annual threshold is reached, then they are progressively discounted as the spend increases. My first asthma prescription this year cost me around $200, and I paid $35 just yesterday for prescription strength B-12 tablets. In nearly six years, I’ve never had my total yearly prescription cost in Denmark come in below that of my $10 – $20 US co-pay.I pay roughly six times as much for my free healthcare in Denmark as I did for my employer-sponsored plan in the US, and it covers far less. But that’s not the point of this post. The point of this post is to tell you what it’s like to live with free healthcare in Denmark.A DANISH STUDENT’S PERSPECTIVES ON HEALTHCAREhttps://prospectjournal.org/2013/12/02/a-students-perspectives-on-danish-healthcare/.. Peter then described some of the issues that have plagued the healthcare system in Denmark for the past couple of years, and what the government has done to combat these problems. Peter argued that the worst part of having a centralized healthcare system is that treatment is often inaccessible in rural parts of Denmark, as all hospitals and most outpatient clinics are located in cities or suburban areas. People often have to drive up to 50 miles for a weekly checkup, or even further for access to surgical treatments. To counteract this problem, the Danish government has been focusing on developing more outpatient clinics and on increasing the number of emergency care centers in rural areas. While not all treatment types are available for patients at these outpatient clinics, patients don’t have to encounter long ambulance lines and waits at the emergency rooms.One of the unsolved issues that still remains for Danish citizens’ concerns the quality of care at these mega-hospitals. One major issue is overcrowding at hospitals, creating long waits for procedures in cases that are not immediately life threatening. Hospitals are usually fully booked, with patients sharing rooms and being rushed out as soon as possible. Additionally, there are long waiting lines for surgeries, often more than a month, and patients are forced to cope with their problems while they wait. However, Peter claims that this trend is increasingly accepted as the norm, as people understand that it is impossible to have excellent, individualized care for every single citizen. No matter the socio-economic status of the patients, the facility and doctors that treat them are the same. This equality is what drives the system effectively and allows it to work with minimal issues.Why Denmark isn't the utopian fantasy it is made out to behttps://www.independent.co.uk/news/world/europe/why-denmark-isnt-the-utopian-fantasy-it-is-made-out-to-be-a6720701.html… Politicians in the U.S. like Bernie Sanders praise Denmark for its relative income equality, its free universities, parental leave, subsidized childcare, and national health system. That all sounds pretty good, right?It is fantastic in theory, except that, in Denmark, the quality of the free education and health care is substandard: They are way down on the PISA [Programme for International Student Assessment] educational rankings, have the lowest life expectancy in the region, and the highest rates of death from cancer. And there is broad consensus that the economic model of a public sector and welfare state on this scale is unsustainable. The Danes’ dirty secret is that its public sector has been propped up by — now dwindling — oil revenues. In Norway’s case, of course, it’s no secret. …… One thing that’s often glossed over among outsiders is the extraordinarily high tax level, which is high for the middle class as well as the wealthy. Do Danes think that they get their money’s worth in social services? Do you?Denmark has the highest direct and indirect taxes in the world, and you don’t need to be a high earner to make it into the top tax bracket of 56% (to which you must add 25% value-added tax, the highest energy taxes in the world, car import duty of 180%, and so on). How the money is spent is kept deliberately opaque by the authorities. Danes do tend to feel that they get value for money, but we should not overlook the fact that the majority of Danes either work for, or receive benefits from, the welfare state. …The Danish Health Care System: An Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT analysis)The three major challenges are interrelated: 1. Demography (aging, more chronically ill), 2. The manpower situation (a declining workforce), and 3. Fiscal sustainability in view of not only the demographic development but also the welfare effect of a steadily increasing income level: When gross domestic product, GDP, increases by one percent, health expenditures increase by 1.2 - 1.3%, hence gradually capturing a greater share of GDP. …… Be careful with the interpretation of the cost‐benefit ratios – they are tricky compared to the QALY-ratios commonly used in health economics. They cannot be equated to savings‘ in the health care system. Consider, for example, Solution 2 in the table below.The cost‐benefit ratio is 1:26. This means that individual willingness to pay for an additional life year leads to this result (in accordance with the thinking behind cost‐benefit analysis). However, viewed from the health care system‘s perspective, the solution is cost neutral‘ according to a health economic evaluation of the experiment. For practical purposes it is this result that is of interest. However, if one wants to put a monetary value on the added life time, this can be done by applying an estimate of the individual‘s willingness to pay for (a fraction of) an extra life year. It should be obvious that this cannot be interpreted as savings, but rather is the monetary value of additional life time. It should be noted that the individual willingness to pay may differ from the political willingness to pay for an added life year – and resource allocation in health care essentially is political. …… Within the next two decades publicly financed health expenditures will increase with between an (unlikely) 20% and a more likely 35% in real terms. To this should be added an increase in social expenditures of app. 13% under the assumption of 0.3% additional growth. …… Slow introduction of new treatments?In many areas Denmark have not been on the forefront of implementing new technologies and treatments. The slow adoption of new technologies and drugs may be due to the before mentioned successful cost containment but this is not the only reason. The awareness and capability to implement new technologies is another reason as in general what determines diffusion of new treatments where economics is only part of the explanatory variables.Let’s look at some sustainability issues in the United Kingdom:The NHS - Britain's national religion - doesn’t have a prayerhttp://www.telegraph.co.uk/news/nhs/10959391/The-NHS-Britains-national-religion-doesnt-have-a-prayer.html10 charts that show why the NHS is in troublehttp://www.bbc.com/news/health-38887694Rationing of NHS services ‘leaving patients in pain and distress’, says new reporthttps://www.independent.co.uk/news/uk/politics/nhs-rationing-the-kings-fund-report-patients-pain-distress-cuts-district-nurses-sexual-health-a7628101.htmlN.H.S. Overwhelmed in Britain, Leaving Patients to Waithttps://www.nytimes.com/2018/01/03/world/europe/uk-national-health-service.html?mtrref=search.myway.com&gwh=C0C462EEA64AA2936BD246A5900E0756&gwt=payUS vs UK: Allied Healthcare at Home and Abroadhttps://www.aimseducation.edu/blog/us-vs-uk-allied-healthcare/Availability of CareGetting care when you need it is universally important. Speedy care in the emergency room is essential. The UK healthcare system target is to have a patient wait time of four hours or less for 95% of its patients.Currently, they’ve achieved this wait time for approximately 85% of emergency care patients. By comparison, 95% of visitors to the ER are seen within three hours of arrival. The average wait time for emergency and accident care in a US emergency room is 58 minutes.Patients Are “Dying in Corridors" of Britain’s Socialised Health Systemhttps://mises.org/wire/patients-are-%E2%80%9Cdying-corridors-britain%E2%80%99s-socialised-health-systemHealth Check: The NHS and Market Reformshttps://iea.org.uk/publications/research/health-check-the-nhs-and-market-reformsThe recent Commonwealth Fund study, which ranked the NHS well, has its merits, but it is structurally designed to favour an NHS style model of healthcare. The study’s limitations are perhaps best, albeit unintentionally, captured by The Guardian’s coverage of the report which stated: ‘The only serious black mark against the NHS was its poor record on keeping people alive.’Does Britain Have the World’s Best Health System? Only If You Ignore Outcomeshttps://mises.org/wire/does-britain-have-world%E2%80%99s-best-health-system-only-if-you-ignore-outcomes… How is it possible, then, that the NHS should have ranked so highly in this recent study by the influential Commonwealth Fund health think tank, despite all these major problems? The answer is in the study’s careful selection of the criteria used as metrics of success, in order to give the most weight to the few areas in which the NHS actually does succeed.The fraying edges of universal health carehttps://www.washingtontimes.com/news/2019/apr/10/universal-health-system-in-britain-collapsing-a-ha/If you’re wondering what Democrats have in mind when they tout “Medicare For All,” look no further than England. There are more reports of the U.K.’s National Health System’s collapse, this time featuring horror stories of rationing care for the elderly. Doctors are now sounding alarms bells that seniors with cataracts are going blind as they wait for surgical approval.Cancer waiting timeshttps://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/access-to-treatment/waiting-times-after-diagnosisBeing diagnosed with cancer can sometimes take a while. At times, just about everyone will have to wait to have tests or to get the results. Sometimes people have to wait for appointments to begin their treatment. This can be frustrating and difficult to cope with.Within the UK, there are targets for maximum waiting times to start treatment. The different UK nations have their own targets around referral for suspected cancer and waiting times to a diagnosis.Urgent referral for suspected cancerYour GP might arrange for you to see a hospital doctor (specialist) urgently because you have symptoms that could be due to cancer. This can be very worrying, but it’s important to know that 9 in every 10 people (90%) referred this way will not be diagnosed with cancer.In England, an urgent referral means that you should see a specialist within 2 weeks. In Northern Ireland, the 2 week wait ONLY applies if you are referred for suspected breast cancer.This 2 week time limit does not exist in Scotland and Wales. But wherever you live, you are seen as quickly as possible.These examples are what happens within “single-payer” healthcare systems:Who is Charlie Gard, what is the disease he suffered from and what happened in the court case?The story of Charlie GardNHS doctors determined that Charlie Gard had a rare and incurable disease. The problem with that diagnosis is that medicine has not advanced to the point of absolute surety.List of Brain Dead Patients Who've RecoveredHospital Doctors Misdiagnose Woman as Brain DeadMan Diagnosed as Brain Dead RecoversOne-in-five ‘vegetative’ patients is misdiagnosed: StudyDoctors Diagnose Comatose Patient As Brain Dead And Refuse To Treat Her — They Were WrongMother's joy as her 'brain dead' son makes a miracle recoveryMrs Reid, married to David, was told by doctors his brain had 'completely died' and he spent a further nine months on the hospital's Paul ward.Signs of LifeEven if we concede that the doctors were 99.99% sure of their diagnosis, what happened next was a Kafkaesque, totalitarian nightmare. Bureaucrats within the EU refused to let the Gard family use THEIR OWN MONEY to do everything they could to save their child. “Single-payer” healthcare systems refuse funding for cases they deem economically unfeasible. This is no different from private insurance doing the same. But to deny a citizen the right to use their own money is dictatorial.The case of Alfie Evans followed with the same results. What may have saved Oliver Cameron were those two previous cases. Because there was now a loud enough outcry from the populace to at least let the family try to save their child. The problem was that doctors within the NHS lacked the innovative technical expertise to perform the surgery. Oliver was allowed travel to the U.S. NHS doctors accompanied him so that they could learn the procedure from U.S. doctors:Baby Oliver saved in U.S. after UK doctors said his heart couldn't be fixedNHS to fund baby's US heart operationThe NHS said it was also discussing whether a UK surgeon might accompany Oliver to Boston to learn from the surgeons in the US so the innovative surgery could "potentially be offered in the UK in future".The UK Finally Allowed a Sick Baby to Seek Treatment in the US — Now the Baby Is Tumor-FreeHealthcare systems in Europe are not the panacea many supporters of government run systems claim:Health Care Reform: The European Experiencehttps://www.ncbi.nlm.nih.gov/books/NBK231468/The fear of liability for malpractice and related defensive medicine did not significantly contribute to the introduction of quality assurance mechanisms in Europe, but partly explains the substantial lag in implementation of quality monitoring and improvement compared with that in the United States. Attitudes regarding advances in medicine in particular and science in general are ambivalent, notably when human dignity is at stake. Admiration and zero-risk expectations are mixed with accusations of pointless therapeutic assault. This in turn explains the reluctance of health professionals to expose their decision-making to peer review and scrutiny by members of the public…… Europe's human resources for health care are plagued with a series of problems. An unbalanced supply of various categories of health care workers is compounded by geographic and functional maldistributions. There is a marked oversupply of physicians, dentists, and pharmacists in most countries. Graduates compete for limited employment opportunities in health facilities and programs in the public and private sectors. Increasing numbers of young doctors join the ranks of Europeans who receive unemployment benefits. Others engage in various forms of “alternative medicine,” which are often questionable practices. Growing numbers enlist in international aid organizations and disaster areas, either natural or those caused by people, which span the globe…… Nursing in Europe is slipping into a deep crisis. A severe and growing shortage of nurses is starting to have a negative impact on patient care. Because of the demographic “degreening” of the population, there are fewer potential candidates for nursing and allied health professions. Cost containment and related shifts of inpatient care to alternate sites for care have contributed to a greater dependency on nurses to care for sicker patients. “Burnout” among health care workers has reached unheard-of proportions. Financial compensation is gradually being perceived as grossly unfair and insulting.Strikes and “work-by-rule” actions are frequent and, in turn, contribute to alarming declines in recruitment. During the last 4 years, Belgium, France, The Netherlands, and the United Kingdom have repeatedly been confronted with outbursts of anger from demoralized nurses, ambulance drivers, and even junior doctors.In the U.S, Medicare is an example of a “single-payer” system:$1.1T: CMS Sets Record for Annual Spending by a Federal AgencyThe Centers for Medicare and Medicaid Services (CMS) spent over $1.113 trillion in fiscal year 2013 — setting a record for the most money spent by a federal agency or department in a single year.Social Security and Medicare Funds Face Insolvency, Report FindsAn annual government report on the status of the programs painted a dire portrait of their solvency that will saddle the United States with more debt at a time when the economy is starting to cool and taxes have just been cut.According to the report, the cost of Social Security, the federal retirement program, will exceed its income in 2020 for the first time since 1982. The program’s reserve fund is projected to be depleted in 16 years, at which time recipients will get smaller payments than they are scheduled to receive if Congress does not act.Meanwhile, Medicare’s hospital insurance fund is expected to be depleted in 2026 — the same date that was projected a year ago. At that point, doctors, hospitals and nursing homes would not receive their full compensation from the program and patients could face more of the financial burden.Controlling costs through raising taxes:Reductions in a family’s ability to purchase goods and services, and accumulate savings, has many ripple effects for quality of life, as mentioned in the OECD “Better Life Index.” What is compassionate about reducing a family’s ability to provide costly education for children who do not have grades that allow eligibility for scholarships or government financed education? Because most of the “free education” systems of Europe are only free to those whose grades are high enough. What is compassionate about reducing a family’s ability to provide their children educational experiences through travel? What is compassionate about reducing a family’s ability to provide their children with better housing choices? What is compassionate about reducing a family’s ability to provide their children with better nutritional choices? What is compassionate about reducing an individual’s ability for a retirement that provides more choices?Controlling costs through reduction in services (rationing):Despite false claims to the contrary, medical rationing is a part of reducing costs in government run systems. Quality care is simply denied to the elderly and people whose illness has been deemed too costly by government bureaucrats.Controlling costs through innovation reduction:As has been shown, the U.S., having more vestiges of a free market than most countries, supplies the lion’s share of medical research and innovation from which the rest of the world benefits. As has also been shown, that percentage has decreased dramatically since the inception of the AHCA. Further government control of the U.S. healthcare system will reduce the ability of the U.S. to provide medical innovation. This is a Luddite approach. I find it bizarre that people demand rapid technological innovation for their phones but think nothing of slowing or stagnating technological innovation for healthcare.Europe’s health systems on life supportFacts About European HealthcareAs the population is increasing in Europe, the health care costs are also increasing, but the quality of the service is degrading day by day. The challenge in front of the government is how to strike a balance between increasing population and facilities providing health care. To add to the agony, Europe has a majority of aging population, which definitely needs good health care services and benefits. Health care industry in Europe faces major criticism. It is constantly compared to other developed countries.Why single payer health care is a terrible option… Massive waiting lists and dangerous delays for medical appointments… Life-threatening delays for treatment, even for patients requiring urgent cancer treatment or critical brain surgery… Delayed availability of life-saving drugs… Worse availability of screening tests… Significantly worse outcomes from serious diseasesIt might be said that the bottom line about a health care system is the data on outcomes from treatable illnesses. To no one's surprise, the consequences of delayed access to medications, diagnosis and treatment are significantly worse outcomes from virtually all serious diseases, including cancer, heart disease, stroke, high blood pressure and diabetes compared to Americans.And while some studies have noted that Canadians and Germans, for example, have longer life expectancies and lower infant mortality rates than Americans do, they are misleading. Those statistics are extremely coarse and depend on a wide array of complex inputs having little to do with health care, including differences in lifestyle (smoking, obesity, hygiene, safe sex), population heterogeneity, environmental conditions, incidence of suicide and homicide and even differences in what counts as a live birth.

“Being an amputee myself with functional lower limb prosthetics, I can say that the device enable me to function normally. My prosthetics brought back my confidence and self esteem to participate in mainstream activities of the society, thus changing my outlook in life to positive to more positive. Definitely, my prosthetics had an impact on my present status or the quality of life I am enjoying now because I basically perform all the task that is assigned to me which at the end the day results to quality output and good pay.” Johnny “Coming from a country where there is not much awareness and resources for dealing with post-spinal cord injured victims, my return home was indeed an enormous challenge. Living in a house that was inaccessible, members of my family have had to persevere with daily lifting me up and down the house. Physiotherapy had become a crucial necessity and as a result of the continuous costs incurred, my mother took up the task to administer physiotherapy as well as stand in as my caretaker. During my rehabilitation process, getting admitted for treatment during times of illness or to use physiotherapy facilities was close to impossible as a result of the overwhelming numbers on the waiting list. My rehabilitation period despite challenging was a humbling moment of my life and a continuous process that I face until today. I have learned disability is not inability and a strong mentality and great attitude have been very important!” Casey “Families find themselves in difficulty after a member of the family has a stroke. I consider myself a stroke survivor but my family are stroke victims. I have been fortunate and have been able to return to work, but I have had to battle all the way. We do not get the help we need, services are so variable and there is not enough speech and language therapy and physiotherapy. After my stroke I had to learn to do everything again, including swallowing and to learn to talk. The first thing that came back to me with my speech was swearing, my first sentence had four expletives in it, but I am told that was normal.” Linda “If you don’t have a proper wheelchair, that is when you really feel that you are disabled. But if you have a proper wheelchair, which meets your needs and suits you, you can forget about your disability.” Faustina 4 Rehabilitation 95 Rehabilitation has long lacked a unifying conceptual framework (1). Historically, the term has described a range of responses to disability, from interventions to improve body function to more comprehensive measures designed to promote inclusion (see Box 4.1). The International Classification of Functioning, Disability and Health (ICF) provides a framework that can be used for all aspects of rehabilitation (11–14). For some people with disabilities, rehabilitation is essential to being able to participate in education, the labour market, and civic life. Rehabilitation is always voluntary, and some individuals may require support with decision-making about rehabilitation choices. In all cases rehabilitation should help to empower a person with a disability and his or her family. Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) calls for: “… appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. The Article further calls on countries to organize, strengthen, and extend comprehensive rehabilitation services and programmes, which should begin as early as possible, based on multidisciplinary assessment of individual needs and strengths, and including the provision of assistive devices and technologies. This chapter examines some typical rehabilitation measures, the need and unmet need for rehabilitation, barriers to accessing rehabilitation, and ways in which these barriers can be addressed. Understanding rehabilitation Rehabilitation measures and outcomes Rehabilitation measures target body functions and structures, activities and participation, environmental factors, and personal factors. They contribute 96 World report on disability Box 4.1. What is rehabilitation? This Report defines rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”. A distinction is sometimes made between habilitation, which aims to help those who acquire disabilities congenitally or early in life to develop maximal functioning; and rehabilitation, where those who have experienced a loss in function are assisted to regain maximal functioning (2). In this chapter the term “rehabilitation” covers both types of intervention. Although the concept of rehabilitation is broad, not everything to do with disability can be included in the term. Rehabilitation targets improvements in individual functioning – say, by improving a person’s ability to eat and drink independently. Rehabilitation also includes making changes to the individual’s environment – for example, by installing a toilet handrail. But barrier removal initiatives at societal level, such as fitting a ramp to a public building, are not considered rehabilitation in this Report. Rehabilitation reduces the impact of a broad range of health conditions. Typically rehabilitation occurs for a specific period of time, but can involve single or multiple interventions delivered by an individual or a team of rehabilitation workers, and can be needed from the acute or initial phase immediately following recognition of a health condition through to post-acute and maintenance phases. Rehabilitation involves identification of a person’s problems and needs, relating the problems to relevant factors of the person and the environment, defining rehabilitation goals, planning and implementing the measures, and assessing the effects (see figure below). Educating people with disabilities is essential for developing knowledge and skills for self-help, care, management, and decision-making. People with disabilities and their families experience better health and functioning when they are partners in rehabilitation (3–9). The rehabilitation process Identify problems and needs Assess eects Relate problems to modiable and limiting factors Dene target problems and target mediators, select appropriate measures Plan, implement, and coordinate interventions Source: A modified version of the Rehabilitation Cycle from (10). Rehabilitation – provided along a continuum of care ranging from hospital care to rehabilitation in the community (12) – can improve health outcomes, reduce costs by shortening hospital stays (15–17), reduce disability, and improve quality of life (18–21). Rehabilitation need not be expensive. Rehabilitation is cross-sectoral and may be carried out by health professionals in conjunction with specialists in education, employment, social welfare, and other fields. In resource-poor contexts it may involve non-specialist workers – for example, community-based rehabilitation workers in addition to family, friends, and community groups. Rehabilitation that begins early produces better functional outcomes for almost all health conditions associated with disability (18–30). The effectiveness of early intervention is particularly marked for children with, or at risk of, developmental delays (27, 28, 31, 32), and has been proven to increase educational and developmental gains (4, 27). 97 Chapter 4 Rehabilitation to a person achieving and maintaining optimal functioning in interaction with their environment, using the following broad outcomes: ■ prevention of the loss of function ■ slowing the rate of loss of function ■ improvement or restoration of function ■ compensation for lost function ■ maintenance of current function. Rehabilitation outcomes are the benefits and changes in the functioning of an individual over time that are attributable to a single measure or set of measures (33). Traditionally, rehabilitation outcome measures have focused on the individual’s impairment level. More recently, outcomes measurement has been extended to include individual activity and participation outcomes (34, 35). Measurements of activity and participation outcomes assess the individual’s performance across a range of areas – including communication, mobility, self-care, education, work and employment, and quality of life. Activity and participation outcomes may also be measured for programmes. Examples include the number of people who remain in or return to their home or community, independent living rates, return-to-work rates, and hours spent in leisure and recreational pursuits. Rehabilitation outcomes may also be measured through changes in resource use – for example, reducing the hours needed each week for support and assistance services (36). The following examples illustrate different rehabilitation measures: ■ A middle-aged woman with advanced diabetes. Rehabilitation might include assistance to regain strength following her hospitalization for diabetic coma, the provision of a prosthesis and gait training after a limb amputation, and the provision of screen-reader software to enable her to continue her job as an accountant after sustaining loss of vision. ■ A young man with schizophrenia. The man may have trouble with routine daily tasks, such as working, living independently, and maintaining relationships. Rehabilitation might mean drug treatment, education of patients and families, and psychological support via outpatient care, communitybased rehabilitation, or participation in a support group. ■ A child who is deafblind. Parents, teachers, physical and occupational therapists, and other orientation and mobility specialists need to work together to plan accessible and stimulating spaces to encourage development. Caregivers will need to work with the child to develop appropriate touch and sign communication methods. Individualized education with careful assessment will help learning and reduce the child’s isolation. Limitations and restrictions for a child with cerebral palsy, and possible rehabilitation measures, outcomes, and barriers are described in Table 4.1. Rehabilitation teams and specific disciplines may work across categories. Rehabilitation measures in this chapter are broadly divided into three categories: ■ rehabilitation medicine ■ therapy ■ assistive technologies. Rehabilitation medicine Rehabilitation medicine is concerned with improving functioning through the diagnosis and treatment of health conditions, reducing impairments, and preventing or treating complications (12, 37). Doctors with specific expertise in medical rehabilitation are referred to as physiatrists, rehabilitation doctors, or physical and rehabilitation specialists (37). Medical specialists such as psychiatrists, paediatricians, geriatricians, ophthalmologists, neurosurgeons, and orthopaedic surgeons can be involved in rehabilitation medicine, as can a broad range of therapists. In many parts of the world where specialists in rehabilitation medicine are not available, services may be provided by doctors and therapists (see Box 4.2). 98 World report on disability Table 4.1. Child with cerebral palsy and rehabilitation Difficulties faced by the child Rehabilitation measures Possible outcomes Potential barriers People involved in the measures Unable to care for self → Therapy – Training for the child on different ways to complete the task. – Assessment and provision of equipment, training parents to lift, carry, move, feed and otherwise care for the child with cerebral palsy. – Teaching parents and family members to use and maintain equipment. – Provision of information and support for parents and family. – Counselling the family. → Assistive technology – Provision of equipment for maintaining postures and self-care, playing and interaction, such as sitting or standing (when age-appropriate) – Parents better able to care for their child and be proactive. – Reduced likelihood of compromised development, deformities, and contractures. – Reduced likelihood of respiratory infections. – Access to support groups or peer support. – Coping with stress and other psychological demands. – Better posture, respiration, feeding, speech, and physical activity performance. – Timeliness of interventions. – Availability of family and support. – Financial capacity to pay for services and equipment. – Availability of well trained staff. – Attitudes and understanding of others involved in the rehabilitation measure. – Physical access to home environment, community, equipment, assistive devices and services. – The child, parents, siblings, and extended family. – Depending on the setting and resources available: physiotherapists, occupational therapists, speech and language therapists, orthotists and technicians, doctors, psychologists, social workers, community-based rehabilitation workers, schoolteachers, teaching assistants. Difficulty walking → Rehabilitation medicine – Botulinum toxin injections. – Surgical treatment of contractures and deformities (therapy interventions usually complement these medical interventions). → Therapy – Therapy, exercises and targeted play activities to train effective movements. → Assistive technology – Orthotics, wheelchair or other equipment. – Decreased muscle tone, better biomechanics of walking. – Decrease in self-reported limitations. – Increased participation in education and social life. – Access to post-acute rehabilitation. – Doctor, parents, therapist, orthotist. Communication difficulties → Therapy – Audiology. – Activities for language development. – Conversation skills. – Training conversation partners. → Assistive technology – Training to use and maintain aids and equipment, which may include hearing aids and augmentative and alternative communication devices. – Better communication skills. – Participation in social, educational and occupational life opportunities. – Improved relationships with family, friends, and the wider community. – Reduced risk of distress, educational failure, and antisocial behaviour. – Availability of speech language therapists. – Social and economic status of the family. – Costs of purchasing and maintaining devices. – Parents, speech and language pathologist/therapist, communication disorders assistant, community-based rehabilitation worker, teachers, and assistants. Note: The table shows some potential rehabilitation measures for a child with cerebral palsy, possible outcomes, potential barriers, and the various people involved in care. 99 Chapter 4 Rehabilitation Box 4.2. Clubfoot treatment in Uganda Clubfoot, a congenital deformity involving one or both feet, is commonly neglected in low and middle-income countries. If left untreated, clubfoot can result in physical deformity, pain in the feet, and impaired mobility, all of which can limit community participation, including access to education. In Uganda the incidence of clubfoot is 1.2 per 1000 live births. The condition is usually not diagnosed, or if diagnosed it is neglected because conventional invasive surgery treatment is not possible with the resources available (38). The Ponseti clubfoot treatment involving manipulation, casting, Achilles tenotomy, and fitting of foot braces has proven to result in a high rate of painless, functional feet (Ponseti, 1996). The benefits of this approach for developing countries are low cost, high effectiveness, and the possibility to train service providers other than medical doctors to perform the treatment. The results of a clubfoot project in Malawi, where the treatment was conducted by trained orthopaedic clinical officers, showed that initial good correction was achieved in 98% of cases (39). The Ugandan Sustainable Clubfoot Care Project – a collaborative partnership between the Ugandan Ministry of Health, CBM International, and Ugandan and Canadian universities – is funded by the Canadian International Development Agency. Its purpose is to make sustainable, universal, effective, and safe treatment of clubfoot in Uganda using the Ponseti method. It built on the existing health care and education sectors and has incorporated research to inform the project’s activities and evaluate outcomes. The project has resulted in many positive achievements in two years including: ■ The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for clubfoot in all its hospitals. ■ 36% of the country’s public hospitals have built the capacity to do the Ponseti procedure and are using the method. ■ 798 health-care professionals received training to identify and treat clubfoot. ■ Teaching modules on clubfoot and the Ponseti method are being used in two medical and three paramedical schools. ■ 1152 students in various health disciplines received training in the Ponseti method. ■ 872 children with clubfoot received treatment, an estimated 31% of infants born with clubfoot during the sample period – very high, given that only 41% of all births occur in a health care centre. ■ Public awareness campaigns were implemented – including radio messages and distribution of posters and pamphlets to village health teams – to inform the general public that clubfoot is correctable. The project shows that clubfoot detection and treatment can quickly be incorporated into settings with few resources. The approach requires: ■ Screening infants at birth for foot deformity to detect the impairment. ■ Building the capacity of health-care professionals across the continuum of care, from community midwives screening for deformity, to NGO technicians making braces, and orthopaedic officers performing tenotomies. ■ Decentralizing clubfoot care services, including screening in the community, for example through communitybased rehabilitation workers, and treatment in local clinics, to address treatment adherence barriers. ■ Incorporating Ponseti method training into the education curricula of medical, nursing, paramedical, and infant health-care students. ■ Establishing mechanisms to address treatment adherence barriers including travel distance and costs. 100 World report on disability Rehabilitation medicine has shown positive outcomes, for example, in improving joint and limb function, pain management, wound healing, and psychosocial well-being (40–47). Therapy Therapy is concerned with restoring and compensating for the loss of functioning, and preventing or slowing deterioration in functioning in every area of a person’s life. Therapists and rehabilitation workers include occupational therapists, orthotists, physiotherapists, prosthetists, psychologists, rehabilitation and technical assistants, social workers, and speech and language therapists. Therapy measures include: ■ training, exercises, and compensatory strategies ■ education ■ support and counselling ■ modifications to the environment ■ provision of resources and assistive technology. Convincing evidence shows that some therapy measures improve rehabilitation outcomes (see Box 4.3). For example, exercise therapy in a broad range of health conditions – including cystic fibrosis, frailness in elderly people, Parkinson disease, stroke, osteoarthritis in the knee and hip, heart disease, and low back pain – has contributed to increased strength, endurance, and flexibility of joints. It can improve balance, posture, and range of motion or functional mobility, and reduce the risk of falls (49–51). Therapy interventions have also been found to be suitable for the long-term care of older persons to reduce disability (18). Some studies show that training in activities of daily living have positive outcomes for people with stroke (52). Box 4.3. Money well spent: The effectiveness and value of housing adaptations Public spending on housing adaptations for people with difficulties in functioning in the United Kingdom of Great Britain and Northern Ireland amounted to more than £220 million in 1995, and both the number of demands and unit costs are growing. A 2000 research study examined the effectiveness of adaptations in England and Wales, using interviews with recipients of major adaptations, postal questionnaires returned by recipients of minor adaptations, administrative records, and the views of visiting professionals. The main measure of “effectiveness” was the degree to which the problems experienced by the respondent before adaptation were overcome by the adaptation, without causing new problems. The study found that: ■ Minor adaptations (rails, ramps, over-bath showers, and door entry systems, for example) – most costing less than £500 – produced a range of lasting, positive consequences for virtually all recipients: 62% of respondents suggested they felt safer from the risk of accident, and 77% perceived a positive effect on their health. ■ Major adaptations (bathroom conversions, extensions, lifts, for example) in most cases had transformed people’s lives. Before adaptations, people used words like “prisoner”, “degraded”, and “afraid’ to describe their situations; following adaptations, they spoke of themselves as “independent”, “useful”, and “confident”. ■ Where major adaptations failed, it was typically because of weaknesses in the original specification. Adaptations for children sometimes failed to allow for the child’s growth, for example. In other cases, policies intended to save money resulted in major waste. Examples included extensions that were too small or too cold to use, and cheap but ineffective substitutes for proper bathing facilities. ■ The evidence from recipients suggests that successful adaptations keep people out of hospitals, reduce strain on carers, and promote social inclusion. ■ Benefits were most pronounced where careful consultation with users took place, where the needs of the whole family had been considered, and where the integrity of the home had been respected. Adaptations appear to be a highly effective use of public resources, justifying investment in health and rehabilitation resources. Further research is needed in diverse contexts and settings. Source (48). 101 Chapter 4 Rehabilitation Distance training was used in Bangladesh for mothers of children with cerebral palsy in an 18-month therapy programme: it promoted the development of physical and cognitive skills and improved motor skills in the children (53). Counselling, information, and training on adaptive methods, aids, and equipment have been effective for individuals with spinal cord injury and younger people with disabilities (54–56). Many rehabilitation measures help people with disabilities to return or continue to work, including adjusting the content or schedule of work, and making changes to equipment and the work environment (57, 58). Assistive technologies An assistive technology device can be defined as “any item, piece of equipment, or product, whether it is acquired commercially, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities” (59). Common examples of assistive devices are: ■ crutches, prostheses, orthoses, wheelchairs, and tricycles for people with mobility impairments; ■ hearing aids and cochlear implants for those with hearing impairments; ■ white canes, magnifiers, ocular devices, talking books, and software for screen magnification and reading for people with visual impairments; ■ communication boards and speech synthesizers for people with speech impairments; ■ devices such as day calendars with symbol pictures for people with cognitive impairment. Assistive technologies, when appropriate to the user and the user’s environment, have been shown to be powerful tools to increase independence and improve participation. A study of people with limited mobility in Uganda found that assistive technologies for mobility created greater possibilities for community participation, especially in education and employment (60). For people in the United Kingdom with disabilities resulting from brain injuries, technologies such as personal digital assistants, and simpler technologies such as wall charts, were closely associated with independence (61). In a study of Nigerians with hearing impairments, provision of a hearing aid was associated with improved function, participation and user satisfaction (62). Assistive devices have also been reported to reduce disability and may substitute or supplement support services – possibly reducing care costs (63). In the United States of America, data over 15 years from the National Long-Term Care Survey found that increasing use of technology was associated with decreasing reported disability among people aged 65 years and older (64). Another study from the United States showed that users of assistive technologies such as mobility aids and equipment for personal care reported less need for support services (65). In some countries, assistive devices are an integral part of health care and are provided through the national health care system. Elsewhere, assistive technology is provided by governments through rehabilitation services, vocational rehabilitation, or special education agencies (66), insurance companies, and charitable and nongovernmental organizations. Rehabilitation settings The availability of rehabilitation services in different settings varies within and across nations and regions (67–70). Medical rehabilitation and therapy are typically provided in acute care hospitals for conditions with acute onset. Follow-up medical rehabilitation, therapy, and assistive devices could be provided in a wide range of settings, including specialized rehabilitation wards or hospitals; rehabilitation centres; institutions such as residential mental and nursing homes, respite care centres, hospices, prisons, residential educational institutions, and military residential settings; or single or multiprofessional practices (office or clinic). Longer-term rehabilitation may be provided 102 World report on disability within community settings and facilities such as primary health care centres, schools, workplaces, or home-care therapy services (67–70). Needs and unmet needs Global data on the need for rehabilitation services, the type and quality of measures provided, and estimates of unmet need do not exist. Data on rehabilitation services are often incomplete and fragmented. When data are available, comparability is hampered by differences in definitions, classifications of measures and personnel, populations under study, measurement methods, indicators, and data sources – for example, individuals with disabilities, service providers, or programme managers may experience needs and demands differently (71, 72). Unmet rehabilitation needs can delay discharge, limit activities, restrict participation, cause deterioration in health, increase dependency on others for assistance, and decrease quality of life (37, 73–77). These negative outcomes can have broad social and financial implications for individuals, families, and communities (78–80). Despite acknowledged limitations such as the quality of data and cultural variations in perception of disabilities, the need for rehabilitation services can be estimated in several ways. These include data on the prevalence of disability; disability-specific surveys; and population and administrative data. Prevalence data on health conditions associated with disability can provide information to assess rehabilitation needs (81). As Chapter 2 indicated, disability rates correlate with the increase in noncommunicable conditions and global ageing. The need for rehabilitation services is projected to increase (82, 83) due to these demographic and epidemiological factors. Strong evidence suggests that impairments related to ageing and many health conditions can be reduced and functioning improved with rehabilitation (84–86). Higher rates of disability indicate a greater potential need for rehabilitation. Epidemiological evidence together with an examination of the number, type, and severity of impairments, and the activity limitations and participation restrictions that may benefit from various rehabilitation measures, can help measure the need for services and may be useful for setting appropriate priorities for rehabilitation (87). ■ The number of people needing hearing aids worldwide is based on 2005 World Health Organization estimates that about 278 million people have moderate to profound hearing impairments (88). In developed countries, industry experts estimate that about 20% of people with hearing impairments need hearing aids (89), suggesting 56 million potential hearing-aid users worldwide. Hearing aid producers and distributors estimate that hearing aid production currently meets less than 10% of global need (88), and less than 3% of the hearing aid needs in developing countries are met annually (90). ■ The International Society for Prosthetics and Orthotics and the World Health Organization have estimated that people needing prostheses or orthotics and related services represent 0.5% of the population in developing countries; and 30 million people in Africa, Asia, and Latin America (91) require an estimated 180 000 rehabilitation professionals. In 2005 there were 24 prosthetic and orthotic schools in developing countries, graduating 400 trainees annually. Worldwide existing training facilities for prosthetic and orthotic professionals and other providers of essential rehabilitation services are deeply inadequate in relation to the need (92). ■ A national survey of musculoskeletal impairment in Rwanda concluded that 2.6% of children are impaired and that about 80 000 need physical therapy, 50 000 need orthopaedic surgery, and 10 000 need assistive devices (93). Most of the available data on national supply and unmet need are derived from 103 Chapter 4 Rehabilitation disability-specific surveys on specific populations such as: ■ National studies on living conditions of people with disabilities conducted in Malawi, Mozambique, Namibia, Zambia, and Zimbabwe (94–98) revealed large gaps in the provision of medical rehabilitation and assistive devices (see Table 2.5 in Chapter 2). Gender inequalities in access to assistive devices were evident in Malawi (men 25.3% and women 14.1%) and Zambia (men 15.7% and women 11.9%) (99). ■ A survey of physical rehabilitation medicine in Croatia, the Czech Republic, Hungary, Slovakia, and Slovenia found a general lack of access to rehabilitation in primary, secondary, tertiary, and community health care settings, as well as regional and socioeconomic inequalities in access (100). ■ In a study of people identified as disabled from three districts in Beijing, China, 75% of those interviewed expressed a need for a range of rehabilitation services, of which only 27% had received such services (101). A national Chinese study of the need for rehabilitation in 2007 found that unmet need was particularly high for assistive devices and therapy (102). ■ United States surveys report considerable unmet needs – often caused by funding problems – for assistive technologies (103). Unmet need for rehabilitation services can also be estimated from administrative and population survey data. The supply of rehabilitation services can be estimated from administrative data on the provision of services, and measures such as waiting times for rehabilitation services can proxy the extent to which demand for services is being met. A recent global survey (2006–2008) of vision services in 195 countries found that waiting times in urban areas averaged less than one month, while waiting times in rural areas ranged from six months to a year (104). Proxy measures may not always be reliable. In the case of waiting times, for instance, lack of awareness of services and beliefs about disability influence treatment-seeking, while restrictions on who is legitimately waiting for services can complicate data interpretation (105–107). Indicators on the number of people demanding but not receiving services, or receiving inadequate or inappropriate services, can provide useful planning information (108). Data on rehabilitation often are not disaggregated from other health care services, however, and rehabilitation measures are not included in existing classification systems, which could provide a framework for describing and measuring rehabilitation. Administrative data on supply are often fragmented because rehabilitation can take place in a variety of settings and be performed by different personnel. Comparing multiple data sources can provide more robust interpretations, if a common framework like the ICF is used. As an example, the Arthritis Community Research and Evaluation Unit in Toronto merged administrative data sources to profile rehabilitation demand and supply across all regions of the province of Ontario (109). The researchers triangulated population data with the number of health-care workers per region to estimate the number of workers per person: they found that the higher concentration of workers in the southern region did not coincide with the highest areas of demand, causing unmet demand for rehabilitation. Addressing barriers to rehabilitation The barriers to rehabilitation service provision can be overcome through a series of actions, including: ■ reforming policies, laws, and delivery systems, including development or revision of national rehabilitation plans; ■ developing funding mechanisms to address barriers related to financing of rehabilitation; 104 World report on disability ■ increasing human resources for rehabilitation, including training and retention of rehabilitation personnel; ■ expanding and decentralizing service delivery; ■ increasing the use and affordability of technology and assistive devices; ■ expanding research programmes, including improving information and access to good practice guidelines. Reforming policies, laws, and delivery systems A 2005 global survey (110) of the implementation of the nonbinding, United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities found that: ■ in 48 of 114 (42%) countries that responded to the survey, rehabilitation policies were not adopted; ■ in 57 (50%) countries legislation on rehabilitation for people with disabilities was not passed; ■ in 46 (40%) countries rehabilitation programmes were not established. Many countries have good legislation and related policies on rehabilitation, but the implementation of these policies, and the development and delivery of regional and local rehabilitation services, have lagged. Systemic barriers include: ■ Lack of strategic planning. A study of rehabilitation medicine related to physical impairments – excluding assistive technology, sensory impairments, and specialized disciplines – in five central and eastern European countries suggested that the lack of strategic planning for services had resulted in an uneven distribution of service capacity and infrastructure (100). ■ Lack of resources and health infrastructure. Limited resources and health infrastructure in developing countries, and in rural and remote communities in developed countries, can reduce access to rehabilitation and quality of services (111). In a survey on the reasons for not using needed health facilities in two Indian states, 52.3% of respondents indicated that no healthcare facility in the area was available (112). Other countries lack rehabilitation services that have proven effective at reducing longterm costs, such as early intervention for children under the age of 5 (5, 113–115). A study of users of community-based rehabilitation (CBR) in Ghana, Guyana, and Nepal showed limited impact on physical well-being because CBR workers had difficulties providing physical rehabilitation, assistive devices, and referral services (116). In Haiti, before the 2010 earthquake, an estimated three quarters of amputees received prosthetic management due to the lack of availability of services (117). ■ Lack of agency responsible to administer, coordinate, and monitor services. In some countries all rehabilitation is integrated in health care and financed under the national health system (118, 119). In other countries responsibilities are divided between different ministries, and rehabilitation services are often poorly integrated into the overall system and not well coordinated (120). A report of 29 African countries found that many lack coordination and collaboration among the different sectors and ministries involved in disability and rehabilitation, and 4 of the 29 countries did not have a lead ministry (119). ■ Inadequate health information systems and communication strategies can contribute to low rates of participation in rehabilitation. Aboriginal Australians have high rates of cardiovascular disease but low rates of participation in cardiac rehabilitation, for example. Barriers to rehabilitation include poor communication across the health care sector and between providers (notably between primary and secondary care), inconsistent and insufficient data collection processes, multiple clinical information systems, 105 Chapter 4 Rehabilitation and incompatible technologies (121). Poor communication results in ineffective coordination of responsibilities among providers (75). ■ Complex referral systems can limit access. Where access to rehabilitation services is controlled by doctors (77), medical rules or attitudes of primary physicians can obstruct individuals with disabilities from obtaining services (122). People are sometimes not referred, or inappropriately referred, or unnecessary medical consultations may increase their costs (123–126). This is particularly relevant to people with complex needs requiring multiple rehabilitation measures. ■ Absence of engagement with people with disabilities. The study of 114 countries mentioned above did not consult with disabled people’s organizations in 51 countries, and did not consult with families of persons with disabilities about design, implementation, and evaluation of rehabilitation programmes in 57 of the study countries (110). Countries that lack policies and legislation on rehabilitation should consider introducing them, especially countries that are signatories to the CRPD, as they are required to align national law with Articles 25 and 26 of the Convention. Rehabilitation can be incorporated into general legislation on health, and into relevant employment, education, and social services legislation, as well as into specific legislation for persons with disabilities. Policy responses should emphasize early intervention and use of rehabilitation to enable people with a broad range of health conditions to improve or maintain their level of functioning, with a specific focus on ensuring participation and inclusion, such as continuing to work (127). Services should be provided as close as possible to communities where people live, including in rural areas (128). Development, implementation, and monitoring of policy and laws should include users (see Box 4.4) (132). Rehabilitation professionals must be aware of the policies and programmes given the role of rehabilitation in keeping people with disabilities participating in society (133, 134). National rehabilitation plans and improved collaboration Creating or amending national plans on rehabilitation, and establishing infrastructure and capacity to implement the plan are critical to improving access to rehabilitation. Plans should be based on analysis of the current situation, consider the main aspects of rehabilitation provision – leadership, financing, information, service delivery, products and technologies, and the rehabilitation workforce (135) – and define priorities based on local need. Even if it is not immediately possible to provide rehabilitation services for all who need them, a plan involving smaller, annual investments may progressively strengthen and expand the rehabilitation system. Successful implementation of the plan depends on establishing or strengthening mechanisms for intersectoral collaboration. An interministerial committee or agency for rehabilitation can coordinate across organizations. For example, a Disability Action Council with representatives from the government, NGOs, and training programmes was established in Cambodia in 1997, to support coordination and cooperation across rehabilitation providers, decrease duplication and improve distribution of services and referral systems, and promote joint ventures in training (136). The Council has been very successful in developing physical rehabilitation and supporting professional training (physical therapy, prosthetics, orthotics, wheelchairs, and CBR) (137). Further benefits include (136): ■ joint negotiation for equipment and supplies; ■ sharing knowledge and expertise; ■ continuing education through sharing specialist educators, establishing clinical education sites, reviewing and revising curricula, and disseminating information; 106 World report on disability ■ support for the transition from expatriate professional services to local management. Developing funding mechanisms for rehabilitation The cost of rehabilitation can be a barrier for people with disabilities in high-income as well as low-income countries. Even where funding from governments, insurers, or NGOs is available, it may not cover enough of the costs to make rehabilitation affordable (117). People with disabilities have lower incomes and are often unemployed, so are less likely to be covered by employer-sponsored health plans or private voluntary health insurance (see Chapter 8). If they have limited finances and inadequate public health coverage, access to rehabilitation may also be limited, compromising activity and participation in society (138). Lack of financial resources for assistive technologies is a significant barrier for many (101). People with disabilities and their families purchase more than half of all assistive devices directly (139). In a Box 4.4. Reform of mental health law in Italy – closing psychiatric institutions is not enough In 1978 Italy introduced Law No. 180 gradually phasing out psychiatric hospitals and introducing a communitybased system of psychiatric care. Social psychiatrist Franco Basaglia was a leading figure behind the new law that rejected the assumption that people with mental illness were a danger to society. Basaglia had become appalled by the inhuman conditions he witnessed as the director of a psychiatric hospital in northern Italy. He viewed social factors as the main determinants in mental illness, and became a champion of community mental health services and beds in general hospitals instead of psychiatric hospitals (129). Thirty years later, Italy is the only country where traditional mental hospitals are prohibited by law. The law comprised framework legislation, with individual regions tasked with implementing detailed norms, methods, and timetables for action. As a result of the law, no new patients were admitted to psychiatric hospitals, and a process of deinstitutionalization of psychiatric inpatients was actively promoted. The inpatient population dropped by 53% between 1978 and 1987, and the final dismantling of psychiatric hospitals was completed by 2000 (130). Treatment for acute problems is delivered in general hospital psychiatric units, each with a maximum of 15 beds. A network of community mental health and rehabilitation centres support mentally ill people, based on a holistic perspective. The organization of services uses a departmental model to coordinate a range of treatments, phases, and professionals. Campaigns against stigma, for social inclusion of people with mental health problems, and empowerment of patients and families have been promoted and supported centrally and regionally. As a consequence of these policies, Italy has fewer psychiatric beds than other countries – 1.72 per 10 000 people in 2001. While Italy has a comparable number of psychiatrists per head of population to the United Kingdom, it has one third the psychiatric nurses and psychologists, and one tenth of the social workers. Italy also has lower rates of compulsory admissions (2.5 per 10 000 people in 2001, compared with 5.5 per 10 000 in England) (131), and lower use of psychotropic drugs than other European countries. “Revolving door” readmissions are evident only in regions with poor resources. Yet Italian mental health care is far from perfect (130). In place of public sector mental hospitals, the government operates small, protected communities or apartments for long-term patients, and private facilities provide longterm care in some regions. But support for mental health varies significantly by region, and the burden of care still falls on families in some areas. Community mental health and rehabilitation services have in some areas failed to innovate, and optimal treatments are not always available. Italy is preparing a new national strategy to reinforce the community care system, face emerging priorities, and standardize regional mental health care performance. Italy’s experience shows that closing psychiatric institutions must be accompanied by alternative structures. Reform laws should provide minimum standards, not just guidelines. Political commitment is necessary, as well as investment in buildings, staff, and training. Research and evaluation is vital, together with central mechanisms for verification, control, and comparison of services. 107 Chapter 4 Rehabilitation national survey in India, two thirds of the assistive technology users reported having paid for their devices themselves (112). In Haiti, poor access to prosthetic services was attributed partially to users being unable to pay (117). Spending on rehabilitation services is difficult to determine because it generally is not disaggregated from other health care expenditure. Limited information is available on expenditure for the full range of rehabilitation measures (68, 74, 138). Governments in 41 of 114 countries did not provide funding for assistive devices in 2005 (110). Even in the 79 countries where insurance schemes fully or partially covered assistive devices, 16 did not cover poor people with disabilities, and 28 did not cover all geographical locations (110). In some cases existing programmes did not cover maintenance and repairs for assistive devices, which can leave individuals with defective equipment and limit its use (76, 112, 140). One third of the 114 countries providing data to the 2005 global study did not allocate specific budgets for rehabilitation services (110). OECD countries appear to be investing more in rehabilitation than in the past, but the spending is still low (120). For example, unweighted averages for all OECD countries between 2006 and 2008 indicate that public spending on rehabilitation as part of labour market programmes was 0.02% of GDP with no increase over time (127). Health care funding often provides selective coverage for rehabilitation services – for example, by restricting the number or type of assistive devices, the number of therapy visits over a specific time, or the maximum cost (77) – in order to control cost. While cost controls are needed, they should be balanced with the need to provide services to those who can benefit. In the United States, government and private insurance plans limit coverage of assistive technologies and may not replace ageing devices until they are broken, sometimes requiring a substantial waiting period (77). A study of assistive device use by people with rheumatic disease in Germany and the Netherlands found significant differences between the two countries, thought to result from differences in country-related health care systems with respect to prescription and reimbursement rules (141). Policy actions require a budget matching the scope and priorities of the plan. The budget for rehabilitation services should be part of the regular budgets of relevant ministries – notably health – and should consider ongoing needs. Ideally, the budget line for rehabilitation services would be separated to identify and monitor spending. Many countries – particularly low-income and middle-income countries – struggle to finance rehabilitation, but rehabilitation is a good investment because it builds human capital (36, 142). Financing strategies can improve the provision, access, and coverage of rehabilitation services, particularly in low-income and middle-income countries. Any new strategy should be carefully evaluated for its applicability and cost–effectiveness before being implemented. Financing strategies may include the following: ■ Reallocate or redistribute resources. Public rehabilitation services should be reviewed and evaluated, with resources reallocated effectively. Possible modifications include: – changing from hospital or clinic-based rehabilitation to community-based interventions (74, 83); – reorganizing and integrating services to make them more efficient (26, 74, 143); – relocating equipment to where it is most needed (144). ■ Cooperate internationally. Developed countries, through their development aid, could provide long-term technical and financial assistance to developing countries to strengthen rehabilitation services, including rehabilitation personnel development. Aid agencies from Australia, Germany, Italy, Japan, New Zealand, Norway, Sweden, the United Kingdom, and the United States have supported such activities (145–147). 108 World report on disability ■ Include rehabilitation services in foreign aid for humanitarian crises. Conflict and natural disaster cause injuries and disabilities and make people with existing disabilities even more vulnerable – for example, after an earthquake there are increased difficulties in moving around due to the rubble from collapsed buildings and the loss of mobility devices. Foreign aid should also include trauma care and rehabilitation services (135, 142, 148). ■ Combine public and private financing. Clear demarcation of responsibilities and good coordination among sectors is needed for this strategy to be effective. Some services could be publicly funded but privately provided – as in Australia, Cambodia, Canada, and India. ■ Target poor people with disabilities. The essential elements of rehabilitation need to be identified, publicly funded, and made available for free to people with low incomes, as in South Africa (149) and India (8). ■ Evaluate coverage of health insurance, including criteria for equitable access. A study in the United States on access to physical therapy found that health care funding sources provided different coverage for physical therapy services depending on whether people had cerebral palsy, multiple sclerosis, or spinal cord injury (74). Increasing human resources for rehabilitation Global information about the rehabilitation workforce is inadequate. In many countries national planning and review of human resources for health do not refer to rehabilitation (135). Many lack the technical capacity to accurately monitor their rehabilitation workforce, so data are often unreliable and out-of-date. Furthermore, the terms to describe the workers vary, proven analytical tools are absent, and skills and experience for assessing crucial policy issues are lacking (150, 151). Many countries, developing and developed, report inadequate, unstable, or nonexistent supplies, (83, 152, 153) and unequal geographic distribution of, rehabilitation professionals (82, 140). Developed countries such as Australia, Canada, and the United States report shortages of rehabilitation personnel in rural and remote areas (154–156). The low quality and productivity of the rehabilitation workforce in low-income countries are disconcerting. The training for rehabilitation and other health personnel in developing countries, can be more complex than in developed countries. Training needs to consider the absence of other practitioners for consultation and advice and the lack of medical services, surgical treatment, and follow-up care through primary health care facilities. Rehabilitation personnel working in low-resource settings require extensive knowledge on pathology, and good diagnostic, problem-solving, clinical decision-making, and communication skills (136). Physiotherapy services are the ones most often available, often in small hospitals (144). A recent comprehensive survey of rehabilitation in Ghana identified no rehabilitation doctor or occupational therapist in the country, and only a few prosthetists, orthotists, and physical therapists, resulting in very limited access to therapy and assistive technologies (68). Services such as speech pathology are nearly absent in many countries (144). In India people with speech impairments were much less likely to receive assistive devices than people with visual impairments (112). An extensive survey of rehabilitation doctors in sub-Saharan Africa identified only six, all in South Africa, for more than 780 million people, while Europe has more than 10 000 and the United States more than 7000 (142). Discrepancies are also large for other rehabilitation professions: 0.04–0.6 psychologists per 100 000 population in low-income and lower middle-income countries, compared with 1.8 in upper middle-income countries and 14 in high-income countries; and 0.04 social workers per 100 000 population in low-income countries compared with 15.7 in high-income countries (157). Data from official 109 Chapter 4 Rehabilitation statistical sources showing the large disparities in supply of physiotherapists are shown in Fig. 4.1, and data from a survey by the World Federation of Occupational Therapists showing the disparities in occupational therapists are shown in Fig. 4.2. The lack of women in rehabilitation professions, and the cultural attitudes towards gender, affect rehabilitation services in some contexts. The low number of women technicians in India, for example, may partly explain why women with disabilities were less likely than men to receive assistive devices (112). Female patients in Afghanistan can be treated only by female therapists, and men only by men. Restrictions on travel for women

Executive Summary:Please watch this video, and find out how this sub continent was cut into pieces,This region was slave for almost 1000 years, when the foreigners left they they created a nightmare for the coming generations.Just watch these videos and you will find out who destroyed Indian subcontinent foreigners or our own people.These videos will show Nehru and Jinnah were dating Lady Edwin simultaneously and Nehru was blackmailed to ask for partition. History proves he was a womanizer and died of STD.Messenger( Please click on Messenger and find out the structure standing on sand.Following is a must watch;Lady Edwin, Mountbatten was dating Nehru and Jinnah simultaneouslySee how did Nehru die with Sexually Transmitted Disease.Indian subcontinent: India/Pakistan/Bangladesh, are the principal countries. Foreigners left this land after looting for thousands of years.In fact, they never went, the total evils they sowed the seeds of hate, further divisions, corrupt, lazy lifestyles.Also, now through TV rays, cell phones, and other lifestyles penetrate this household. Although Western lifestyles are okay for them, it is not suitable for the east.These countries have nonfunctional governance and corrupt regimes after regimes.Gender equality may 100 s years away, females are very unsafe.Law and order system is fraudulent and no one is safe.These countries are still the pawn of the west one way or the other. These nations could never break chains of slavery.Here is quick glance:Let us go and beat our chest that we are bit above Angola, and Papua New Guinea in Human development index 2015Let us have a glimpse of ourselves in the mirror:Our region is a bit above Angola, Syrian Arab Republic, Papua New Guinea in Human Development Index (2015).Out of 188 countries India 131, Pakistan 147, Bangladesh 139Pakistan is barely hanging in the list a few point low, in the index it will join, the rank of Swaziland.Human Development ReportsHuman Development ReportsNow here is an article: India versus China.China leaves India behind, heads towards first worldCorruption:Here is data on corruption. Please check the standing of India, Pakistan and Bangladesh.The Global Anti-Corruption CoalitionIndia score 38, position 76/167 out of , Pakistan scores 30, position 117/167 and Bangladesh score 25 position 139/167This nine-year-old girl is one of them.She lives in Dhaka, Bangladesh – one of 114 countries that scores below 50 out of 100 in our 2015 Corruption Perceptions Index, indicating serious levels of public sector corruption.Instead of going to school, she spends her days sorting bottles at a recycling factory. Officially child labour is illegal in Bangladesh. Unofficially a bribe paid to the right official can mean exceptions are made.Like all exploitation, child labour remains a sad reality in environments where citizens are trapped in poverty and corrupt officials can be paid off.It’s just one example of the devastation fuelled by corruption. Others include human trafficking, child mortality, poor education standards, environmental destruction and terrorism.Put simply – public sector corruption is about so much more than missing money. It’s about people’s lives, and it’s a global problem.Health and Sanitation; Please review the listTop 17 Dirtiest Cities in The World - WiseToastMajor portion of the dirtiest cities are from this sub continent.Chinese efforts to lift people out of poverty.In China, 12.4 million people brought above poverty line in 2016: XinhNow the rest of the story:Pakistan was once part of India; my forefathers lived there for thousands of years. And they had to move to present day Indian Punjab, from respected business men/women to refugees on the foot paths of new Delhi.And then Pakistan further split into Bangladesh.Once mighty civilization and huge power, now is pawn in the hands of foreigners, holy babas, religious middlemen, corrupt regimes, hoodlums, super corrupt police and western values/culture nothing wrong with their values it suits them and more power to them. That society and culture is different and it evolved over the time and sum total the east is east and the west is west. Sad part is: We do not need any cultural values and life style from the west,HoweverWe do need Science, Technology, Engineering, Medical Sciences and that is all, rest is not fit for us.Just keep this principle in mind: Families and individuals who kept this mind originally from the east and now in the west, prospered in every way rest destroyed themselves.It is very sad: Some parts of this region are heavily dependent on foreign aid.Mostly these regions are totally destroyed by the middlemen/women’s brain wash and most of the public has destroyed themselves and the region.These foreigners do not have worry of this part of the world, we are going to kill each other, further divide and become more and more weaker.The foreigners took over our lands/culture, and the whole India paid the price of slavery, in the end before they left, they made sure to rip apart the nation, there was transmigration of people, riots, killing and millions of people lost their lives.One independent community of Hindus/Sikhs/Muslims coexisting for hundreds of years became enemies and behaved like madmen/women.In the end, one brother separated from the other two Punjab, mighty Punjab; We were proud people. And we destroyed ourselves to the present state of affairs.Fighting like madmen, one of the worst human behavior on social media, once it was one Punjab/one India/We are talking about destroying each other with Atom bombs that are our beloved land of forefathers.First foreigners were our middlemen, and they looted us, now our middlemen are robbing us.We are used to be slaves and will finally destroy ourselves, that is Punjab/India and Pakistan.This region(the whole Indian subcontinent) becomes full of real dirt, filth, and with no civic sense. Throwing garbage where ever we feel so far in it is not in our own house.The whole world is moving ahead, and we all most of us are in the dark ages of killing each other, illiteracy, pawns of the middlemen, corrupt government, some cities are called the Rape Capitals of the World. Gender equality is 100 s of years away. ( China with 1.4 billion people got her freedom at the same time, as us but compare data with that country and do the math.). And then beat of our chest in shame or glory. A woman can walk by herself in the middle of night by herself, in the mega city of Shanghai/Beijing/Chongqing/and so on. That is called achievement.We have made all our rivers filthy, we cut almost all our trees, we did not get rid of child slavery, we did not get rid of caste system and we still have dowry system, feudal system is still alive and well.We most of us have become incredibly selfish/cunning/unethical.We are losing our culture to the fake nonsense of the west.We are most likely behind in every area science/technology/engineering.Some of us, look at the fake or exaggerated data of some growth, thump our chests and sleepPolice is one of the most corrupt in the world in the Indian sub continent region.In this region drugs/opium flows through from very well known areas of poppy fields. In some regions of the Indian subcontinents these substance abuse has taken over. And due to OD, there are instances where several young men from the same family kick the bucket too soon from the world.In some region due to fake glory, selling the ancestral land just for pomp and glory at a wedding.In both Punjab (Indian and Pakistani) usually we write very glorious history of our past, battle field scenes, ; big dialogues of our forefathers/ mothers/ legendary love stories/ but the present day reality is totally different. We sing songs of the past to make ourselves feel good but present day reality is very bitter. Those brave forefathers are long gone, it is just a show business now.Most of new the music glorifies violence/alcohol/sex/drugs, (Especially Indian Punjab). No wonder the present day new generation is highly inspired by this, and results are in the pudding. Declining sperm counts, OD deaths and girls going out of the community to find suitable life partners, people moving in from the other states basically to hijack the whole state of Punjab.One of my brothers on this post showed this picture of my respectable sisterSaqib Ali Muhammad Aslam, I.C.S. Physics & Mathematics, Punjab Group Of Colleges (2017)Answered 20h ago“I know that our women look more like this…”What do you know about Pakistan?He is professing all Pakistani ladies are like this, I hope he is right, but I do not think so. I wish all my sisters in Pakistan/India are like this beautiful like this inside and outside.He further says :(Saqib Ali Muhammad Aslam)“(I’m legitimately scared of this image)”BTW: She has full right to way she likes to, that is her culture, that her beliefs, unless we so called educated, learn to respect each and everyone, this hate within our own communities are going to finish us.And who knows, behind this Chadar/Burka, there is most beautiful human being inside out.I do not find any difference between these two ladies, for me both are equally respectable. Both have equal rights, insulting one against the other, is not going to take us anywhere.Visit China if you can or explore data, on crime, safety, women’s status, GDP, giving trillions of dollars loan to other countries, super projects around the world, their infra structures, the list goes on and on and on.BTW: Most of the Chinese are atheist,( do not believe in God)China was just about same level or below the Indian subcontinent in 1949, today she is a crown princess, most likely new Empress. Sure something went wrong with us.Showing a few civil projects here and there, showing some guys in fatigues and weapons, and quoting some data here and there, is a pocket change in the world figures.Please visit Three Gorges in China or Google it and see the length/breadth/width of the project. Then brag and measure our projects.Here is partial list:Illiteracy.Extremely poor law and order.No one is safe,Gender inequality, female is very unsafe, it could be anyone’s mother/sister/daughter/. One recent case in one capital city does not wake the world/nations what will it take to wake up from false assurances.Westerner style democracy is useless in the countries who have high rate of poverty, illiteracy and totally corrupt systems.It is designed for high percent of educated populations, a reasonable just, clean governess, more less equal rights and not for poor people who could be bought, sold and some do not understand what vote means such as so called democracy/ies in those part of the world.Extremely corrupt police, fake witnesses, no property rights.Extremely poor civic sense.Fake and failed so called democracy, utter nonsense, ineffective, geared for corrupt and rich people.Lot of fake and empty slogans, fake dialogues in movies, and fake chest thumping exercises without any action. Putting Bandannas and lighting candle lights vigils without any results in the end.Keep the poor/helpless/females in almost slavery situations.Caste system still alive and well.Regional hate for each other due to wrong education/illiteracy/teaching of wrong history.Pawns of the middlemen.Poor stayed poor, generation after generation, they could not break this vicious cycle of poverty. Because the corrupt regimes designed systems to stay in power and loot the country with both hands.Diverting the attention of mass against fake war threats from neighbor/s and keep themselves in power and loot the nations with both hands.Spend money on arms, weapon of destruction rather than education/health.Legal system corrupt, expensive, fake/false witnesses, clogged courts, justice delayed justice denied. Basically might is right.Uncontrolled /Unplanned population growth, even beggars sitting with a good number kids begging along with maimed/handicap parents.Please mark these words: Until the parts are not strong the whole piece is weak. Let me translate, until the whole region is strong, there is no happiness, no peace and when your neighbor is sleeping hungry, it is not a good situation. This region has to find peace and forget all the nuisances to survive. Otherwise, this region is more or less write off.Take Chinese example:They integrated 55 minorities, they live and work in relatively in peace, it make 104 million people who are not Han majority of 1.3 billion.China and the Chinese have nothing but good will in Vietnam/Laos/Cambodia/Thailand.They are leaving no effort spared to have beautiful relations with their neighbors.They realized and liberated woman, it is not 100 percent but close to it.They got rid of drugs/opiumThey brought law and order in line.They got rid of feudalism to zero.This country is challenging the very best in some areas.Do you remember Beijing Olympics, how many Gold our whole region got versus China. Do the math, and this is just the beginning they are just warming up.Does our region has any hope in hell, that we would get to host Beijing ? Ever?Small countries like Spain hosted it? Where are we?China will be hosting winter Olympic, now here is the kicker, this town has no snow, bullet trains will be hauling snow for winter supports from 100 s of Km away from this town.I have spent major portion of my life in the WEST, raised two boys, now grown and have their own lives.We brought up our boys respecting the Western Values also, nothing wrong with it. However, in my view, these things are good for Western in the west.China university bans ChristmasI fully support why China has done it.(Reason these holidays and celebration is total waste of time and money)In the Indian subcontinent we have tremendous amount of our own holidays and celebrations. Honestly we do not need more western ones also. However, west is very smart to sell their ideas and the east , west can afford such activities but the east.Social media, swearing and writing dirty language:This region is a laughing stock, when the civilized discussion is dragged into religions and dirty language. We are sowing a lot hate for each other, and not a very good impression on rest of the world.Our forefathers/mothers gave away their lives for us to gain freedom from the foreigners.In case let us imagine if they ever visit to see us in this region, they will cry their heart out, seeing us in this state of killing, hate, dissecting the region into smaller chunks. I am very sure they will regret their sacrifices for us.As per Hindu scripture: Lord Krishna promised to come to the Earth to when the balance between good and the bad is out of control.Sometimes, when I read earth shattering news from that region, I ask my Lord: what is He waiting for now.One such case of recent rape, I have lost faith in Humanity in that region.The otherKilling of helpless students, I have lost total faith in Humanity in that region.But sometimes I think: Lord is waiting for us to kill each other to make His job simpler.I guess His Wheel of destruction is bit rusted but His job is cut out for Him in the Indian subcontinent.https://www.google.ca/search?q=sudarshan+chakra&tbm=isch&source=iu&ictx=1&fir=OAz9DXsKPnqBcM%253A%252CTejns1hHy_U46M%252C_&usg=__CavtbRRiLJn-Fff5VQpfBaG6NKM%3D&sa=X&ved=0ahUKEwiF4a6zlY3YAhUs5IMKHfwWBpIQ9QEIPjAF#imgrc=OAz9DXsKPnqBcM:https://www.google.ca/search?q=sudarshan+chakra&tbm=isch&source=iu&ictx=1&fir=OAz9DXsKPnqBcM%253A%252CTejns1hHy_U46M%252C_&usg=__CavtbRRiLJn-Fff5VQpfBaG6NKM%3D&sa=X&ved=0ahUKEwiF4a6zlY3YAhUs5IMKHfwWBpIQ9QEIPjAF#imgrc=m0vXmoVcY1ar2M:China leaves India behind, heads towards first worldChina leaves India behind, heads towards first worldROOTS OF POWERMADHAV NALAPATwww.sunday-guardian.com/profile/madhav-nalapatChina leaves India behind, heads towards first worldThirty years ago, China was as dysfunctional as India is to the present day. While Mao Zedong unified his country and transferred some of his confidence in it to the rest of the populace, he was as weak in economics as Prime Minister Manmohan Singh has been. It was only after Deng Xiaoping took charge of economic policy in 1979 that China began its climb to the top. Today, to compare India to China would be even more fatuous than comparing India with Pakistan. Our northern neighbour is so far ahead that it is not even visible in the distance. Our administrators pride themselves on being the "steel frame". A better word for their effect on the country would be straitjacket.Tianjin is an example of how far China has leapt ahead of India. Although more than 150 kilometres away from Beijing, the city is reached by train in a half-hour. Its two universities, Tianjin and Nankai, are working at excellence, as are other universities in China. In the 1980s, almost all were worse than their top 20 Indian counterparts. These days, even middle-rank universities have left Indian ones far behind, another great achievement of the UGC and its babudom. It has an international airport and a huge port, where several ships, including cruise liners, regularly call. Comparing Tianjin with the squalor of Gurgaon, where taxes disappear into the pockets of officials and politicians, is an exercise in raising blood pressure to dangerous levels. If China can do it, why not India? Why not indeed? Look at our officials, look at their political masters, and the answer will become clear.China leaves India behind, heads towards first worldIn China, 12.4 million people brought above poverty line in 2016: XinhuaReuters Staff2 MIN READSHANGHAI (Reuters) - Some 12.4 million people in China were brought above the poverty line in 2016, in part due to more than 230 billion yuan ($33.5 billion) earmarked to help fight poverty, the state news agency Xinhua said late on Tuesday, quoting official statistics.China has said it aims to reduce by at least 10 million annually the number of people living in poverty - which it defines as those with less than 2,300 yuan in annual income - and eradicate poverty by 2020.In China, 12.4 million people brought above poverty line in 2016: XinhThis how the Chinese railway engine looks like, this train attained a maximum speed of 325 km/hrAlsoJust look at their railway stations, orderly, super clean and well behaved passengers.About the author:The author was born after a few year of Indian independence, in a small town of present-day Indian Punjab. Vowed from the early childhood he will get out of poverty, corruption, helplessness, and sufferings. Finally, he did in his first 70 s with only eight American dollars, Master’s degree with very high grades, And Canadian immigration. He worked in every situation, cold up to minus 30, he accepted worst working conditions, and also did another M.Sc). In Canada, to break that barrier of Canadian education, took him nine years to pay back a student loan.He spent 30 years in Canadian corporate world; then one day call it quits to go into own self-employment never looked back.His primary school teacher fired his imaginations and glory of China, culture, civilization, and beauty of Lord Buddha, He never forgot those, and now after several visits and more on the horizon and one day journey may complete.The author knows better where China is heading and how the world will look like in very short years.Napoleon Bonaparte predicted this about two centuries back in time. He was not wrong; maybe my primary school teacher was his reincarnation 60 years back in time. My high school English teacher, the very best teacher of my life, told me Sushil: Get out of this environment if you want to be something. And I did. He further said: We are used to this slavery for thousand years, nothing has changed, the only thing we have now different masters and they will change every five years.“China is a sleeping giant. Let her sleep, for when she wakes she will move the world.”Napoléon BonaparteThe author in China: In Legendary/very famous Yellow Mountains.The author at The Great Wall of China, in one of his previous trips.The Author in Bangkok Thailand: in his very recent trip revolving deck 360 degree.Conclusions:Shape up or ship out,Corrupt systems in the whole Indian Subcontinent are eating the entire area like the termite. Unless the masses rise against the corrupt regimes, this region is doomed. ( This region is standing on the sand, fake/lame/corrupt democracy, and corrupt alternate regimes)Did the Cambodians create a very high civilization in Southeast Asia? Why is today Cambodia a poor country?This article by Axel Schultze proves once great nations become dust when the regimes are corrupt. Indian Subcontinent is a classic case of this destruction.Unless females are liberated and safe, this region will never make it. Rest of the World is changing, and woman has taken an equal role in the development of the nations.Keep your religious differences and faiths at home.Foreigner had already destroyed that region for thousands of years, stop it from further destruction. More trouble and disturbance in the east is in fact good for the west. China woke up and Indian subcontinent did not and kept on self destruction.Religion without Karma is not going to save from starvation and poverty.Do not follow the west they could afford that lifestyle in the past, the game is coming to a slow halt in here too. With Chinese rise, life is not getting any easier here.Having a toilet facility at home is more vital than a cell phone, and buying SIM card, and reloading again and again, when the poor family is starving at home. ( A new addiction).Unless we make peace with the Pundits, Mullahs, Priests, Monks, Granthis, and Priests the progress in this region is out of the question. Reality is: They all like to use American technology, but when they see the erosion of our values, culture, and above scriptures due to Western influence, then their hearts cry.That is why: China has blocked various media to their children and public. And so far China does that China will progress. Once it starts faltering, China will also begin to decline.People in the west go up in the arms, but when you listen and have face to face talk in China with their intellectuals, then you understand the logic. I do, and I am very impressed how they are supercharging their kids for future.The west talks about huge about human rights, justice, value and glory of democracy.First, I have lived here for over 45 years, soon it be 50, all I can tell you, these things are just glorified and over exaggerated B.S.First it is not just society as they say: The poor is poor, and the rich is rich.Chances are the Rich may get away with murder and the poor may rot in the jail. ( It happened and will happen again)Crime rate is very high, And person safety is an issue and extremely high probability to become a victim of crime.Tremendous waste of money every four or five years. One party makes plan other one comes to power and cancels it.Let us have a glimpse of ourselves in the mirror:Human Development ReportsOur region is a bit above Angola, Syrian Arab Republic, Papua New Guinea in Human Development Index (2015).Out of 188 countries India 131, Pakistan 147, Bangladesh 139Let us go and beat our chest that we are bit above Angola, and Papua New Guinea.Bravo well done, let us raise a flag or this achievement.Human Development ReportsCrime figures:Crime Index by City 2017Dhaka Bangladesh Crime Index 69.11Karachi Pakistan Crime Index 64.18Noida India Crime Index 62.48Gurgaon India Crime Index 62.46Delhi India Crime Index 60.79Lower number in Crime Index Mangalore India 17.51 more safer.Let us talk about Health and Sanitation list.Top 17 Dirtiest Cities in The World - WiseToastRawalpindi, Pakistan. ...Khorramabad, Iran. ...Antananarivo, Madagascar. ...Mumbai, India. ...Ahmadabad, India. ...Lucknow, India. ...Dhaka, Bangladesh. ...Baku, Azerbaijan.Delhi India,Karachi, PakistanDaka Bangladesh.Top 17 Dirtiest Cities in The WorldNow let us talk a bit about Terrorism:These people were created by the The west when they denied to be their puppet, they became hard core terrorists.https://www.google.ca/imgres?imgurl=https://upload.wikimedia.org/wikipedia/commons/c/ca/Osama_bin_Laden_portrait.jpg&imgrefurl=https://en.wikipedia.org/wiki/Osama_bin_Laden&h=326&w=294&tbnid=TLcZ0-858mFJPM:&tbnh=160&tbnw=144&usg=__9D2Yn3DaWkuvyoLCVOJ8_i2CJDM%3D&vet=10ahUKEwjNhpPruZPYAhVr74MKHQpXCdwQ_B0ItAEwFQ..i&docid=o4yAZC93rEGh3M&itg=1&sa=X&ved=0ahUKEwjNhpPruZPYAhVr74MKHQpXCdwQ_B0ItAEwFQMr. Osama bin Laden was from extremely wealthy family, educated and excellent relation with Saudi Royalty, he was creation of the West, when their purpose was served. He denied to become puppet, did the west cared to listen to him, most likely not.Osama Ben Laden: A creation of the CIA, by Michel Chossudovsky - internationalnewsMr. Osama bin Laden: (Creation and Destruction)Mr. Saddam HusseinSaddam Hussein: A Dictator Created Then Destroyed By AmericaMr. Muammar al GaddafiHillary Emails Reveal True Motive for Libya InterventionBy Brad Hoff | Jan 6, 2016 | Africa, Editor's Picks, News & Analysis, US | 385The list goes on for your further readings.|United States and state-sponsored terrorismUnited States and state-sponsored terrorism - WikipediaKashmir Princess incidentPiazza Fontana bombingKidnapping attempt and assassination of General René SchneiderContrasCuban exilesColombian paramilitary groupsPlan LazoArmed Forces Directive No. 200-05/91.Kosovo Liberation ArmyCreation and funding of ISIShttp://ww.cnn.com/2016/08/12/middleeast/here-is-how-isis-began/index.htmlHere's how ISIS was really foundedISIS : A CIA Creation to Justify War Abroad and Repression at HomeThrough terrifying headlines and shocking videos, ISIS is being used as a tool to justify war in the Middle East and to cause fear and panic worldwide. No, this is not a “crazy conspiracy theory”, it is simply the oldest trick in the book. ISIS was created by the very forces that are fighting it.* ***Stay tuned more to come.***