Kapok | In praise of the vouchers

Eric Sautedé

Let me be honest: at first I was more than doubtful about what I was reading, and one could even say that I started looking deeper into the matter with pretty self-assured and somehow offensive ulterior motives. Come on, how could this be? “A study concludes that healthcare vouchers have prevented 123 deaths a year,” read a headline, or in this very newspaper, a milder “Study: Medical Vouchers Prevented Fatalities, Should be Given to TNRs.” For those of you not aware of cross-feeding multilingual acronyms, “TNRs” means non-resident workers, as in the very elegant perfunctory statistical category derived from the Portuguese “trabalhadores não residentes”. So vouchers distributed by the government equal saving lives, and this should be indiscriminate when it comes to human life, hence the noble appeal to extend it to all the contributing participants to and of the community. When absolute efficiency meets generosity…
A scientific mind has a craving for heuristic (meaning that one is always trying to find causality) relations: what are the causes behind a phenomenon, and to what extent these causes alone can explain things. In social sciences, the real “hard sciences” as everything is more complex when one deals with human nature, single factor explanations are pretty rare to come by, and often follow rather cryptic statistical considerations in which the whole exercise consists in isolating factors and relating a dependent variable (in this case mortality because of a disease) with an independent one (the introduction of vouchers).
The press reports based on a Lusa dispatch insist on the main conclusion of Professor Zhang Jinghua’s study, that a 24 percent decrease in cardiovascular diseases recorded as of 2010, compared to the 2001-2009 period, can be directly connected to the introduction of medical vouchers back in 2009, resulting in the prevention of 123 deaths a year over 2010-2012 (the claimed drop in mortality, 0.22%, multiplied by an average of 560,000 residents over the period). And vouchers are here seen as having a direct influence on citizens scheduling health checks or taking medical exams that would have otherwise probably not been undertaken without this exclusive incentive.
My first reaction was not to go to the report but to international studies, especially one by the OECD that indicates that the main reasons behind the sharp decrease in cardiovascular disease mortality rates have to do foremost with the decline of tobacco consumption and also with the improvements in medical care—why would Macao be any different? Then, I went to the official statistics, and if it indeed shows a decline in mortality rates for “cardiovascular diseases” in recent years, it also indicates that the year with the least number of deaths because of cardiovascular issues was in 2007 and the mortality rate because of respiratory diseases has increased rather significantly—the number of deaths because of respiratory diseases used to be 1/3 of the one for cardiovascular diseases, now it is 2/3!
So I finally went directly to the source, and Professor Zhang’s study is indeed pretty comprehensive and compelling, taking into account a multiplicity of factors (medical resources—numbers of physicians, nurses and patient beds per thousand population and public healthcare expenditure, economic development level—GDP per capita, the human development index, population aging factor, natural seasonal effects and long-term trends), scrutinizing the yearly reports of the Macao Health Bureau (incidentally pointing out to the inefficiency of the awareness and educational campaigns) and even admitting to certain shortcomings in the lack of compelling statistics about cerebrovascular diseases or simply the rather limited consideration given to the improvement of medical care because of new technologies, better training and more efficient drug therapies. Ultimately, in its own words, the study merely “suggests a robust connection between the timing of the implementation of the Macao Medical Voucher Program and a significant decrease in the mortality from circulatory system diseases in Macao, but their causal relationship awaits confirmation in further research.” The mere fact that the cancer mortality rate has increased significantly over the same period—as indicated in the study—should have led to more caution in the media reports: I would bet my salary that the vouchers program, conversely, was not responsible for that!