Healthcare Systems : Do All Countries Provide Universal Healthcare?
What is Universal Healthcare?
Universal Health Coverage is defined as all individuals accessing medical care and services without any financial burden. This includes health promotion, disease prevention, diagnosis treatment, and rehabilitation.
“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”. – World Health Organisation
Achieving Universal Health Care requires good administration of health services, provision of medicines and other essentials, a skilled workforce and modern infrastructure. The health goal in Sustainable Development Goals (SDG) aims to ‘ensure healthy lives and promote well-being for all at all ages’ by 2030. The SDG declaration also says, ‘we must achieve universal health coverage (UHC) and access to quality health care; No one must be left behind’. The focus on providing UHC hence is an important goal which is complementary to other goals as well. The progress towards providing UHC also helps achieve other sustainable development goals such as alleviating poverty, gender equality and industry, innovation and infrastructure. UHC, therefore, becomes an important factor in achieving health security and equity.
Different Healthcare Systems
The World Health Organization (WHO) has developed a mechanism to measure the progress of UHC in different countries. It divides health care into four main branches, which are:
- Reproductive, maternal, newborn and child health
- Infectious diseases
- Noncommunicable diseases
- Service Capacity and access
Measuring UHC is extremely important as it gives an idea of where a country stands in healthcare provision. The common reason is medical costs in some countries that do not provide UHC, such as South Africa, the United States of America, Iran, Egypt, Nigeria, Etc.
Most countries that provide UHC, such as Australia, Netherlands, Brazil, Etc., have combined private provisions with the public to provide greater access to the people. The South Korean health care system covers 60 per cent of medical expenses, and the remainder is usually covered through the employer or a private insurance company. The United Kingdom has fully free health care provided by the government, and Germany pays for the coverage of private hospitals and doctors. All of Brazil has access to free health services, including tourists and immigrants, without any paperwork requirement. Healthcare has been decentralised in the country, and the people receive it directly through the state or municipality. However, the public and private sectors are completely independent, and the public provides free or low-cost healthcare. Along with free health care only being in public hospitals, there is an issue of overcrowding, and low availability of doctors as most doctors work in urban hospitals. Along with this, Brazil is also trying to increase their sanitisation in favelas through government schemes which establish clinics, increase the availability of clean water and manage the sewage system to reduce the spread of diseases.
There is no public-based universal health insurance coverage in the United States of America. It spent 17.8 per cent of its GDP, i.e. 3.2 trillion dollars in 2015, on health care alone which was majorly sourced from the public and private insurance companies. Even after the introduction of the Social Security Act (1965) and the Affordable Care Act (2010) in the states, many people cannot access good health care since it is not directly subsidised. The Social Security Act helped implement Medicare and Medicaid, the apex insurance companies in the country. Medicare ensures that people over 65 have hospital and medical insurance.
On the other hand, Medicaid is state-based, with different eligibility in different states. Individuals need to apply and reenlist annually, which becomes a hassle. As reported by the United States Census Bureau, Medicaid covers only 17.8 per cent of American citizens as of 2020. The Children’s Health Insurance Program (1997) was introduced to help provide children with health coverage who are not eligible for Medicaid. The program will cover 9.6million children by 2020. The Affordable Care Act (2010) forced the population to get health insurance and expanded the range of eligibility to cover more people. The Act resulted in 20 million more people gaining health coverage. In the American system, most of the population receives health insurance through employers or insurance companies; hence, there is a lack of uniformity in healthcare provision.
Source: United States Census Bureau (Report Number P60-274)
Brazil recognises health care as a universal right and responsibility of the state in its constitution. Sistema Unico de Saude (SUS), the Brazilian health system, was adopted in the Brazilian constitution in 1988. It follows three main principles: health being a universal right, decentralisation of healthcare, and social participation in the implementation of healthcare.
“Health is a right of all and an obligation of the State, guaranteed by socioeconomic policies which seek the reduction of the risk of diseases and other grievances and to the universal and equal access to the actions and services in its promotion, protection and recuperation” is stated in the constitution.
The Brazilian Ministry of Health is the authority responsible for the implementation of healthcare. The ministry looks over policy development, implementation and financing. The system is decentralised as federal, state and municipal. The present law regulations, which regulate the health system operation, implemented in 1996, attempt to delegate responsibility for SUS administration to municipal governments, with technical and financial assistance from the federal government and states. The formation of health consortia, which combine the resources of numerous neighbouring towns, is another regionalisation project. The effort to enhance and reorganise the SUS is an important tool for regionalisation assistance. The Family Health Program, implemented by local health secretariats in partnership with states and the Ministry of Public Health, is the major approach for boosting primary healthcare nationwide. Through Piso de Atençao Básica, the federal government provides technical assistance and funds. Technical specialists in the Ministry of Public Health look over disease prevention and give control recommendations. The National Epidemiology Centre (CENEPI), a division of the National Health Foundation (FUNASA), oversees the national epidemiological surveillance system, which collects and analyses data on the country’s health condition.
Following a political transition in 2019, the new Brazilian government continued economic austerity while introducing new social, educational, and environmental policies that might jeopardise public health. Nonetheless, the Ministry of Health has proposed new initiatives to promote and increase primary care access, including appointing a new primary care secretary. These policies aim to extend the use of electronic medical records, establish a new efficiency-based payment mechanism, and develop a strategy for educating and providing physicians in distant locations.
India faces an issue of inequality in the provision of health services due to economic gaps. The healthcare provided in urban areas and private clinics or hospitals is better than that provided in rural areas and public areas. This forces the population to shift to private services if they can afford them. Many areas face the issue of a lack of technology and resources. According to the Economic Survey 2021-22, India spent 2.1 per cent of its GDP on healthcare.
The National Health Mission, a Twelfth Plan initiative of the Indian government, aims to extend the National Rural Health Mission to the entire nation. Providing services to communities with underprivileged populations can be aided through community-based health insurance. The government should restructure health insurance and its reach in India, according to the Indian Journal of Community Medicine (IJOCM).
The National Health Mission (2013), along with its two sub-missions National Rural Health Mission (2005) and National Urban Health Mission (2013), aimed at providing universal healthcare in India. It focused on improving health services, reproductive, maternal, neonatal and adolescent health (RMNCH+A) and communicable and non-communicable diseases. Even though the mission has provided people access to healthcare, India still faces many challenges. The mission has provided states and union territories support for upgrading facilities and buying new technology, however, the main challenge the industry still faces is the quality of healthcare provided varies from public to private sector. People cannot access better quality healthcare in the private sector due to higher prices. The Ayushman Bharat Pradhan Mantri Jan Yojana (AB-PMJAY) aims to provide free access to health insurance coverage for people with low income, Mobile Medical Units (MMUs), Tele-consultation services, implementation of the National Assurance Framework, Free Drug and Diagnostics Service Initiatives, PM Dialysis Programme, Rashtriya Bal Swasthya Karyakram (improve the overall quality of life of children) and Janani Shishu Suraksha Karyakram (free and cashless services for pregnant women) are the initiatives taken under the National Health Mission for achieving UHC in India.
A combination of the public and private sectors is used in one programme that several Indian state governments have adopted to increase access to healthcare. In order to accomplish the health-related Millennium Development Goals, the Public-Private Partnership Initiative (PPP) was established. A policy that permits the participation of commercial enterprises or non-governmental organisations is present in almost every new state health project. Public-private partnerships’ efficacy in the healthcare industry is widely contested.
The PPP outcomes in Maharashtra and West Bengal demonstrate efficacy when combined with federal health services. They help India bridge the affordability and accessibility gap. High out-of-pocket costs for non-medical expenses prevent people from accessing healthcare. Therefore, such health programmes need to be spread throughout India.
Source: The Indian Express, 2019
Health care systems vary greatly from country to country. Different systems, involving varying degrees of participation from the public and commercial sectors, are adopted by different nations to provide healthcare to their inhabitants. The most important outcome to be achieved is that the services offered are accessible and affordable. From universal coverage under fully financed national systems to no coverage at all, leaving people to pay for health care entirely out of pocket, the range of ways that health care is provided worldwide can greatly affect the welfare of the people. The impoverished typically have less access to healthcare than people in wealthy nations, and even within nations, the poor have less access to healthcare. However, new diseases pose new difficulties for those afflicted by them as well as the network of institutions and countries devoted to resolving global health issues.
The involvement of communities and marginalised individuals, encouragement of local adaptation, and thorough monitoring of effects on the poor are essential components of success. It is still difficult to discover ways to guarantee that vulnerable groups have a role in how strategies are created, put into practice, and considered in ways that show advances in access for the underprivileged.
Research Intern at CPRG India