[This article is published as the first part of a series in the January 2013 issue of Infomed (pgs:12-15)]
In health policy circles the acronym with the buzz is, UHC. It is used interchangeably for both Universal Health Coverage and Universal Health Care, although the accepted expansion is Universal Health Coverage.
Universal Healthcare, as the term suggests, is defined as the universal guarantee of healthcare to all citizens. It implicitly affirms healthcare as a right. The colossal scope of UHC necessitates government involvement to ensure its success. Governments do this either through legislation, mandate, or regulation. Achieving Universal Health Care is dependent on balancing two critical factors – coverage and cost. The details of delivery and access are addressed under the broad umbrella of coverage while health economics wrestles with the tough problem of the cost and funding of the details. For the present, coverage has precedence. Globally, healthcare delivery systems are somewhat in place even if, in many cases, rudimentary. Yet many millions around the world go without access because they can’t afford it. UHC models were developed internationally, to plug the gap that kept people out of the healthcare system and to satisfy the moral, ethical and economic need of progressive societies. No one model fits all groups. Member countries are working in close collaboration with the WHO to develop indigenous versions that include the local culture and involve the local community.
UHC is a globally recognized public health concept, goal and aspiration that varies in its details according to the population it aims to serve. Therefore, the term does not seek to define standards but expresses within it the components and characteristics of an affordable health system accessible by all. These include: people, services and needs; where people should get free and affordable medical services according to their needs1. A concise yet comprehensive definition has been articulated by the HLEG (High Level Expert Group) report2, commissioned by the Indian Government to develop a blue print for health reform. Here, UHC is defined as: “Ensuring equitable access for all Indian citizens regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality as well as public health services addressing the wider determinants of health, with the government being the guarantor and enabler, although not necessarily the only provider of health and related services.”
At the level of the consumer, UHC aims to provide the 4As (affordable, accessible, assured quality and appropriate health); whilst simultaneously guaranteeing the 3Es at the delivery platform (efficiency, effectiveness and equitable health with accountability)
Making the case for UHC:
The argument for UHC can be neatly summed under three headings: 1. Moral/ethical, 2. Economic and 3. Financial hardship
The moral/ethical question: The political and economic dialogue has spilled over into health with the oft touted question; is health a responsibility or a right; a duty or an entitlement? For those that work in the health sector and for the people who have had a personal experience with illness, this question is moot. Their experience attests to the common knowledge that while responsible health behavior leads to better outcomes; that alone, in and of itself, cannot guarantee freedom from debilitating disease. Linking ‘freedom from disease’ to responsible behavior is mistaking the correlative for the causative. Our bodies are biological machines. Despite the adoption of the best possible practices; there are times (the simple process of aging is itself an example) when the balance tilts to infirmity and/or disease. At that point, can a society dissociate itself from the obligation to provide the benefit of available treatment and knowhow to a large swath of its people simply because of financial considerations? Health is a right to be enjoyed by all; not a privilege to be enjoyed by a few. This is also asserted as such, by Article 25 of the UN’s Universal Declaration of Human Rights3.
Economic inequity: We live in a large heterogeneous structure called society, within which actions are enmeshed and interrelated with outcomes. Health is a complex system within this framework. A healthy population is a determinant of economic and social development. Contrarily, a society wherein large numbers of people are ill or do not have access to treatment, languishes from a marked waste of human potential, man-hours and productivity. The chasm in health metrics is an ever widening one, between rich and poor nations; between the haves and the have-nots. A recent WHO report4 describes the socio-economic disparity in stark numbers: A citizen of a wealthy nation can live up to 40 years longer than someone in a poor country. Of the 136 million women who give birth annually, about 58 million (43 %) receive no medical assistance during childbirth or the postpartum period. Per capita health care spending statistics reveals more of the same, ranging from around 6000 USD in wealthy nations to 20 USD in the poorest. Traditionally, countries that have large gaps in economic equality have more difficulty transitioning from private systems to a public funded UHC. Health and economic inequity make the civic structure lopsided and promote unstable growth with the ultimate consequence of social unrest, chaos and collapse.
Financial Hardship: In the context of health, the WHO4 defines financial catastrophe as, spending that exceeds 40% of household income on health after basic costs have been met. Even for those that can afford health to some moderate extent; the potent combination of rising costs and inadequate coverage can lead to financial catastrophe in a health crisis. This is true across the spectrum of nations from the very rich to the very poor. Medical expenses are the commonest cause of bankruptcy in the US (almost 60 % of personal bankruptcy). At the other end of the scale, more than 100 million people around the world are pushed below the poverty line, annually, because of medical bills and another 150 million suffer financial hardship.
A cursory look at the graph of health care costs worldwide shows movement in only one direction – upward. Countries that have a more homogeneous, less fragmented system of paying for health are able to better contain costs. At the same time, they also provide an equitable standard of services. More than 3 billion people around the world rely on direct payment (out of pocket) to pay for medical care. High out of pocket costs invariably result in people choosing to not take treatment at all and often, women and children are the first to fall through the money gap. Health economics research has consistently proven that wherever direct payment is the dominant reimbursement method; fewer people can afford to purchase health, people with precarious financial situations teeter into poverty and/or medical bankruptcy and those that can afford to pay at the time of need, face rising costs and unaffordability at a later time. The solution to keep costs down is to increase coverage, pool funds, pool financial risk, standardize reimbursement, make it accountable and reduce direct payment to lower than 15% of total cost.
(This is the first article in a series. The next will focus on the Evolution of UHC)
1. The long road to Universal Health Coverage, The Rockefeller Foundation: http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf
2. HLEG report on UHC for India: http://uhc-india.org/
3. Universal Declaration of Human Rights: http://www.un.org/en/documents/udhr/
4. The world health report 2010 on Health Systems Financing. http://www.who.int/whr/2010/en/index.html