By many measures the world has never been in better health. Since 2000 the number of children who die before they are five has fallen by almost half, to 5.6 million. Life expectancy has reached 71, again of five years. More children than ever are vaccinated. Death from Malaria, TB, HIV/AIDs are much lower.
But medicine can do much better. According to the World Health Organization (WHO), half the world is without access to essential health services including antenatal (before birth) care, insecticide- treated mosquito nets, screening for common cancers, and vaccination against diphtheria, tetanus and whooping cough. Safe basic surgery is out of reach for 5 billion people. Those who can see a doctor pay a high price (out of pocket cost) relative to their income. Millions of them go into debt to pay for their medical care. Most Indians fall into the half described by WHO.
What is universal health care?
Universal health care is a health care system that provides health care and financial protection to all citizens of a country. United Nations member states including India, have agreed to work toward worldwide universal health care coverage by 2030.
Universal healthcare does not imply coverage for all people for every sickness. It can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.
Brief History
The first move towards a national health insurance system was launched in Germany in 1883 with the Sickness Insurance Law. The former Soviet Union established fully public health care in 1920 .Following the World War 11, universal health care system began to be set up around the world: New Zealand in 1941, United Kingdom’s National Health Service in 1948, Western European Countries in 1960s, Japan in 1961, Canada in 1968, South Korea in 1989, and Thailand in 2001. More than 110 countries now have some form of health insurance schemes.
Case for universal health care
The prestigious British Magazine “The Economist” in its April 28, 2018 issue has the cover story: Within reach: universal healthcare, worldwide. It has described all the reasons why all counties including the poor ones should go for universal health coverage.
Universal basic health care (like basic education) is sensible- because its yields benefits to society as well to individuals. Good health is something everyone wants in order to realize their full potential.
Most people think that universal health care is only for the rich countries. However,” countries need not wait to be rich to provide basic healthcare to all”says the Economist. There is already a lot of spending on health in poor countries –by individual, government and businesses. In India for example, more than 60% of health spending is through out of pocket payment, even though government claims to provide free health care. More services could be provided if all the money – and the risk of falling ill – were pooled.
Small amount of money can go a long way if spent in a proper way. Health economist Dean Jamison has identified 200 effective medical and public health interventions on which to spend the limited amount of the money in poor countries. Around half of that money will go to primary health centers and not to city hospitals. Chile and Costa Rica spend about one eighth of what America does per person and have similar life expectancies. Thailand has been providing universal health care since 2002. In 2008, 98% of the population had access to safe drinking water and 98% had access to improve sanitation. The life expectancy in Thailand is 71 for males and 78 for females.
Present status of health care in India
India has a mixed system of health care – government (central, state, municipal), corporate and private. The system is broken. They do not coordinate with one another. The care in the government and municipal hospital is supposed to be free but they are not. Patients pay for the tests, medicines, operations and also bribes to the hospital staff. Patients are going into debt to pay for medical care, especially for surgeries. The health care expenditure by the government is very low by international standard. India is spending only 1.58% of its GDP on health care. Western European Countries, United Kingdom and Canada spend around 10 to 12%. United States spends 18%. Thailand is spending 4.5%.
There is no social security system or health insurance paying for the health care cost for vast majority of Indians. Out of pocket health care spending is quite high as percentage of family income. Millions of families are getting into serious debt because of unexpected health care expenditure. There is no quality health care in the rural areas. Patients have to travel far.
Fortunately, India’s present government is keen to introduce universal health insurance and increase the health care spending. The government’sbudget presented in February 2018 shows strong desire to improve the health services in India. The NITI Aayog is expected to introduce a three –year action plan soon.
How should government of India Proceed?
1-Go for universal health care
The goal of the central government should be to provide universal health care over next 3-5 years to all Indians – children and adults, rich or poor, residing in rural, urban or tribal areas.
2-Single payer system
The government should adopt a single payer system as it is done in United Kingdom and Canada to control cost. Without a single payer system it will be impossible to control cost as it is happening in the United States of America.
3-Emphasizepublic health measures
Emphasize public health measures like provision of safe drinking water, sanitation, reduction of air pollution, reduction in the use of alcohol and tobacco products (pan, bidi, cigarettes, and chewing tobacco), immunizations and nutrition for pregnant mothers and young children. Public health measures are very cost effective in preventing diseases and saving lives.
4-Primary health care
Good primary health care is an essential for decent health care system, especially in a poor country like India, with poor infrastructures and inadequate health care workers. In rural India, one study shows that 66% of the population does not have access to simple preventive medicines and 33% of rural population must travel more than 30km to get treatment. India had started the primary health centers in 1960s but they have not done the job of providing primary care to all Indians.
5-Basic surgery
According to an article published in the British Medical Journal “Lancet” (2015) nine in ten people living in the developing countries including India, do not have access to “safe and affordable” surgical care. Lack of emergency obstetric (pregnancy) care like emergency cesarean section is a case in point.
Surgeries are expensive in all countries. Surgery is also more likely than other forms of medical care to have severe financial consequences. Studies have shown that 15 to 20% of patients with acute surgical care, ended up in poverty.
Surgery is seen as an expensive luxury and “neglected step child” of global health. But many surgeries like- hernia repair, cataract, cesarean section, repair of simple fractures (broken bones) and wound care can be done at sub divisional and district level hospitals at reasonable cost.
It is important that low cost surgeries should be made a core part of the universal healthcare.
Conclusion
More than 110 countries now have some sort of health insurance schemes. Yet most are patchy, so users have to supplement with out-of-pocket payments or private insurance. But if all the money which now being spent on health care in India (government, private, business), can be pooled, all the people in India can be provided with universal healthcare with little bit of more spending. The present central government is thinking in these lines. It is time it should implement it. It is not a question of money (even though that is what the politicians will say) but it is question of will. Thailand and China have already done it. It is time for India to provide universal health care to all.
DrSaheb Sahu is a graduate of AIIMS (New Delhi) and a pediatrician in USA. He has also been the Managing Director Kalinga Hospital, Bhubaneswar, Odisha, for 4 years. He has funded a charitable rural clinic in Western Odisha for more than 20 years.