By Drs. Sylvain Ehrenfeld and Reba Goodman
Since its founding in 1948 the World Health Organization (WHO) has promoted universal health coverage. For Dr. Tedros Ghebreyesus, the newly elected Director General of WHO, universal coverage is an ethical issue. In his words: “Do we want our fellow citizens to die because they are too poor? Or millions of families impoverished by catastrophic health expenditures because they lack financial risk protection? Or the young mother who dies in childbirth because she lacks access to health care?”
A recent issue of Lancet Global Health points out that many countries at different levels of economic development have implemented universal health coverage, e.g., Thailand, Costa Rica and Cuba et al, showing this to be more a political than an economic challenge. The constitution of WHO establishes access to health care as a human right and a responsibility of governments. The preamble of the constitution states:
“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.”
Further in the preamble: “Governments have a responsibility for the health of their people which can be fulfilled only by the provisions of adequate and social measures.” The constitution was ratified by all member states and came into force in April 1948. An early example of a national health system was in 1883 in Germany under the administration of Otto von Bismarck, partly as a tactic to deflect growing support for Socialism. Currently, about a third of countries are covered, a third are progressing toward universal health coverage, and a third haven’t started.
Target date: 2030
More than 100 low- and middle-income countries, home to almost three-quarters of the world’s population, have taken steps to deliver universal health coverage. The UN is working to get all covered by 2030. Universal coverage has been implemented in many ways. They all involve some level of government involvement via legislation, regulation and taxation. Many countries use mixed public and private systems.
Let’s consider wealthy countries. There are basically three main ways universal health coverage is achieved:
- Government run (tax-funded) system (Britain)
- Privately run but mostly government-funded (Canada, France)
- Private insurance companies, with regulation and subsidies to insure universal coverage (Switzerland, Netherlands)
The United States recently introduced universal health care using the third system, the Affordable Care Act (Obamacare). The current U.S. president, Donald Trump, has threatened to undermine this system by cutting subsidies.
The Commonwealth Fund compared health care among advanced countries. The top three performers–Britain, Australia, and the Netherlands–all use different systems.
Many developing countries striving to provide universal health care are struggling to do so. Among the problems facing developing countries are poverty, corruption and an insufficient number of health workers such as doctors and nurses. Also, in many rural areas it can be difficult to access services. A number of poorer countries have shown that providing universal health care is an achievable goal. Some success stories are Costa Rica, Cuba, Sri Lanka, Thailand and Rwanda.
Remarkable rise in life expectancy
In Thailand, the bulk of the population had to rely on out-of-pocket payment for medical care, which many could not afford. In 2001, the government introduced a minimum charge with exemptions for people who could not afford even the minimum charge. The result of universal health coverage in Thailand has been a significant drop in mortality and a remarkable rise in life expectancy, which is now 74 years.
After a devastating genocide in 1994, Rwanda has achieved remarkable health gains from universal coverage. Premature mortality has fallen sharply and life expectancy has increased significantly. Costa Rica and Cuba, both poor countries, have universal health coverage and a life expectancy of almost 80 years. Many poor countries are striving to increase coverage. According to the World Bank, Ghana has increased coverage to 38%, Peru to 62%. Vietnam to 68% and Thailand to 96%.
Lower infant mortality
The World Health Organization has promoted the strategy of Primary Health Care, which stresses local participation in managing health services, the use of local clinics, and the training of local people in performing basic treatments that do not require a doctor. It stresses education and prevention. According to the World Bank, primary care can deal with 90 percent of health problems. A survey of 102 developing countries in 2015 found that those with established primary health care systems had higher life expectancy and lower infant mortality.
Technology, while in the early stages, can help to improve primary care in poor countries. A recent example is the use of a slate of relatively cheap ($640) devices that can perform 33 common medical tests, including measuring blood pressure and blood sugar levels. In conclusion, universal health coverage with political will can result in an affordable dream. This is a goal we should all rally around.
Dr. Sylvain Ehrenfeld, an IHEU representative to the UN, and Dr. Reba Goodman are members of the Ethical Culture Society of Bergen County. Special thanks to Charlene Nicole Fulmore, assistant to Dr. Goodman.