From the rich and ageing population of Tokyo to the youthful poor of New Delhi, a cry is going up: provide universal health coverage to ensure broader medical support for people around the world.
Much of the potential benefit of advances in treatments in recent years, as well as of technological revolutions under way in areas from drugs to big data, will be lost without changes in the way healthcare is funded. Many see healthcare coverage for all — free at the point of care to patients — as pivotal.
Without sufficient funding, new and often expensive therapies cannot be purchased, and existing resources are stretched by an ageing population with ever more chronic conditions.
Without a system to ensure access to medical services for all, those without the ability to pay will be excluded, creating inequity that sparks social and political tensions.
That is not just the view of officials or doctors. “You can’t make healthcare transactional and wait for the patient to pay,” says Frans van Houten, chief executive of Philips, the Dutch group that has restructured itself as a healthcare business spanning diagnostics to data. “It’s essential to build primary and secondary care.”
In richer countries such as the UK, there are debates about overall levels of funding, and the scope for preferential access for the small minority of the population that have private health insurance in addition to the universally available National Health Service.
More fundamentally in many poorer countries, patients are often excluded from the system entirely or condemned to limited second-class care because they are required to pay “out of pocket” which soon extends beyond their means. Lower-cost sub-standard care with inappropriate medicines, or patients unable to afford a complete course of treatment, often reduces productivity and creates a wider cross-border health threat to others: drug resistance.
A study last year estimated that at least half the world’s population still lacks access to essential health services. Some 800m people spend more than 10 per cent of their household budget on healthcare, and almost 100m are pushed into extreme poverty each year by out-of-pocket health expenses.
The report’s two institutional backers reflected growing international focus on universal health coverage, the World Bank, led by Jim Yong Kim, a former health specialist, has made the sector (alongside education) a top priority for economic and social development.
The World Health Organisation, is headed by Tedros Adhanom Ghebreyesus, a former Ethiopian health minister elected director-general in 2017.
Both men have pressed the economic case for universal coverage not just with health ministers but national finance ministers who hold the purse strings.
The Japanese government, notably through its ministry of foreign affairs, has strongly supported efforts to focus leaders’ attention on health coverage.
But the greatest revolution is taking place within countries, with politicians increasingly accepting the case for universal health coverage. Some models for universal coverage have long existed in middle-income countries like Thailand.
Others, such as Kenya with its new health financing strategy unveiled late last year, are following suit. Narendra Modi, India’s prime minister, this year pledged moves towards what some have dubbed “Modicare”.
Critics point out that coverage will be largely for more specialist secondary and tertiary care; they warn too that its implementation mainly by a private medical sector could lead to spiralling costs. Yet a number of India’s regional administrations, including Delhi itself with its Mohalla clinics for basic community care since 2015, have moved still further ahead.
“It’s partly a function of affluence,” says Rob Yates from the Centre on Global Health Security at the think-tank Chatham House in London. “As countries get richer, they spend more on health. Universal health coverage is like a country growing up — citizens recognise that the country is at an income level where people should not die in the streets.”
He argues that there is still too much divisive debate about “angels on a pinhead” when the principles of universal health coverage are clear.
On service delivery, many are agnostic on the role of state compared with private sector provision.
But on funding, whether through tax or social financing, Mr Yates makes the case for a public mechanism to cover an entire population so the wealthier subsidise the poor, and the healthy the sick.
Others disagree, notably in the US, where President Trump pledged to unwind even the incremental benefits of Obamacare, even though he was ultimately unable to follow through on this pledge.
Yet even in the US, politicians in a number of states — such as Gavin Newsom, the lieutenant-governor of California — are calling for a single-payer system in which the state, rather than multiple insurers, fund healthcare. The debate is far from over.
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