Universal health coverage: an illustrated history
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The UN on September 23 is holding a high-level meeting at the General Assembly in New York on universal health coverage.
The event, led by Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, aims to garner commitments to sustain investment in health and accelerate progress towards universal health coverage across the world.
Universal health coverage is defined by the WHO as giving everybody access to health services that are of sufficient quality to be effective, without inflicting financial hardship as the price to pay for it.
The concept is not a new one: it could be argued its origins lie in ancient Egypt.
Beginnings of universal health coverage
Scrolls dating back more than 3,000 years resurfaced in 2015, revealing workers in the Egyptian town of Deir el-Medina in the flourishing Nile River Valley enjoyed paid time off and home visits from a workplace doctor.
Chancellor Otto von Bismarck’s attempts to unify German states included the Sickness Insurance Act of 1883, forcing companies to offer insurance to employees through a scheme where both paid into a fund.
The system expanded to eventually include accidents in 1884, disability in 1889 and unemployment insurance in 1927.
In 1911, Britain passed the National Insurance Act. This covered health and unemployment, and required individuals to pay into a fund alongside contributions from employer and the state. The scheme was available to 1.4m people.
But it was not until 1948 that Britons gained universal health coverage, with the establishment of the National Health Service, free at the point of use and financed by the state. Often described as the closest thing the UK has to a national religion, the NHS featured prominently during the 2016 Brexit referendum. The Leave campaign promised to divert savings from leaving the EU to the service.
China’s barefoot doctors
China’s Nationalist party opened a westernised department of public health service in 1927, aiming to go beyond the limitations of traditional medicine. The country’s revolutionary government of 1949 took healthcare inspiration from the Soviet Union, which had run a state healthcare system since 1922.
Chinese leader Mao Zedong advocated the idea of “barefoot doctors” — farmers trained by community or county hospitals and then sent to service rural populations.
In 1978, an international WHO conference at Alma-Ata, in what is today Kazakhstan, praised the barefoot doctors and identified primary care as essential for global public health. Today the Chinese are struggling to restructure their system and widen access to care.
Solutions for growing populations
By the middle of the 20th-century, healthcare systems around the world were evolving.
President Harry Truman started a debate over US public healthcare in 1945. This eventually resulted in the creation under President Lyndon Johnson of two government programmes: Medicare and Medicaid.
Medicare, established in 1965, covers the elderly, while Medicaid caters for the unemployed and the poor.
Medicare coverage was extended in 1972 to cover the disabled and people with chronic kidney disease, and later under President Barack Obama to include low-income families.
The US remains an anomaly among industrialised nations for lacking a universal healthcare system.
Mr Obama’s Affordable Care Act — popularly know as Obamacare — was the subject of fierce criticism from some opposition politicians, stoking misconceptions such as the notion that the UK used “death panels” to decide which elderly people deserved care.
Obamacare created a state-run market for people who did not get insurance from their employers and expanded Medicare for low-income families, although by 2017 an estimated 28m Americans in 2017 remained uninsured.
Healthcare reform is a key issue in the upcoming presidential race as some Democratic frontrunners call for “Medicare for all”.
In India, Prime Minister Narendra Modi in 2018 unveiled ambitious plans — dubbed ‘Modicare’ — to reform the public health system in the second-most populous country in the world.
According to the Center for Global Development, India is home to one-third of global maternal deaths and spends just 1 per cent of gross domestic product on public health. Some 60m people fall into poverty every year because of healthcare bills.
Modicare has been criticised for its lack of funding and underemphasis on primary care services.
Sarah Hawkes, a professor of global public health at University College London, says much could be learned from the successes and failures of western healthcare systems.
“It’s very clear from the story of the NHS that we can’t keep on [as we are],” she said. “The financial implications of trying to treat ourselves out of a diabetic epidemic, for example, are so vast that it’s impossible to imagine any financial system that would be able to cope with that.”
At the same time, as Africa becomes one of the world’s fastest growing continents, countries will need healthcare systems robust enough to keep up with their expanding populations. African nations could well leapfrog parts of the western experience, which for example has belatedly involved placing more emphasis on prevention rather than treatment.
Alongside improved diagnostics and supply chains, universal health coverage will also enable people to hold providers to account and monitor whether they are getting the services they are entitled to, says Prof Hawkes.
“You can get across the notion that you have a right to healthcare and it is not this discretionary gift from your government. You hold government accountable and you can monitor what’s going on. That’s a fundamental sea-change in the social contract.”
World leaders have committed to introduce universal health coverage by 2030 as part of the UN’s Sustainable Development Goals. FT writers discuss the policies and innovations in technology that could help bring this about.