[Ip-health] The Economist: Universal health care, worldwide, is within reach

[Thiru Balasubramaniam]

https://www.economist.com/news/leaders/21741138-case-it-powerful-oneincluding-poor-countries-universal-health-care-worldwide

Medicine: Universal health care, worldwide, is within reach

The case for it is a powerful one—including in poor countries

 Print edition | Leaders

Apr 28th 2018

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 5.6m. Life expectancy has reached 71, a gain of five years. More
children than ever are vaccinated. Malaria, TB and HIV/AIDS are in retreat.

Yet the gap between this progress and the still greater potential that
medicine offers has perhaps never been wider. At least half the world is
without access to what the World Health Organisation deems essential,
including antenatal care, insecticide-treated bednets, screening for
cervical cancer and vaccinations against diphtheria, tetanus and whooping
cough. Safe, basic surgery is out of reach for 5bn people.


Those who can get to see a doctor often pay a crippling price. More than
800m people spend over 10% of their annual household income on medical
expenses; nearly 180m spend over 25%. The quality of what they get in
return is often woeful. In studies of consultations in rural Indian and
Chinese clinics, just 12-26% of patients received a correct diagnosis.

That is a terrible waste. As this week’s special report shows, the goal of
universal basic health care is sensible, affordable and practical, even in
poor countries. Without it, the potential of modern medicine will be
squandered.

How the other half dies

Universal basic health care is sensible in the way that, say, universal
basic education is sensible—because it yields benefits to society as well
as to individuals. In some quarters the very idea leads to a dangerous
elevation of the blood pressure, because it suggests paternalism, coercion
or worse. There is no hiding that public health-insurance schemes require
the rich to subsidise the poor, the young to subsidise the old and the
healthy to underwrite the sick. And universal schemes must have a way of
forcing people to pay, through taxes, say, or by mandating that they buy
insurance.

But there is a principled, liberal case for universal health care. Good
health is something everyone can reasonably be assumed to want in order to
realise their full individual potential. Universal care is a way of
providing it that is pro-growth. The costs of inaccessible, expensive and
abject treatment are enormous. The sick struggle to get an education or to
be productive at work. Land cannot be developed if it is full of
disease-carrying parasites. According to several studies, confidence about
health makes people more likely to set up their own businesses.

Universal basic health care is also affordable. A country need not wait to
be rich before it can have comprehensive, if rudimentary, treatment. Health
care is a labour-intensive industry, and community health workers, paid
relatively little compared with doctors and nurses, can make a big
difference in poor countries. There is also already a lot of spending on
health in poor countries, but it is often inefficient. In India and
Nigeria, for example, more than 60% of health spending is through
out-of-pocket payments. More services could be provided if that money—and
the risk of falling ill—were pooled.

The evidence for the feasibility of universal health care goes beyond
theories jotted on the back of prescription pads. It is supported by
several pioneering examples. Chile and Costa Rica spend about an eighth of
what America does per person on health and have similar life expectancies.
Thailand spends $220 per person a year on health, and yet has outcomes
nearly as good as in the OECD. Its rate of deaths related to pregnancy, for
example, is just over half that of African-American mothers. Rwanda has
introduced ultrabasic health insurance for more than 90% of its people;
infant mortality has fallen from 120 per 1,000 live births in 2000 to under
30 last year.

And universal health care is practical. It is a way to prevent free-riders
from passing on the costs of not being covered to others, for example by
clogging up emergency rooms or by spreading contagious diseases. It does
not have to mean big government. Private insurers and providers can still
play an important role.

Indeed such a practical approach is just what the low-cost revolution
needs. Take, for instance, the design of health-insurance schemes. Many
countries start by making a small group of people eligible for a large
number of benefits, in the expectation that other groups will be added
later. (Civil servants are, mysteriously, common beneficiaries.) This is
not only unfair and inefficient, but also risks creating a constituency
opposed to extending insurance to others. The better option is to cover as
many people as possible, even if the services available are sparse, as
under Mexico’s Seguro Popular scheme.

Small amounts of spending can go a long way. Research led by Dean Jamison,
a health economist, has identified over 200 effective interventions,
including immunisations and neglected procedures such as basic surgery. In
total, these would cost poor countries about an extra $1 per week per
person and cut the number of premature deaths there by more than a quarter.
Around half that funding would go to primary health centres, not city
hospitals, which today receive more than their fair share of the money.

The health of nations

Consider, too, the $37bn spent each year on health aid. Since 2000, this
has helped save millions from infectious diseases. But international health
organisations can distort domestic institutions, for example by setting up
parallel programmes or by diverting health workers into pet projects. A
better approach, seen in Rwanda, is when programmes targeting a particular
disease bring broader benefits. One example is the way that the Global Fund
to Fight AIDS, Tuberculosis and Malaria finances community health workers
who treat patients with HIV but also those with other diseases.

Europeans have long wondered why the United States shuns the efficiencies
and health gains from universal care, but its potential in developing
countries is less understood. So long as half the world goes without
essential treatment, the fruits of centuries of medical science will be
wasted. Universal basic health care can help realise its promise.

-- 
Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org