Monthly Archives: October 2012

Ensuring universal health care around the himalayas

Two unique experiments in health care are being orchestrated on either sides of the Himalayas. Both China and India are grappling with the ideals of universal health care(UHC): trying to provide equitable and accessible healthcare to the entirety of its populace, an idea that has been up for talks here in Nepal as well for a few years now. The lessons we learn from the either of our two neighbors’ experiments should prove to be very insightful.

Universal health care has been dubbed as the next big thing in public health. Its ability to shape people’s health over the next several decades has been thought to be nothing short of phenomenal. Our own priorities match hand in hand with that of UHC: the last constitution has enshrined universal health care as a fundamental right. But so have some 19 countries of Latin America, and numerous others all over the world. Without a formidable plan and commensurate action, such policies will be just that: vacuous rhetorics.

That’s where China and India shine. They are putting money where their words are and have a restless audacity to achieve out of this world results previously thought unattainable. Between these two giants, they aim to provide accessible and equitable health care to more than a third of humanity, irrespective of an individual’s ability to pay, thereby preventing people spiralling into a vortex of poverty due to a catastrophic illness as it often the case for poor and middle income people right now.

China has audacious plans. The country has earmarked more than a hundred  and twenty five  billion dollars in additional health care spending to scale up health services to its entire people, and by some estimates health care spending in China will easily top more than half a trillion dollars by the year 2020.  Such spending will come mostly from the government, but private spending out of pooled sources like private insurance will also play a part. Between a hybrid network of public and private providers and pooled resources using public and private funds, China aims to achieve its goals of ensuring the health of everyone of its citizens.

India’s plans are equally bold if not bolder. It plans to provide a basic set of health services to everyone, with costs offset by the government from resources collected from general taxation. For a country that has helped rescue much of the developing world from their AIDS epidemics by means of its cheap generics, it is such an embarrassment that thus far, healthcare seemed so distant for a majority of its people due to unaffordable drug and service charges.

That is finally about to mend. And that is not an unachievable goal. Based on some conservative estimates, the government of India will have to spend at least 3-4% of the GDP on health, in order to achieve such results. That is not a big number to spend in healthcare: The UK government through the NHS spends some 8% of the GDP on healthcare. The US spends a whopping 18% of the GDP on healthcare, sixty percent of which comes from the government in the form of programs such as Medicare and Medicaid.

Current health spending by the Government of India is at around 1.4% of the GDP, only a quarter of the total health care spending. Two thirds of health spending in that country is out of pocket. As a result, for the poor the consequences of a severe illness are sometimes more catastrophic than the illness itself. No wonder then that poor people lose lives to an illness at an alarming rate, through lack of adequate care or by refusing to seek care, because the health system has failed them.

Our own experiences match much of India’s. A large section of our population has been effectively barred from formal health services. Like India, we have toyed with the idea of eliminating user fees at government health facilities to improve access to health care to a subset of underserved people. Research from much else of the world shows, user fees, howsoever nominal deter the most vulnerable and the marginalised from much needed health services. Revenues from such fees have also been shown to be a very poor and an unreliable means of financing health care. Our results since eliminating such fees have been encouraging; health services usage has gone up in these select groups.

It pays for us to be cognizant of a mix of  insurance based and government funded healthcare system like that in China, but that may be difficult for us to implement given that the organised sector through which we could implement employment based insurance system is miniscule. Leaving health care hostage to a predatory for-profit multi-payer private insurance system like the one in the US should not be anyone’s idea of universal health care given how such has healthcare system has systematically excluded a sixth of the population in that country, even while it threatens to usurp the entire economy due to runaway costs.

While stalled politics in the country has left every other priority on the back burner, tomorrow’s Nepal can’t be built no matter what kind of ingenious constitution the politicians come up with, if today’s children continue to risk perennial ill health and preventable death. Our commitment to universal health care is barely a start to end this injustice. Realising this dream will mean matching the talk with the walk, much the way our neighbours are starting to do.