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Universal Healthcare- Best Practices around the World and in India

Syed Fazil Shariq SA - Tata Institute of Social Sciences

About Universal Health Care

Universal health care (also called universal health coverage, universal coverage, universal care, or socialized health care) is a health care system that provides health care and financial protection to all citizens of a particular country. Universal health care does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions:

· who is covered,

· what services are covered,

· and how much of the cost is covered

It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship. As part of Sustainable Development Goals, United Nations member states have agreed to work toward worldwide universal health coverage by 2030.

Best Practices around the world:

In Canada, the government finances health insurance, and the private sector delivers a lot of the care. Insurance is run at the province level. Many Canadians have supplemental private insurance through their jobs to help pay for prescription drugs, dentists and optometry. The government ends up paying for about 70 percent of health care spending in all.

In Britain, The government not only finances care, but also provides it through the National Health Service. Coverage is broad, and most services are free to citizens, with the system financed by taxes, though there is a private system that runs alongside the public one. About 10 percent buy private insurance. Government spending accounts for more than 80 percent of all health care spending.

In the case of United States of America has a mix of clashing ideas where private insurance through employment; single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many low-income people; private insurance through exchanges set up by the Affordable Care Act; as well as about 28 million people without any insurance at all. Hospitals are private, except for those run by the Veterans Health Administration.

Singapore has a unique approach. Basic care in government-run hospital wards is cheap, sometimes free, with more deluxe care in private rooms available for those paying extra. Singapore’s workers contribute around 37 percent of their wages to mandated savings accounts that may be spent on health care, housing, insurance, investment or education, with part of that being an employer contribution. The government, which helps control costs, is involved in decisions about investing in new technology. It also uses bulk purchasing power to spend less on drugs, controls the number of medical students and physicians in the country, and helps decide how much they can earn.

Australia provides free inpatient care in public hospitals, access to most medical services and prescription drugs. There is also voluntary private health insurance, giving access to private hospitals and to some services the public system does not cover. The government pays for at least 85 percent of outpatient services, and for 75 percent of the medical fee schedule for private patients who use public hospitals. Patients must pay out of pocket for whatever isn’t covered. Most doctors are self-employed, work in groups and are paid fee-for-service. More than half of hospitals are public.

Everyone in France must buy health insurance, sold by a small number of nonprofit funds, which are largely financed through taxes. Public insurance covers between 70 percent and 80 percent of costs. Voluntary health insurance can cover the rest, leaving out-of-pocket payments relatively low. About 95 percent of the population has voluntary coverage, through jobs or with the help of means-tested vouchers. The Ministry of Health sets funds and budgets; it also regulates the number of hospital beds, what equipment is purchased and how many medical students are trained. The ministry sets prices for procedures and drugs.

Switzerland has a universal health care system, requiring all to buy insurance. The plans resemble those in the United States under the Affordable Care Act: offered by private insurance companies, community rated and guaranteed-issue, with prices varying by things like breadth of network, size of deductible and ease of seeing a specialist. Almost 30 percent of people get subsidies offsetting the cost of premiums, on a sliding scale pegged to income. Although these plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit basis, providing additional services and more choice in hospitals. For these voluntary plans, insurance companies may vary benefits and premiums; they also can deny coverage to people with chronic conditions. Most doctors work on a national fee-for-service scale, and patients have considerable choice of doctors, unless they've selected a managed-care plan.

A majority of Germans (86 percent) get their coverage primarily though the national public system, with others choosing voluntary private health insurance. Most premiums for the public system are based on income and paid for by employers and employees, with subsidies available but capped at earnings of about $65,000. Patients have a lot of choice among doctors and hospitals, and cost sharing is quite low. It's capped for low-income people, reduced for care of those with chronic illnesses, and nonexistent for services to children. There are no subsidies for private health insurance, but the government regulates premiums, which can be higher for people with pre-existing conditions. Private insurers charge premiums on an actuarial basis when they first enroll a customer, and subsequently raise premiums only as a function of age — not health status. Most physicians work in a fee-for-service setting based on negotiated rates, and there are limits on what they can be paid annually.

Ayushman Bharat - The case of India :

The programme is aimed at making interventions to address health holistically, in primary, secondary and tertiary care systems. The initiatives under the programme are:

  1. Health and Wellness Centre - The centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services.

  2. National Health Protection Scheme - The scheme provides coverage of upto Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.

Besides, 24 new Government Medical Colleges and Hospitals will be set up, by up-grading existing district hospitals in the country. This would ensure that there is at least 1 Medical College for every 3 Parliamentary Constituencies and at least 1 Government Medical College in each State of the country. The corresponding targets for Ayushman Bharat are 10 crore families and a maximum coverage of Rs. 5 lakhs.


· Rashtriya Swastha Bima Yojana (RSBY), an existing domestic medical insurance scheme, the actual expenditure for Financial Year 2017-18 was only Rs. 470.52 crores, as opposed to the budgeted Rs. 1,000 crores. It covered around 3.63 crore families up to a maximum expenditure of Rs. 30,000 in health-care cost. the experience of RSBY shows evidence that there has been an increase in hospitalization in private hospitals and, as a result, the expenditure not covered under the scheme has risen. Moreover, most insurance schemes do not cover out-patient visit costs, which are significantly higher for chronic illnesses.

· A scheme for expanding access in tertiary health care cannot work without significantly widening the supply of hospital beds and specialist doctors and there is a massive shortage in the supply of services — trained staff, hospitals and diagnostic centers. The deficit in doctors is particularly wide, with India being at least 75% short of the number of qualified doctors it needs

· The beneficiary lists have not been prepared yet and the overall implementation seems to be rushed through by the government. The realization that a scheme with such a large scope cannot be properly implemented without adequate preparation is needed.

Future Scope:

At least six states are said to be ready to roll out a pilot of the new health care scheme, but there is little clarity on the details.

It was earlier assumed that the scheme would be an insurance-based mechanism, but there are indications to the contrary now. Government seems to have envisioned a greater administrative role in the proposed scheme through public-private partnership.

If so, this is a positive as it will provide welcome flexibility in the initial stages, and allow for experimentation across different designs If the government intends to have a properly working health system, it should ensure that primary healthcare apparatus is properly structured. Notably, most Primary and community health care centers are understaffed, under-funded, under-trained and under-equipped.

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