How to Sustainably Finance Universal Health Care

By Mary Suma Cardosa, Chan Chee Khoon, Chee Heng Leng, Jomo Kwame Sundaram

KUALA LUMPUR: To achieve universal health coverage, a country needs a healthcare system that provides equitable access to high quality health care requiring sustainable financing over the long term. Publicly provided healthcare should be on the basis of need, a citizen’s entitlement for all regardless of means.

Health inequalities growing

But recent decades have seen health care trending towards a two-tier system – a perceived higher quality private sector, and lower quality public services. One typical consequence is medical doctors, especially specialists, leaving public service for much more lucrative private practice.

This ‘brain drain’ has led to longer waiting times and complaints of deteriorating public service quality, as more people with means turn to private facilities. As costs in private hospitals are high and increasing, this causes those who can afford private health insurance to turn to it to hedge their bets.

If these trends are not checked, the gap between private and public health sectors in terms of charges and quality will grow, increasing polarisation in access to quality health care between haves and have-nots.

Health care financing

Financing arrangements are key to developing an equitable healthcare system that is financially sustainable in the long run. For universal coverage and equitable access, health financing should be based on social solidarity through cross-subsidisation, with the healthy financing the ill, and the rich subsidising the poor.

Experience the world over shows health markets functioning poorly, both in financing and providing healthcare. Furthermore, heavy reliance on market solutions has contributed to spiralling costs and constrained healthcare access.

Private health insurance

A voluntary private health insurance (PHI) scheme cannot be financially viable in the long term as individuals with lower health risks are less likely to buy insurance from a scheme which they see as primarily benefiting others less healthy.

Since voluntary schemes are usually based on PHI, government support for such schemes would strengthen these companies. There are good reasons to be wary of the growing influence of PHI interests in healthcare financing discussions.

Premiums for PHI are risk-rated, meaning that individuals with pre-existing conditions and higher risks – such as the elderly, or those with family histories of illness – will face un-affordably high premiums or be denied coverage.

‘Moral hazard’ and ‘supplier-induced demand’ in a ‘fee-for-service’ reimbursement system encourage unnecessary investigations and over-treatment, or costly monitoring to limit such abuse. Hence, PHI companies use ‘managed healthcare’ services to contain costs by limiting investigations and treatments.

Voluntary PHI schemes charge high premiums while fee-for-service payments escalate costs which inevitably raise premiums. Thus, the US spends the most on health in the world, but with surprisingly modest health outcomes to show for it.

Much public expenditure is needed to insure the poor, especially those with prior health conditions. Achieving UHC would require costly public subsidisation of such profitable arrangements. This would not be cost-effective, let alone equitable.

Government support for PHI companies would strengthen their growing presence and influence, typically involving transnational insurance conglomerates. PHI companies are likely to try to undermine others threatening their interests.

Social health insurance

Unlike VHI, social health insurance (SHI) is usually mandatory to cover the entire population. Although often proposed and promoted with the best of intentions, the limitations and problems of SHI are also important to consider.

SHI would effectively require collecting an additional ‘payroll tax’ from the public. This could be designed with various distributional consequences, e.g., if flat, it would be regressive. As an additional tax would reduce take-home incomes, SHI schemes have been difficult to introduce.

Like PHI, SHI also has inherent tendencies for over-treatment and cost escalation due to ‘moral hazard’ and ‘supply-induced demand’. These require costly, strong and typically bureaucratic administrative controls.

Surviving SHI schemes owe their ‘success’ to specific reasons, e.g., Germany’s evolved from its long history of union-provided health insurance. But most working people in developing countries are not in formal employment, let alone unionised. Hence, SHI would have difficulty gaining broad acceptance.

In any case, Germany and other countries with successful SHI in the past have been moving to greater revenue funding of healthcare as formal employment and unionisation decline with changing labour arrangements.

With SHI, government revenue would still have to cover the indigent and poor. It is difficult to collect premiums from the self-employed, or the casual and informal workers not on regular payrolls. But universal coverage would not be achieved without including them.

Revenue financed healthcare

Inherited revenue-based healthcare financing is basically sound and should not be replaced due to other healthcare system problems. In most societies, revenue-sourced healthcare financing can be retained, reinforced and improved by:

o increasing government health care allocations.

o reducing ‘leakages’ by eliminating waste, corruption, ‘cronyism’, etc.

o promoting ‘developmental governance’, competitive bidding, etc.

o raising government revenue, especially from more progressive taxation, e.g., wealth, ‘windfall’ and ‘sin’ taxes, especially on activities worsening health risks such as tobacco and sugar consumption.

Revenue financing better

Revenue-financing avoids many administrative costs incurred by PHI and SHI. It has no need for an elaborate parallel system, costly mechanisms and more staff to register, track and pay SHI contributors and beneficiaries, and to deter selfish opportunistic behaviour.

Compared to PHI, SHI seems like a step forward for countries with weak or non-existent public healthcare systems. But moving from revenue-financing to SHI would be a step backwards in terms of both equity and cost-effectiveness.

SHI requires additional layers of health care system administration – to enrol, collect, ascertain coverage, determine benefits and make payments – which incurs unnecessary costs compared to revenue-financing.

Hence, such insurance systems involve much more per capita health spending, raising it by 3-4%. Despite being much more costly than revenue financed systems, they do not have better health outcomes.

As SHI effectively imposes a payroll tax, it discourages employers from hiring employees with ‘proper’ labour contracts. Hence, SHI was estimated to reduce formal contracts by 8-10% and total employment by 5-6% in rich countries.

International evidence clearly shows progressive tax-funded public health systems are more equitable, cost-effective and beneficial than SHI. Public health programmes needing popular participation, e.g., breast or cervical cancer screening, have worse outcomes with SHI compared to revenue-financing.

This can be best achieved by improving or developing a revenue-funded healthcare system, with additional resources deployed to expand and enhance primary health care, and better service conditions for medical personnel.

Strengthening public healthcare services can do much, not only to improve staff work conditions, but also morale and pride in their work.

Mary Suma CARDOSA is a medical doctor specializing in pain management and past President of the Malaysian Medical Association. CHAN Chee Khoon, ScD, is a health systems and health policy analyst with postgraduate training in epidemiology. CHEE Heng Leng, PhD, is an academic researcher working in the area of health and health care policy. All are members of the Citizens Health Initiative.

Covid-19 Cannot Be Defeated by a Divided World

Jomo Kwame Sundaram, Anis Chowdhury SYDNEY and KUALA LUMPUR, Jul 16 (IPS)  - Announcing an independent evaluation of the global Covid-19 response on 9th July, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus asked why it has been "difficult for humans to unite and fight a common enemy that is killing people indiscriminately?". He warned: "The greatest threat we face now is not the virus itself. Rather, it is the lack of leadership and solidarity at the global and national levels… we cannot defeat this pandemic as a divided world", highlighting inter-governmental conflicts over the pandemic and its containment. 

Solidarity desperately needed With more than 600,000 acknowledged deaths, almost 13 million are believed to have been infected by Covid-19 in mid-July. In less than half a year, every country had been affected by the pandemic, designated by the WHO as a "public health emergency of international concern" (PHEIC) on 30th January. Richard Horton, editor of the prestigious Lancet medical journal, has urged the United Nations to convene an emergency special session of the UN General Assembly (UNGA) to make "appropriate recommendations to Members for collective measures".  A "meeting under the auspices of the UN is the only means available to construct a global response to this pandemic". Wondering "why such a global gathering has not yet taken place", he pleaded, "It must take place. And soon".  Covid-19 has been devastating, not only because of its heavy toll on human life, but also because of its adverse impacts on livelihoods, especially for much of the ‘precariat', particularly in the most vulnerable developing countries.  The pandemic's indirect impacts are not well understood as national health systems, already undermined by years of under-investment and creeping privatization, struggle to cope.  Other preventable deaths are rising as less people get medical attention due to loss of livelihoods and health coverage. The Global Fund to Fight AIDS, Tuberculosis and Malaria has estimated an additional 1·44 million deaths from the three killer diseases.  Horton warns, "Global health has entered a period of rapid reversal...Yet no plan is in place, or even being proposed, to address this global regression in human health". For him, "this pandemic deserves historically unrivalled global political leadership. And yet all we have is silence". He asks, "How have we fallen so low?".  WHO "left out to dry" Helen Clark, former New Zealand Prime Minister and co-chair of the independent review, lamented that the WHO has been undermined by lack of support from the United Nations Security Council (UNSC) and the G20, observing, "toxic geopolitics have stopped it doing anything useful at all". On 7th July, the United States gave the required one year's notice to the UN that it would withdraw from the WHO. With the world's largest economy, US withdrawal will greatly weaken WHO finances when it is needed more than ever. The US has not provided meaningful world leadership in recent years, but has instead increasingly undermined the multilateral order it was the primary architect of. Yet, the current campaign against the WHO is unprecedented, and is widely believed to be connected to political, economic and diplomatic mobilization to check China's rise.  In the current context, US withdrawal is expected to greatly undermine multilateral cooperation more broadly. sides endangering the lives and health of billions worldwide, it will undermine multilateralism more generally, not only in the UN system, but even at the World Trade Organization (WTO). WHO could have done better Undoubtedly, the WHO's role in the pandemic could have been better, although how so depends on one's perspective. Despite resource constraints and member-imposed regulations and protocols, it has done well, designating the outbreak a ‘public health emergency of international concern' (PHEIC) on 30th January.  Then, there were only 7,818 confirmed cases of human-to-human transmission, mostly in China, and 82 cases in 18 countries outside China. The WHO advised all countries to "be ready to contain any introduction of the virus and its spread through active surveillance, early detection, isolation and case management, contact tracing, and prevention".  Yet, mistakes were undoubtedly made, e.g., discouraging the use of face masks, ostensibly to ensure adequate protective personal equipment for medical personnel and other ‘frontline workers'.  But there is no conclusive evidence, except for uncorroborated claims by the anti-China Japanese and Taiwanese authorities, greatly amplified by the media in India, Australia and the US, of the WHO being controlled by and biased towards China. Refusing to prepare The first WHO fact-finding mission to China emphasized the success of prompt, early precautionary measures, including testing, tracing, isolation and treatment. Contagion could still have been contained by adopting WHO recommended measures. Yet, except for a handful of East Asian countries and Kerala state, in southwest India, much of the rest of the world, including most who could afford more adequate precautionary measures, did little to contain the contagion until they had little choice but to impose ‘stay in shelter' lockdown measures.  When the WHO declared Covid-19 a "pandemic" on 11th March, there were over 118,000 confirmed cases and 4,291 deaths in 114 countries, with more than 90% of cases in four countries: China, Iran, Italy and South Korea.  By then, new infections were already declining rapidly in China and South Korea, while 81 countries reported no cases, and 57 had ten cases or less. Yet, inaction persisted, even justified in terms of developing ‘herd immunity'. To be sure, many rich countries had been weakening the WHO for decades before the Covid-19 pandemic. Reliable long-term mandatory funding had fallen from 62% of its budget in 1970-71 to 18% in 2017.  As Stewart Patrick noted, "much of the blame can be laid at the feet of member states, which have saddled the WHO with an ever-expanding mission set reflecting their individual priorities, while providing it with a modest operating budget… smaller than that of some big city U.S. hospitals.  "Compounding these difficulties, national governments have repeatedly proved resistant to accepting WHO guidance or fulfilling their international legal obligations during declared public health emergencies".  Security Council must act  In 2014, the UNSC responded promptly to the Ebola crisis, declaring the virus a threat to peace and security, thus ‘legally obliging' Member States to do whatever they can to check the threat.  Despite its much greater morbidity and mortality impacts worldwide, the UNSC took half a year to back the UN Secretary-General's global ceasefire appeal following the Covid-19 outbreak.  Covid-19 is arguably the greatest threat to peace and security since the Second World War. Now that the UNSC is finally acting, only seven of the 15-member Council can convene UN Member States for an emergency UNGA special session to do the right thing.

Also available online here: http://www.ipsnews.net/2020/07/covid-19-cannot-defeated-divided-world/

Rethink Food Security and Nutrition Following Covid-19 Pandemic

Jomo Kwame Sundaram, Wan Manan Muda KUALA LUMPUR, Malaysia, Jul 02 (IPS)  - The Covid-19 crisis has had several unexpected effects, including renewed attention to food security concerns. Earlier understandings of food security in terms of production self-sufficiency have given way to importing supplies since late 20th century promotion of trade liberalization.

Transnational food business Disruption of transnational food supply chains and the devastation of many vulnerable livelihoods by policy responses to the Covid-19 pandemic have revived interest in earlier understandings of food self-sufficiency. But, even if successful, winding back policy will not address more recently recognized food challenges such as malnutrition and safety. All too many food researchers have been successfully compromised, e.g., with generous research and travel funding, by food and beverage businesses to discourage criticisms of their lucrative business practices. It is important for authorities to make sure that food is produced safely for consumers. The authorities should not only be concerned when food exports are blocked by foreign importers for failing to meet phyto-sanitary standards. Is food safe for consumption? Are toxic agro-chemicals putting consumers at risk? Are anti-biotics, used for animal breeding, putting animal and human health at risk of antimicrobial resistance? Are food processing practices compromising consumers' nutrition? Malnutrition threat looming larger The world has to deal with three major types of malnutrition, i.e., dietary energy undernourishment, or hunger; ‘hidden hunger', due to micronutrient deficiencies of vitamins, minerals and trace elements; and diet-related non-communicable diseases (NCDs). Many of the poor typically lack means to improve their condition, with the poorest often lethargic, due to not getting enough to eat, or not being able to gain sufficient nourishment from food due to gastrointestinal diseases, typically due to poor sanitation and hygiene. Although hunger and starvation have reportedly been declining in recent decades, dietary energy undernourishment has been falling more slowly than poverty although the poverty line is supposedly defined by an income level to avoid hunger. The nutrition situation in the world remains worrying as other manifestations of malnutrition -- including stunting, obesity, diabetes and anaemia -- have been growing, or declining slowly at best, according to available official evidence. Micronutrient deficiencies Micronutrient deficiencies threaten human health and wellbeing, but rarely get much public policy attention. ‘Hidden hunger' is due to diets lacking essential micronutrients -- vitamins, minerals, trace elements -- vital for the body to develop and function well. Insufficient vitamin A, iron, calcium and zinc seem to be the major micronutrient deficiencies of public health importance. All too many people are anaemic, with especially serious consequences for women of reproductive age. In many countries, iodine deficiencies have been successfully tackled by iodizing salt, while vitamin A is typically tackled with costly supplements for children under five. Such hidden hunger is usually better addressed by dietary diversity to consume food with the needed micronutrients. Biofortification can help, but for this to work well, close collaboration is needed between nutritionists and dieticians on the one hand, and scientists working to improve food crops and animal-source foods on the other. Child undernutrition Most parents are not aware that the ‘first 1000 days', from conception until the child is two, is most critical for child development. Maternal and infant malnutrition start during pregnancy, especially with pregnant mothers suffering micronutrient deficiencies or diet-related NCDs. We can and must do much more to enable and promote ‘exclusive breastfeeding' for the first six months of every child's life. Various work and maternity leave arrangements as well as childcare facilities should be made available to enable widespread adoption of such practices. While international measures suggest that wasting, stunting and underweight among children are declining all too slowly, child undernutrition remains high, with national shares still rising in many, including middle income countries. Child stunting not only adversely effects children's physical development, but also their cognitive development. How can societies and economies progress if future generations continue to be handicapped from the outset. Non-communicable diseases The crises of obesity, diabetes and other diet-related NCDs in middle income countries remains alarming, with NCDs among the leading causes of premature death and disability. The prevalence of overweight, obesity, diabetes and related morbidities has increased in most countries. Overweight and obesity are risk factors for NCDs, such as diabetes, cardiovascular diseases and cancers, which reduce the quality of life and productivity, unnecessarily raising health costs, both private and public. Often, people are not aware of the consequences of eating much more carbohydrates, calories or ‘dietary energy' than they normally use or need. Over-eating -- often wrongly termed over-nutrition or over-nourishment -- often leads to diet-related NCDs and their consequences. Various non-infectious diseases are due to what we have eaten or drunk in excess, especially processed sugars. Excessive consumption of ‘starchy' foods or carbohydrates raises blood sugar levels which cause diabetes and other problems including excessive weight gain. Thus, sugar ‘addiction' directly contributes to various malnutrition problems. Meanwhile, excessive salt consumption contributes to hypertension or ‘high blood pressure' which, in turn, causes various other health problems. Meanwhile, deep fried food has become the most popular type of ‘fast food', concealing possible staleness or even ‘rotting', as more prepared meals are increasingly purchased and consumed, not prepared at home. Balanced, healthy diets The consequences of not eating properly need to be widely understood. Healthy eating requires dietary diversity. Healthy diets should be adequately diverse, to ensure consumption of various foods. Consuming a variety of nutritious foods can supply all the nutrients people need. We all need macronutrients (carbohydrates, protein, fats), without overeating staples like rice or bread, or fatty, sugary and salty food, and micronutrients, especially vitamins and minerals. Governments, employers, family and peer pressure can help encourage better eating. Food regulations and meal arrangements can thus improve eating practices, behaviour and habits. When people better understand the effects of their food behaviour, and have relevant, easily comprehensible and actionable knowledge and information, many will try to improve their food behaviour. But misleading ‘information' from food and beverage companies and advertising firms is widespread and influential in popular culture. The problem is made worse by popular, even iconic figures who dispense misleading ideas, even half-truths, as part of their own discourses and narratives, often without meaning to do harm, but as part of their own efforts to gain or retain popularity, legitimacy and authority. Various media and popular culture -- at the workplace, at worship and at home -- as well as peers, family and friends greatly influence food behaviours. Women, typically the main caregivers, are particularly important, often choosing the food purchased, prepared and consumed. Transforming food systems Food systems need to be repurposed to better produce and supply safe and nutritious food. Ensuring that food systems improve nutrition is not just a matter of increasing production. The entire ‘nutrition value chain' -- from farm to fork, from production to consumption -- needs to be considered to ensure the food system better feeds the population. Food systems have to improve production practices, post-harvest processing and consumption behaviour. Resource use and abuse as well as environmental damage due to food production and consumption need to be addressed to ensure sustainable food systems. Governments must realize that improving nutrition is crucial for economic and social progress. No country can achieve and sustain development with a malnourished population. Without healthy people, future productivity and progress will be severely compromised. Good nutrition and food safety are necessary for healthy societies and future progress. Governments should use the Covid-19 induced reconsideration of food security in relation to supply chains to better address malnutrition and safety issues. Food security initiatives prompted by pandemic considerations should promote food system changes that will encourage more sustainable and healthy diets. This opportunity to strengthen food systems must also prioritize nutrition, food safety and dietary diversity. Professor Wan Manan Muda is Visiting Professor at Alma Ata University in Jogjakarta, Indonesia. He was Professor of Public Health and Nutrition at Universiti Sains Malaysia, and long active in Malaysian university reform efforts. Link http://ipsnews.net/2020/07/rethink-food-security-nutrition-following-covid-19-pandemic