While the debate on health reform in the USA rages, the nation must confront the fact that, despite its wealth, an estimated 47 million of its citizens have no health coverage at all. In a Viewpoint published Online First and in an upcoming edition of The Lancet, Pulitzer Prize winner and best-selling author Laurie Garrett (Council on Foreign Relations, New York City, USA) and colleagues say that achievement of Universal Health Coverage is not connected to a country's GDP, and cites several examples of countries much poorer than the USA who are doing better.
In addition to the completely exposed American citizens above, the USA also has a further 25—45 million citizens who are covered by insurance so inadequate that major medical events may cause family bankruptcy. Studies have shown that at least half of all bankruptcies filed by American families in 2005 were caused by medical events catastrophic to the family's finances.
Yet many countries with low GDPs, such as Costa Rica, Cuba, Gambia, and Gabon have attained impressive prepaid coverage compared with richer countries such as China, India, and the USA. But many low-income countries struggle with the obvious—lack of money, meaning that some do not spend the minimum of US$34 per person per year on healthcare deemed necessary by the WHO Macroeconomic Commission. Some countries are well below this—Bangladesh ($12) and Ethiopia ($4). Out-of-pocket expenses can cripple families financially, and force them to redirect funds from elsewhere, eg, by withdrawing their children from school.
Garrett and colleagues note that this 'perverse economic trend'—in which the poorest people have the most costly care, as a percentage of personal income and without the benefits of health insurance or social protection—is a major contributor to maternal mortality and to parental decisions denying education to girls. Introduction of universal health financing schemes, on the other hand, improves performance in other social sectors such as education and reduces bankruptcy and other financial emergencies.
The authors say that the countries which have had the most success with universal health care strategies have managed to answer three questions at the highest political levels: i) What are the role and responsibilities of the state for the health of its people? ii) What are responsibilities for the individual for his/her health? iii) What third parties are acceptable, and what are their roles/responsibilities?
Mexico is a nation that has answered all three questions by increasing its spending on health from 4.8% of GDP in 2003 to 6.5% in 2006. Innovative schemes were created to leverage taxation, employer contributions, and individual payments. By 2007 the number of Mexican people covered increased by 20%, use of health services soared, and the numbers of households facing impoverishment plummeted. Mexico is on track to achieve its goal of universal health coverage by 2010, as is the whole of Latin America, which will give hope to Africa, the Middle East and Asia that they can make similar positive steps.
The authors say that the introduction of universal health coverage through insurance schemes that initially target special groups, such as women and children, the very poor, and people with catastrophic illnesses, is a strategic approach that is gaining traction. For example, a new global campaign linked to the Millennium Development Goals promotes "Free quality services for women and children at the point of use and other access barriers removed". United Nations Secretary-General Ban Ki-Moon in his address to the Global Health Forum in New York, USA, this year lent unequivocal support to the universal health coverage aspiration, and to near-term targeting of poor and vulnerable populations.
They conclude: "It is prudent for the world community to accelerate efforts aimed at ensuring health coverage for all, linking the goal with all donor, non-governmental organisation, and country health aspirations and targets related to health, rights, and poverty. This effort will need working on many fronts, starting with the political will of governments and civil societies."
For Laurie Garrett, Council on Foreign Relations, New York City, USA, please contact Sarah Doolin, Communications Office. T) +1 212.434.9886 E) lgarrett@cfr.org
For full Viewpoint, see: http://press.thelancet.com/unihealth.pdf
Journal
The Lancet