Universal health coverage (UHC)

• UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma Ata declaration in 1978. UHC cuts across all of the health-related Sustainable Development Goals (SDGs) and brings hope of better health and protection for the world’s poorest.
• Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
• There is no single, best path for reforming health financing arrangements to move systems closer to universal health coverage, i.e. to improve access to needed, effective services while protecting users from financial ruin.
• In most countries, the government pays for health care provided by private companies. These include the systems in Australia, Canada, France, Germany, Singapore, and Switzerland. United States also provides subsidies to health insurance companies through Obamacare. 
• When the government both pays for and provides the services, that is socialized medicine. The United Kingdom has this. The United States has it for its veterans and the armed forces.
• Countries often combine universal health coverage with other systems to introduce competition. These include pay as you go, prepay, and private insurance models. Allowing these options can lower costs, expand choice, or improve care.

HEALTH CARE IN INDIA

• Health care is a service that people would very much rather not have to use. Of the total health spending in India, the government contributes just 29%. In the UK, the government's share is 83%. For many other countries, this figure ranges between 45% and 55%. As a proportion of GDP, India spends just 1.2% on health while US spends about 8.3% of its GDP. 
• For ensuring health to all, the government's health care spending must be increased from the present 1.2% to 5% very quickly and to 8-10% if necessary. As government sector fails to provide primary and secondary medical care, around 80% of these services were being provided by the private sector and 70% by the small hospitals and individuals doctors. 
• Only a healthy nation can be happy, productive and prosperous.
• Private healthcare expenditure amounts to around 4% of the GDP. Of this, health insurance accounts for 5-10% of expenditure, employers account for around 9% while personal expenditure amounts to an astounding 82%.
• Barely 10-15% of the population has some form of insurance coverage. 40% households report loss of income during illness. Nearly 8-9% of households takes loans to meet their medical expenses. Meeting healthcare expenses is one of the major concerns for households.
• Nearly 22% of urban and 33% of rural households (all India 30%) are financially-vulnerable with negative surplus income due to private healthcare expenses. For such households, a medical emergency would tip them over the financial edge. The present 30% vulnerable households will rise to 86% in case of an additional burden of Rs. 1 lakh towards medical expenses.
• Only 34% households in India said that they can “easily” meet their medical expenses. More than half of metro households (53%) fall in this category.
• While private health insurance coverage is on the rise, this system is far from efficient to meet the needs of diverse population segments. The absence of a comprehensive health insurance is pushing already vulnerable households below the poverty line at the rate of 3.4% (4 crores) of population, annually.
• The sheer cost of providing quality health care makes universal health care a large expense for governments.
• The key issue is when a large majority of population is feeling overwhelmed by the cost of healthcare, should it be left to the supermarkets to promote healthy living and create systems where medical services can be attained in a timely and cost-effective manner? Or do policy-makers need to look at “healthcare” as a key element of the economic well-being of the country?

Read source article 1

ADVANTAGES OF UHC

• When governments pay for health care, they work to ensure doctors and hospitals provide quality care at a reasonable cost. They must collect and analyze data. They can also use their purchasing power to influence health care providers.
• UHC lowers health care costs for an economy. The government controls the price of medication and medical services through negotiation and regulation.
• UHC eliminates the administrative costs of a dealing with different private health insurers. Doctors only deal with one government agency. It standardizes billing procedures and coverage rules.
• UHC forces hospitals and doctors to provide the same standard of service at a low cost. In a competitive environment like the United States, health care providers focus on new technology. They offer expensive services and pay doctors more. They try to compete by targeting the wealthy. They charge more to get a higher profit. It leads to higher costs.
• Universal health care creates a healthier workforce. Preventive care reduces the need for expensive emergency room usage. Before Obamacare, 46% of emergency room patients went because they had no other place to go. They used the emergency room as their primary care physician. 
• Early childhood care prevents future social costs. These include crime, welfare dependency, and health issues. Health education teaches families how to make healthy lifestyle choices, preventing chronic diseases.
• Governments can impose regulations and taxes to guide the population toward healthier choices. Regulations make unhealthy choices, such as drugs, illegal. Taxes, such as those on cigarettes and alcohol, make them more expensive.

DISADVANTAGES OF UHC

• Universal health care forces healthy people to pay for others' medical care.
• Chronic diseases, like diabetes and heart disease, make up 85% of health care costs. These diseases can often be prevented with lifestyle choices. The sickest 5% of the population consume 50% of total health care costs. The healthiest 50% consume only 3% of the nation's health care costs. 
• With free universal health care, people may not be as careful with their health. The don't have the financial incentive to do so. Without a copay, people might overuse emergency rooms and doctors.
• Most universal health systems report long wait times for elective procedures. The government focuses on providing basic and emergency health care. 
• Governments limit payment amounts to keep costs low. Doctors have less incentive to provide quality care if they aren't well paid. They might spend less time per patient to keep their costs down. They have less funding for new life-saving technologies.
• Health care costs overwhelm government budgets. Some Canadian provinces spend 40% of their budget on health care. That reduces funding for other programs like education and infrastructure.
• To cut costs, the government may limit services with a low probability of success. It may not cover drugs for rare conditions. It may prefer palliative care over expensive end-of-life care.
• On the other hand, the U.S. medical system does a heroic job of saving lives, but at a cost. 
• Care for patients in the last 6 years of life makes up one-fourth of the Medicare budget. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One-fifth undergo surgery.

Read source article 2

The Heritage Index of Economic Freedom 2018, which ranks the pecuniary freedom of citizens, found that the top ten nations in the list all had universal healthcare schemes. Hong Kong, Singapore, Australia, New Zealand, Canada, Switzerland, and Denmark are among the the top ten countries. The United States is ranked 12 and India ranked 130 out of 180 countries. Medical insurance is one of the systems most abused anywhere in the world. In India, it is more so. The drug companies, corporate hospitals, doctors and diagnostic services form cartel and loot gullible patients and inefficient insurance companies. This leads to ever increasing health insurance premiums with no matching quality services. This must stop. 

UHC in India with annual spend of over Rs.800,000 crores (@5% of GDP of $2.6 trillion in 2016) requires gigantic organisation(s) and is no easy task. But that is the least that should be done for India to become healthy, productive and prosper. Every year we find an impassioned paragraph in FM's budget speeches and that is the end of it. But so far governments have neglected health care and private sector exploiting and pushing 4 crore people annually below poverty line is a matter of national shame. 

Health insurance increases the costs, burdens doctors, patients compelled to follow their procedures and promotes corruption. Government taxing its citizens to pay for health care where services are government-owned, and service providers are government employees is the least cost and best option but requires intense efforts are needed for managing multiple layers of the organisations efficiently, transparently while being vigilant. Primary care must be in public sector only, while secondary health and tertiary health care could be in both public and private sectors.

World Health Organization Ranking of India  is at 112 of 190 countries. USA is at 37, Pakistan at 122, Bangladesh at 88, Sri Lanka at 76, Nepal at 150, China at 144 indicates pathetic conditions prevailing in our health care sector.

Dissenting Diagnosis: private medical sector's hard truths

Dr Arun Gadre and Dr Abhay Shukla, authors of the book

• Traditionally, doctors have enjoyed great social prestige and the gratitude of their patients, but this has not spread to higher personal or professional standards or to the highest ethical standards.
• Complaints about the state of medical care are increasing in today’ India: whether it’s unnecessary investigations, botched operations or expensive—sometimes even harmful—medication. But while the unease is widespread, few outside the profession understand the extent to which the medical system is being distorted. 
• Dr Arun Gadre and Dr Abhay Shukla have gathered evidence from seventy-eight practising doctors, in both the private and public medical sectors, to expose the ways in which vulnerable patients are exploited by a system that promotes unscrupulous medical practices. At a time when the medical sector is growing rapidly, especially in urban areas, with the proliferation of multi-specialty hospitals and the adoption of ever-more sophisticated technologies, rational and ethical medical care is becoming increasingly rare. 
• Honest doctors feel under siege, professional bodies meant to regulate the medical sector fail to do so, and the influence of the powerful pharmaceutical industry becomes even more pervasive. Drawing on the frank and courageous statements of these seventy-eight doctors dismayed at the state of their profession, Dissenting Diagnosis lays bare the corruption afflicting the medical sector in India and sets out solutions for a healthier future.
• With testimonials from 78 doctors practicing in six states and across 23 fields of medicine (including traditional), the book spares no one. From big "hospital malls" right down to autorickshaw drivers (paid to direct patients to specific clinic), it claims, everyone is on the take.
• According to  WHO about 3.5 crores of Indians are pushed below poverty line each year just on account of expenditure on private medical services since they can not access good quality public health care services. 
• Regulatory bodies that exist today are inward-looking, closed committees, incestuous groups that lack openness and hence fail to check their own members. 
• Doctors who were grounded in the idea of service have felt ground swept away under their feet, their traditions of 'keep the patient foremost' rapidly buried under the ruthless logic of 'keep profits foremost'. There has been decline of transparency in medical sector and over all position of  many doctors and their associations has been complicit silence or active support of the guilty.
• Many private doctors often send patients with complicated illness or terminal diseases to government hospitals or AIIMS as dumping ground. And poor patients who can't afford expenses of private medical care also come to these institutions. That is why doctors from these institutions have significant knowledge. 
• The rot is deepening with the increasing onslaught of big corporate hospitals, growing pressure from the pharmaceutical industry and massively expanding clout of medical equipment agencies.

SOME EXCERPTS

• When a teenager’s family approached me for a second opinion about terminating an unwanted pregnancy, I discovered that the girl was not pregnant to begin with. The family was shown someone else’s blood work to convince them of the need for an abortion, says Pune-based gynaecologist, Dr Arun Gadre.
• There’s a code of honour among doctors and while they may compete, publicly, one doctor will not criticise another. It is extremely hard for the families of patients to fight medical malpractices and get justice because they would simply not find a doctor to come forward and testify in court, as would be required.
• Just as shopping malls have come up to sell groceries and consumer goods, corporate and large multi-specialty private hospitals have come up to sell medical services. Majority of these corporate hospitals are not owned by doctors. Seeing the large profits to be made in private medical sector, non-medical investors are pouring money into these private medical businesses to maximise returns on their investment.
• While there do exist doctors practising ethically, they are far-far less compared to those who have fallen prey to unethical activities for whatever reasons; and the former are constantly being threatened and frightened into making way for the latter.
• A senior pathologist explained to the authors: ‘Even my MBBS friends — who have now become consultants — do not refer patients to me because I don’t give them cuts.’
• Learning from the lives of those among us who still practise rational and ethical medicine, and taking guidance from them, is one great way to start.
• We have sunk to such depths that I have come to the conclusion that things will (now) improve simply because there is no way they can become any worse says a general surgeon.
• The 'packages' offered by multispeciality corporate hospitals, incorporating a range of tests under 'master checkup', not only drains an individual of his hard-earned money but the collected samples go down the 'sink' as well. The sink tests essentially means samples collected from patients are just thrown into the wash basin without testing as doctors prescribe such tests, which by mutual understanding, are "not actually carried out" by the pathologist.
• These corporate hospitals run on a perverted concept. Their only purpose is to satisfy the interests of their shareholders. The more profit the better. They go on prescribing needless investigations and surgeries.
• The initial chapters contain information about things that most educated people have an inkling of: the nexus between pharmaceutical companies and corporate hospitals; the pressure on doctors to prescribe as many costly investigations and tests as possible, to earn a pre-specified revenue for their hospitals; the lack of transparency and the emotional exploitation of patients’ families in situations where every second counts and composed reflection isn’t possible.
• It has become a common practice to bring expensive new medicines to market in place of useful cheaper medicines just to increase profits.
• Many elderly persons who only need proper spectacles have been told to get operated for cataract (which they don’t even have), and they are told the charges are Rs.30,000-40,000. Those who have insurance fall into the trap and go in for the surgery. Those who don’t have insurance, if go for a second honest opinion, they might get saved!
• Some hospitals where they don’t actually admit patients, but merely prepare the paperwork for insurance claim. The hospital, the patient and the TPA share the proceeds.
• A senior super-specialist urologist had to leave a corporate hospital because its young MBBS CEO castigated him for not performing a particular operation for removal of a kidney stone where there was no need for any such procedure.
• A person had to sell his apartment after a major corporate hospital came up with a bill of an astounding Rs 42 lakh for the treatment of his wife. "The actual expenditure cannot possibly even come close to this."
• Medical Council of India (MCI), has turned a blind eye to the systemic assualt on ethics in the medical profession. Whatever actions the MCI ethics committee take in Delhi, the state councils defy.
• With onslaught of technology, doctors lost their clinical sense. They increasingly depend on investigations rather on their experience and skills. Doing full body investigations routinely without any indications.
• When the patient is young, and the disease is reversible - certainly doctor should use ventilator. But what is the point in pushing forward for a short while an old man's death with ICU and ventilator that too while doctor ruin him financially and increase his sufferings?
• Modern medicine is not personalized medicine as it used to be but became an evident based medicine. Most diseases get cured with idiopathic treatment. If not then investigations were ordered on fifth day but in these modern days they are ordered on day one. 
• If prescriptions of generic medicines is made mandatory, cost of medicines would become very low. It is a rare patient who gets away with one or two investigations. Most patients hold a list of unnecessary investigations.
• Among other shocking revelations, the book describes how in the absence of serious ailments, a "pretense" of surgery is performed, a patient is given anesthesia and some stitches are put on the skin, to show that an operation has been done.
• Dr Vijay Ajgaonkar, a senior Mumbai-based diabetologist, says “If you look at the issue objectively, it is not our role to make money by taking advantage of another person’s illness. But this is exactly what is happening. They put terminally ill 70 to 80-year-olds on ventilators, keeping the hospital meter running by unnecessarily using the ICU and ventilator.”
• Doctors do not even record the patient's history properly, said Dr Punyabrata Goon, a General Practitioner in Kolkata. They just write out a list of investigations as they get a commission for doing that, he says. "Almost all the laboratories in our area give 50% commission and almost all the doctors accept these commissions. For many doctors, the money earned through commissions is much more than that earned from fees. In our area, the commission rates are: X-rays 25%, and 33% for MRIs and CT scans," he says.
• Even a normal fever is shown as dengue or in worst case scenario.
• A young doctor's lament, on him being pulled up by the CEO of a corporate hospital for "low conversion rate" of 15% as opposed to 40% fixed by the management is also recorded in the book. Conversion rate means out of the total number of patients seen by the doctor, the percentage which are advised to undergo surgery or procedures.
• That malpractices in healthcare exist will come as no surprise to anyone who has dealt firsthand with the beast.
• A young man says - I remember my dadi’s exasperated cackle when she was being sent home following a stint in Max Saket in late 2014: after five days in the hospital where a doctor would drop by once or twice a day, give a curt instruction and swish out in 30 seconds (having added Rs 900 to our already-sizable bill for each such “consultation”), she was discharged with a diagnosis of piles when, even in her groggy state, she knew it was no such thing; that her gastric problems were an effect of the blood-thinners she had been taking since her angioplasty. How she rolled her eyes and muttered as we put her on the stretcher for the ambulance. Sure enough, after she spent a very uncomfortable month at home, we were back in the hospital explaining her case all over again to a new set of smiling doctors who made the correct diagnosis this time – not so much because of competence, I suspect, but because there were only so many available possibilities.
• The story about a speed-obsessed senior surgeon, for instance, who accidentally cut a major artery during a routine kidney operation, consequently had to remove the entire organ instead of just the stones – and later told the patient’s family that he had executed a heroic last-minute turnaround because the kidney was damaged beforehand. Another story is about a hospital that hid a deceased patient’s body to put pressure on the family since they hadn’t been able to pay the full bill.

Asia’s third-largest economy spends about 1% of its GDP on public health, compared with China’s 3% and the United States’ 8.3%. In European countries, the figure is even higher. Indian states manage their health budgets separately, but the overall direction in which the sector is moving is alarming. In 2015, India was ranked 112 in healthcare globally by WHO, which is tragic for an economy of this size. India has to step up expenditure on public health to at least to 5% and needs to regulate the sector.

It is better to deserve honors and not have them 

than to have them and not deserve them ... Mark Twain

Tagore Telugu Movie (2003) - Hospital Very Funny Scene

During mid 1970's, a colleague of mine visited an ophthalmologist who has sent him to a neurologist at KEM Hospital in Mumbai (then Bombay). He was diagnosed brain tumor and was admitted and emergency surgery was done within hours. He was a bachelor and had neither money nor a companion with him. His uninformed absence was noted in the office. After two weeks he walked into office and explained colleagues what has happened to him that made everyone dumbfounded. Gone are those days, where anyone could undergo brain surgery with zero expenditure and no one to attend him! 

The root causes of all these maladies are greed in all walks of life, capitation fees in private medical colleges and total disregard for ethics and values. Ethical & Moral education must be imparted right from childhood in addition to the western school syllabus. These days most doctors are non-merit & capitation fees paid students and their competence is hardly excellent. 

These days most doctors & hospitals are predators in the guise of saviors. Since we don't have choice, we should take care of ourselves.

Defecating Outdoors

Nearly a billion people still defecate outdoors, world wide of which half of them live in India.The problem isn’t just a lack of toilets—it’s a lack of toilets that people want to use. The results in millions of deaths and disease-stunted lives.

• Defecating in the open is as old as humankind. 
• As long as population densities were low and the earth could safely absorb human wastes, it caused few problems.
• In rural India outdoor defecation is considered the manly thing to do. 
• Open defecation, as strange as this may sound to Westerners, offers young women a welcome break from their domestic confines and the oversight of in-laws and husbands.
• In rural northern India open defecation is more prevalent than in the south, where people express a keen preference for relieving themselves outdoors. It’s healthier, they feel. It’s natural and even virtuous. Many rural Indians consider even the most immaculate latrine religiously polluting; a toilet near the home seems more unclean to them than answering the call of nature 200 yards away. Flies, however, can travel more than a mile.
• Pit latrines have a huge drawback: They fill up. And rather than empty a pit with a shovel or hire a pump truck or easier still to dig a new latrine, rural Indians, especially in northern India, often opt to build no latrine at all.
• Privately constructed pit latrines were four to five times larger than the 50 cubic feet recommended by the WHO. That’s the size used all over the world and a family of six won’t fill it for five years.
• In recent years Dalits struggling for equality have begun to shun the sorts of jobs historically used to justify their oppression. And so the cost of emptying a pit latrine has risen as demand for the service has outstripped the supply of willing workers. Given this fraught social and economic landscape, some rural Indians save enough money to build a latrine pit so big (~1000 cft) they’ll never have to empty it. Or that most of them who could afford a simple latrine, choose to conduct their business in outdoors.
• Diseases caused by poor sanitation and unsafe water kill more children.
• In 2015 the United Nations called for an end to open defecation by 2030. 
• In India, open defecation got reduced from 75% to 44%, in the past 25 years.
• The health toll in India is staggering. Diarrhea kills many children under age five each year. Millions more struggle on with chronically infected intestines that don’t absorb nutrients and medicines well. Underweight women give birth to underweight babies, more vulnerable to infections, more likely to be stunted, and less able to benefit from vaccines. 
• In 2016, 39% of Indian children under age five were stunted.

Sanitation is more important than independence ... Mahatma Gandhi

Simple pit latrines though not fully sanitary are simplest, cheapest and are the most common form of latrines. Despite its disadvantages like odor and fly and mosquito nuisances they are promoted to discourage open defecation and other unsanitary practices. Although expensive, the flush latrines and sewers require running water, which many parts of India still don’t have. With education and affluence these things will vanish over time and in the meantime government should focus more on running water supply, sanitation and sewerage lines which are essential for flush latrines without which what ever is talked is just publicity and political gimmick.