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?

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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.

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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.

Corporate hospitals killing small hospitals and exploiting patients

No matter how compelling the reasons, governments cannot be guided by emotions of moral outrage and of right and wrong. A democratic society is founded on the basis of the rule of law that must guide government actions. This is so in order to avoid governments misusing their power, resorting to arbitrary action and ensuring fair play and natural justice. This then implies casting a special responsibility on the governments who are charged with the duty of providing good governance to its people. 

• Having declared health as an industry working on the principle of return on investment and making profits over the welfare and well being of the patients, governments have a special duty to lay down laws, rules and regulations to stop providers and hospital establishments from getting away with predatory behavior or malpractice.
• During the past twenty years, following liberalisation policies, the growth of the IT industry and other factors, as well as disposable incomes among certain classes, have increased – though this is not the case across the social spectrum. 
• As one doctor has said, Pune city, which should have fifty Sassoon Hospitals (public hospitals), has only one, although new corporate and multi-speciality hospitals are coming up daily.
• These corpotrate hospitals are bright and glittering. In some ways, they are like shopping malls. Some have even been registered as charity hospitals, but their only objective is profit. Partly because of their state-of-the-art equipment, but also because of a growing lack of choice, as older hospitals run by trusts or individuals close down, people are going to these hospitals. Such hospitals foster the impression that they provide high-quality services, which justifies their high costs of care.
• There is another important aspect of such “hospital-malls”. New technology costs lakhs and crores of rupees. If these machines are now indispensable for diagnosis, hospitals run by individual doctors are less able to compete. If the medical sector is left to the mercy of the market, and if the foundation of the whole business is profit, where will this take us?
• Government health services have been weakened due to government indifference, and that is why there is scope for corporate hospitals to prosper. Due to the entry of corporates, the order of priorities has changed. Now the doctors’ priority is no longer the best interests of the patients, but the profit earned by the shareholders of the company.
• In corporate hospitals, each patient may be seen by multiple specialists. An orthopaedic is called because the hands and feet are aching; a neurologist for numbness in the hands. They come and look at the patient and their charges are added to the bill. Is it useful for multiple specialists to examine a patient? This question is never even asked. Investigations are not based on what the patient’s illness is, and whether there is a need for specific investigations. Given any complaint, they produce a list of investigations that must be done. 
• Totally unnecessary surgeries are being performed in corporate hospitals. During investigations, they may see a small stone in the gall bladder. It is not causing the patient any problems. But they scare the patient into going in for a surgery.
• Public relations officers of many corporate hospitals keep roaming around to visit doctors; they entice doctors to send patients (to their hospitals) by tempting them with cuts. Nearly everybody indulges in this practice. It must be legally banned.
• These corporate hospitals charge bills of Rs 1 lakh and more, while the surgeon gets only Rs 4000 to 5000.
• Some corporate and large hospitals admit bogus patients under the Rajiv Gandhi Health Scheme (a publicly funded health insurance scheme). They give the admitted person money, and plenty to eat and drink. They prepare records showing that an angioplasty or angiography has been done on that person, when actually nothing has been done. How the government comes out with such schemes, without first regulating private hospitals is a mystery? Without regulation, the basic objectives of such schemes are lost, and they become mechanisms for corporate hospitals to loot public funds.
• There is no humanism to be found in corporate hospitals. Small hospitals are being destroyed due to these corporates. In small hospitals, there is at least the possibility that the doctor has not lost his basic sense of humanism. They wait for the patient to make the payment. They give concessions. None of this happens in corporate hospitals. This must stop.
• A corporate ophthalmology hospital maintain everything five-star style, but forget about the patient. When the patient comes, they give him lemonade or tea. They advertise that they have the latest hi-tech optics shop. The patient melts because of the free lemonade, and he buys a pair of spectacles that have an actual value of Rs 200 or so, for Rs 3000–5000! The in-house optician is the main income avenue of corporate hospitals. Sometimes they offer a free check-up. The scheme has a 20-per-cent-off offer, just like in a mall. The whole atmosphere is designed to tempt.
• Corporates can implement government schemes and insurance schemes. For small private hospitals when reimbursements are delayed they don’t have the time to keep making trips back and forth to get payment from the insurance company.
• Corporate hospitals vie for tie-ups with large public sector companies. These public enterprises give exorbitant reimbursement to their employees. The big corporates draw in cases from all over the state. But junior trainee doctors operate on those cases! Further, often the quality of these corporate hospitals is not as good as they claim in their advertisements. When they do a cataract operation, they even charge a high amount of money for an expensive lens, but implant an average-quality lens.
• If a patient goes with my referral note, he gets 30 to 40 per cent off on an MRI (because I do not take any commission). One patient forgot to take my note. He was charged the full amount, and a cut went to some third party - says a practising paediatrician.
• Nowadays people want glamour and marketing. They have become used to the mall culture. The concept of ‘master check- up’ (packages of large number of tests, of which many may be unnecessary) has gotten into their heads. Now doctors who practise ethically and scientifically are looked upon with contempt, because they obviously can’t afford this glitter. But people often don’t know what they are getting into by going to corporate hospitals.

The current obsession to privatise health, as if it is a commercial enterprise like Air India or a ITDC hotel, is not founded on the belief that patients will gain access to good quality of health care. Instead it smacks more of an admission of governments’ inability to govern and enforce laws in order to ensure that in the name of quality, private hospitals do not play havoc with the vulnerable patients. If truly committed to patients well being, then it is incumbent on the government to come up with stringent laws that will not provide any scope to private players to be negligent, callous or exploitative.

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Truth about how some doctors exploit their patients

Fighting the rot in India's private healthcare feat. 

Dr Arun Gadre & Dr. Abhay Shukla

The corporate hospitals provide employment to almost 90% of graduate doctors, 95% of PG doctors .These corporate hospitals have numbed people’s sensitivities. These hospitals are like malls. Our society does not need them. Instead, all tertiary health care should be provided by the government. And corporate hospitals must also be compelled to provide mandatory treatment of emergency cases, whether paid or otherwise. This would enable people go to any of the nearest hospitals for emergency treatment, even if they don't have money or coverage.