Why are Americans so opposed to universal health coverage

Healthcare for All: The global community is setting itself an ambitious goal

All people worldwide should have access to medical care without running the risk of ruining themselves financially. The World Health Organization has put the issue high on the political agenda.

The fever was very high on the fourth day and I couldn't take it home. So I deposited my piece of land to borrow money - for food, medicine and transportation. ”Because she has to have her sick child treated in hospital, the Cambodian mother is facing financial ruin. Viktoria Rabovskaja from the Society for International Cooperation (GIZ) described the case in Deutsches Ärzteblatt (issue 44/2012) a year ago.

150 million people are impoverished every year because they have to pay their medical expenses out of their own pocket. A billion people are left unserved.

Stories like these are still part of everyday life, especially in developing and emerging countries. According to estimates by the World Health Organization (WHO), the fact that they have to pay for health services in cash and out of their own pocket ends in financial catastrophe for 150 million people every year. In addition, there are around a billion people who have no access to health care at all because they cannot afford it, because there is no medical infrastructure or because there is a lack of health professionals.

The United Nations committed itself to the human right to health as early as 1948. "Everyone has the right to a standard of living that guarantees his and his family's health and well-being, including food, clothing, housing, medical care and necessary social services [...]", says Article 25 of the Universal Declaration of Human Rights. But from the realization of this right

the world is still a long way off despite various efforts.

The Millennium Development Goals were certainly a milestone on the way to better health care. In 2000 the United Nations passed the "Millennium Declaration". Hunger, disease and environmental degradation should be combated and access to education improved. The intentions were specified a year later: Eight “Millennium Development Goals” were to be achieved by 2015. Three goals were explicitly related to health: reducing child mortality, improving maternal health, and fighting HIV / AIDS, malaria and other communicable diseases.

This year's WHO World Health Report admits that the Millennium Development Goals could not be fully achieved. In many cases, however, they paved the way for better health care and made progress measurable with a precise set of indicators. The report lists examples: It is true that the world will miss the goal it has set itself of reducing the mortality rate among children under five by two thirds by 2015. Nevertheless, the rate fell by a good 40 percent compared to 1990. Twelve million children died 20 years ago

he before her fifth birthday, in 2011 there were just under seven million.

By 2015, all women should have access to contraception, antenatal care and obstetrics. In three of the six WHO regions, the proportion of births cared for by medical professionals is now more than 90 percent, the WHO writes in its report. However, the situation in other regions is in great need of improvement. In parts of Africa, for example, fewer than 50 percent of births are still being accompanied professionally.

According to the Federal Ministry for Economic Cooperation and Development (BMZ), there is now intensive discussion about a follow-up program for the period after 2015. The United Nations intends to develop global goals for sustainable development by autumn 2014. The WHO wants universal, affordable access to health

universal health coverage play a central role.

The 194 member states of the WHO had already committed themselves to the principles of Universal Health Coverage at the World Health Assembly in 2005. According to this, everyone should have access to the care they need without any financial risk. The prerequisites for this are an efficient health system, an adequate financing system, access to medicines and well-trained health professionals.

The World Health Report in 2010 dealt with the financing issue. Knowing that there can be no blueprint, the WHO recommends observing four principles on the way to health care for everyone: direct payments from patients should be avoided as far as possible and mandatory advance payments (contributions) should be introduced; the largest possible risk pools should be formed and headed

revenues are used to secure the majority of the population.

According to Christopher Dye, the most politically significant step on the way to universal health coverage is the corresponding resolution of the General Assembly of the United Nations last December. "The issue was taken to another level there," says the director of health information, HIV / AIDS, tuberculosis, malaria and neglected tropical diseases at the WHO. "Since then, health is no longer just a value in itself, health is recognized as an important factor for productivity and development."

Dye is the lead author of this year's World Health Report entitled “Research for Universal Health Coverage”, which will also be discussed at the World Health Summit from October 20-22 in Berlin. “We need research to make progress,” says the biologist. What Universal Health Coverage means in detail differs from country to country. And how the concept can be realized can only be decided on the basis of reliable study data. “One of our key messages in the World Health Report is therefore that research is absolutely essential if you can

Wants to achieve the goal of health care for all people. "

It is important that the countries - including the developing and emerging countries - set their own research priorities, because problems and possible solutions are very different. While Western Europe, for example, had to deal with the question of how demographic developments, with more and more elderly people, are affecting health costs, the poorest countries in Africa must first of all ensure access to basic health services for their populations.

According to Dye, it is hopeful that countries such as Brazil, India and China in particular have increased their research investments significantly in recent years. These are average in the countries with

The 2010 and 2013 WHO World Health Reports looked at the funding and role of research in universal access to health care. Like the position paper on “Health Care for All” from Oxfam, both are available at www.aerzteblatt.de/131952.
low or middle income has risen by five percent annually.

"We still lack many answers to the question of how we can get care for all from today's point of view," says the WHO director. "That is why we need a wide range of basic and health services research." Research should not only take place at universities, but must also reflect everyday health care. “We also have to bring together scientists and political decision-makers more quickly so that we can put scientific findings into practice more quickly,” demands Dye.

The health policy dimension of medical study results is shown by an example from Dye's own field of work: studies show that the risk of infection in couples, only one of whom is HIV-positive, drops by almost 100 percent if that partner is treated with antiretroviral drugs. “This means that antiretroviral therapy not only extends the life of the individual patient. It can also be used for prevention and help contain the AIDS pandemic. ”Research can help set health policy priorities, says Dye. Because only half of those infected with HIV in need of treatment still receive antiretroviral therapy. Five million people continue to wait in vain for medication. “We want to exert political influence. Because that's the only way we can achieve our goals, ”says WHO Director Dye. “Our members are the world's health ministers. We have to convince them. They have to say

en: We see that it works, and that is why we are implementing it now. "

"The WHO has done a good job on the subject of Universal Health Coverage," says Tobias Luppe, Health Systems Advisor at Oxfam Germany. She set milestones with the world health reports on funding and research.

Oxfam has now devoted its own report to the topic of “health care for all”, which the organization published in mid-October. Access to equal health care could change the lives of millions of people for the better, it said. For Oxfam, Universal Health Coverage means that everyone has the same financial protection in the event of illness and access to the same high quality health services

n - regardless of their income and solvency.

Unlike the WHO, Oxfam is clearly in favor of tax-financed systems when it comes to funding universal health coverage. Contribution-financed health insurance models leave the majority of people out in developing countries. "In countries like Zambia, Tanzania or Nepal, half of the population works in the informal sector," says Luppe. "How do you intend to collect contributions regularly from these people, who still hardly earn anything?"

Nonetheless, many governments and donors have advocated voluntary private and community-based health insurance models. According to the Oxfam report, however, it has been proven that these reach fewer people, entail high administrative costs and often exclude the poor. Attempts to implement models of social health insurance in developing and emerging countries have also failed. In Tanzania, for example, social health insurances only reached 17 percent of the population ten years after they were introduced. The same applies to the mandatory insurance model in Ghana. It'll largely be considered a success

Achieving the best possible level of health for all people is the task of WHO, an organization of the United Nations. The independent development organization Oxfam is committed to a just world without poverty. Photos: Photo library (2), dpa (4), picture alliance (5), Caro
The model celebrated, but today it only covers 36 percent of the population.

According to the Oxfam report, countries have made the greatest strides towards affordable health care for all that have adopted a tax-funded model, combined in part with formal sector contributions and international development aid. Luppe admits that tax systems in most developing countries are relatively inefficient. You have to work on that. However, the speaker also criticizes the fact that poor countries lose around 160 billion euros every year because multinational companies fail to pay their taxes.

Nevertheless, the development expert observes that many developing and emerging countries are increasingly investing in the health sector with a view to the Millennium Development Goals. As early as 2001, the African health ministers agreed on the goal of spending 15 percent of the national budget on health. “That has been achieved in very few countries,” says Luppe, “but in many countries you are on the right track. And the goal is at least on the political agenda. ”In the countries concerned, too, the realization has prevailed that development cannot be made sustainable

s if one does not invest in the health of the population.

However, Luppe has no illusions. “If you are wondering how to finance a system in such a way that all people in a country have equal access to the same services, whether they are rich or poor, whether they live in the country or in the city, whether they are Men or women are sick or healthy, then there are no quick solutions. ”And certainly no blueprint. Like WHO Director Dye, Luppe also believes that countries need to develop their own strategies. In the context of development cooperation, the donor countries should therefore rely more than before on long-term budget support, which flows into the partner countries' budgets and gives them their own leeway.

Speciosa Wandira-Kazibwe also advocates this. The Ugandan doctor advises the Ministry of Health in her country. At the GIZ forum “Universal Health Coverage: From Promise to Practice” in Bonn at the end of August, she criticized the fact that donors often knew little about local needs. “But our population knows what they want,” said Kazibwe in an interview with Deutsches Ärzteblatt. People have to be involved in planned reforms. “We now urgently need the necessary infrastructure for

Create universal health coverage. That is our top priority. "

But how big is the global community's consensus that access to affordable health care for all is desirable? "The hot phase will come in the next few months," says Tobias Luppe. "Then you will have to start defining the post-2015 agenda." In the US, meanwhile, the wheels are stationary. There the Republicans are blocking the budget because President Barack Obama wants to enforce health insurance for all Americans.

Heike Korzilius

Smart card for the poor

In India, the second most populous country on earth with 1.2 billion inhabitants, 28 percent of the population live below the poverty line. Nevertheless, the people there have to pay more than 80 percent of their medical care expenses out of their own pockets. This puts the country right at the top in a global comparison. After numerous unsuccessful attempts to cover the poor in the event of illness, the Indian government started a new project in 2008 to provide those in need with access to medical care: the National Health Insurance Program (RSBY). The prerequisite for participation is an annual income of a maximum of 75 euros. Those in need receive an insurance card with an integrated chip that contains the thumbprints of up to five family members. The card costs 30 Indian rupees annually, the equivalent of just under 40 cents. In September 2009, an initial 4.4 million smart cards were issued. The program has now been expanded to include 28 of the 35 states. There are almost 36 million smart cards in circulation, ensuring the health care of more than 100 million people. Payment for medical services is made cashless using the card in the 12,000 hospitals participating in the program. Critics such as the organization Oxfam complain that the program only offers limited financial protection against disease-related risks. 74 percent of health expenditure would still have to be paid out of pocket. In addition, the program is characterized by corruption, abuse and rising costs. oil

All are insured

In Mexico, access to health care has no longer been dependent on social status since 2012, but is understood as the right of every citizen. The country has experienced enormous economic growth in the past decade, despite the global economic crisis. Nevertheless, poverty continues to play a major role: half of Mexicans still live below the poverty line. Nevertheless, the government of former President Felipe Calderon has managed to implement sustainable health care reform. While more than 50 million of the 112 million Mexicans had no health insurance in 2003, the country has managed to establish nationwide health insurance and eliminate the inequalities between the individual states in less than a decade. Before the reform, a relatively large number of people in the richer north of the country had health insurance. The further south one looked, however, the more often entire strata of the population were largely excluded from health care. With the reform, Seguro Popular, the public health insurance, was introduced.It is financed through taxes and contributions from the insured, with the lowest income groups paying no contributions. oil

Partnership help

In Indonesia, a country of almost 240 million people, 27 percent of whom live in poverty, insuring members of the informal labor sector is the greatest challenge on the way to comprehensive health insurance. In 2012, around 60 percent of all employees worked in this sector, which means that the majority of the population is in unsteady, extremely vulnerable and mostly poorly paid jobs. Illnesses often mean financial ruin for these people. Within the "Social Security Indonesia" program, the German Federal Ministry for Economic Cooperation and Development advises the Indonesian partners, in particular the National Council for Social Security, on developing and implementing a national strategy for security in the event of illness. At the beginning of next year, the previous health insurance carriers will be merged into a national insurance company. This also includes the previous tax-financed health program, which currently provides health insurance for 86.4 million Indonesians. The goal is to establish nationwide health insurance by 2019. “The population wants nationwide access to health care,” said Hasbullah Thabrany, Professor of Health Policy and Insurance at Universitas Indonesia, at the “Universal Health Coverage: From Promise to Practice” forum held by the Society for International Cooperation in Bonn at the end of August. The unions also exerted pressure. Indonesia started developing social security systems 45 years ago, from which 65 percent of the population benefited. “We now need the political will to achieve the long-term goal of health care for all.” Ol