Free Universal Basic Healthcare

Definition of health as a right is enshrined in the constitution of the World Health Organization which has 194 countries as members.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

Having established this right this blog is talking about two things, free of cost basic healthcare which makes this a complex topic. 

The fundamental conflict in this equation is that of the

• Forms of government (capitalistic free market vs socialist welfare state)
• The difference between public and private goods. 
• Cross subsidizing of healthcare in terms of the healthy large number bearing the cost of treatment of the unhealthy smaller number by the tool of insurance. 
• Preventive vs Curative medicine. 
• Incentives of the stakeholders Caregivers (Doctors & Nurses), Care receivers (Patients) Care providers (Hospitals, Support services and Medical and surgical goods suppliers). 
• Technology driven Future will it help to overcome the challenges facing healthcare?

Forms of Government and their role in healthcare:

The framework of the national and international health rights and declarations. In India even before it attained freedom a committee was set up in 1943 under the guidance of Joseph Bhore who in a report submitted in 1946 suggested an integrated comprehensive approach to healthcare with a three tier system of primary health care, secondary and tertiary centers at village, small town, district and city level with an emphasis on preventive and curative medicine. This was suggested along with medical education reform to overcome the shortage of doctors and nurses. The Constitution of free India made health a state subject as it saw local influences playing a large role in setting up health infrastructure. However, health has not been directly enshrined as a fundamental right but the article 21 which provides a right to life is interpreted as a right to get healthcare. The second important document is Alma-Ata declaration of 1978 via a conference in Kazakhstan where under the umbrella of WHO it was declared that health was not merely an absence of disease but required to encompass both physical and mental and social well being. The glaring differences between countries and within countries was highlighted and getting good healthcare at an affordable cost was a fundamental right. A point to be noted that by 1978 even though at that time due to medical advances the cost of basic healthcare had become high enough for the signatories of this declaration to abandon the dream of free healthcare to promise affordable healthcare. 

To understand the models of health care welfare states vs democratic free markets should be considered. The British NHS service became the initial frontrunner as a model of free healthcare. As long as healthcare remained basic encompassing the fevers, infections, trauma and degenerative or inflammatory disorders this free care based on government using taxpayers money was reasonably successful. The general wisdom was that with free quality services coupled with immunization and higher standards of living the disease burden would become less and this would reduce government expenditure. While notionally NHS was free it was taxpayers money and some foundations the last 50 years has seen a five fold increase in spending. As this became more universal and the population availing of these services increased, the strain on the government resources became more. The NHS however failed to visualize the burden of lifestyle non communicable diseases on the budgets. The saviours of NHS in terms of trained doctors, nurses and paramedical staff has been the manpower from Asian countries. On the other extreme is the market driven American system which has made USA the most expensive healthcare provider in the world. The present NHS waiting list is so long that in many cases irreparable damage occurs before the patients gets service. India and underdeveloped countries (even if we do not like being ranked in that category) , have huge geographical disparities and there are large areas of the country where lack of basic amenities like clean drinking water, sanitation and air pollution make us still face seasonal communicable diseases. These are rampant even in metro cities. On the other hand there are in metro cities the best of facilities and availability of modern cutting edge technology makes our health care world class. But more than 70% of healthcare is provided by private players and 30% by public hospitals. The state in its health policy has in the name public private partnership abdicated its responsibility to provide proper health care. The out of pocket expense incurred as a result of the middle class and poor being forced to seek private and even private charitable care pushes the marginalized into poverty if even one member especially the earning person gets a major illness. The South east Asian countries have good public hospital facilities and coverage by insurance and have got most things right. Singapore and Thailand are good examples of the same and worthy of emulation. In India Kerela and Tamil Nadu have better healthcare than many parts of India especially Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh (the acronym BIMARU being literally appropriate). 

Public Goods vs Private Goods : The matrix below describes the differences and puts into context the differences. 

The non rival non exclusive stuff which can be used by everyone without significantly diminishing the product is a public goods. Now, this will attract freeloaders and therefore private enterprises have no incentive to produce the same and the price of this will not be determined by competition or market forces but by government which taxes the rich directly and the poor indirectly. Many of us who are the smug elite members of society who are creatures of disproportionate privilege think that we who pay direct taxes have a higher right over public goods, little realizing the the poor pay disproportionately higher taxes and therefore should get these free of cost. So water, air, roads, public parks, defense, police, street lights, traffic regulation, fire brigade, government services and public hospital come at low or negligible rates for all citizens. Yet access to even these comes as a privilege to the rich who can by sheer social standing and money power get easier access. The tendency of governments to give these as a doling of favours especially at the time of seeking votes makes this a poor quality product. I as a citizen have yet to come across a government (an exception was Aam Aadmi Party led government of Delhi) focussing on education and healthcare. The simple logic was the elimination of corruption could release enough money to provide free education and basic health and education of a quality which was equal or better than private schools or hospitals. This is a far cry from the neglected or near absent schools and hospitals in BIMARU states. 

Universal Health Insurance: Insurance is based on the premise that a large population pays something to get coverage of cost of treatment of all kinds when needed upto a limit predefined and with predefined conditions (T&C Apply). The model has been used misused and has benefits and drawbacks which are extremely complex. Countries which have a higher penetration of insurance spend more on healthcare and the out of pocket expense is less. However, insurance companies have started dictating the prices. The tendency of doctors, hospitals and patients to collude and make a fast buck by increasing the number of investigations, hospital use of consumables, inflating bills, unnecessary surgeries and admissions created a ground for regulation. Unlike other products of insurance the scope for misuse is high and therefore most insurance companies were not getting profit from health care premiums. On the other hand the country is showing a healthy growth in insurance. Still the balance between costs of health care and insurance penetration leaves a large gap. In India nearly 30% of the population have no insurance and many have inadequate insurance. 

Preventive vs Curative Medicine: It has always been a conundrum that neither hospitals nor insurance companies insist on linking premiums to prevenntive medicines approach where a person who does regular health checks and by adopting healthy life styles shows objective evidence of improved parameters should pay lesses premiums. In this way the larger number of persons taking health insurance will increase the profitability of hospitals, insurance companies while benefiting patients.The burden of non communicable disease on the system will decrease leading to a better chance of providing free or at least affordable basic universal healthcare. 

Technology and Digital Data driven Healthcare: The foreseeable future and wide use of wearable monitoring devices along with gene mapping can lead to anticipating and acting before disease occurs. The hospitals of the future will be like car workshops providing an annual maintenance contract and service as required. Acute and critical intervention will probably remain as main requirements for beds. 

Mental Health Pandemic: This is certainly needed and a completely different approach is needed for this. Universal screening of all patients and visitors through a self administered questionnaire coming to a healthcare setup to identify red flags is needed. A comprehensive approach with all facilities including OPD, Counseling, Therapies and indoor admissions to treat acute psychosis and rehabilitative services under one roof is needed. Lot of work needs to be done in this regard. Even a basic policy on this especially in terms of identifying, destigmatizing and treating these conditions is lacking. The need to combine but also ensure privacy of persons seeking help for mental disorders is a work in progress. 

Conclusion: Universal basic Health care as a corollary to right to life is definitely possible with an alignment of political will and bringing together all stakeholders. However, I think it cannot be free but can certainly be made affordable, through a combination of public healthcare strengthening but only in areas of public goods, leaving the social purposes NGO's to fill in the gaps. Many big corporate houses can do a lot of good by taking care of their own employees and opening healthcare setups run on a strong ethical framework backed by well designed insurance packages with a mix of preventive and curative medicine. Also, all this can create a situation when all stand to gain. The patient, doctor, insurance provider and the caregivers all can work to create affordable quality healthcare built on the bedrock of rationality, ethics and compassion.