The evolution
of healthcare policy from ancient Egypt to the US presidential debates
SEPTEMBER 23,
2019
The UN on September 23 is holding a
high-level meeting at the General Assembly in New York on universal health
coverage.
The event, led by Tedros Adhanom
Ghebreyesus, director-general of the World Health Organization, aims to garner
commitments to sustain investment in health and accelerate progress towards
universal health coverage across the world.
Universal health coverage is defined by
the WHO as giving everybody access to health services that are of sufficient
quality to be effective, without inflicting financial hardship as the price to
pay for it.
The concept is not a new one: it could
be argued its origins lie in ancient Egypt.
Beginnings of universal health coverage
Scrolls dating back more than 3,000
years resurfaced in 2015, revealing workers in the Egyptian town of Deir
el-Medina in the flourishing Nile River Valley enjoyed paid time off and home
visits from a workplace doctor.
Chancellor Otto von Bismarck’s attempts
to unify German states included the Sickness Insurance Act of 1883,
forcing companies to offer insurance to employees through a scheme where both
paid into a fund.
The system expanded to eventually
include accidents in 1884, disability in 1889 and unemployment insurance in
1927.
In 1911, Britain passed
the National Insurance Act. This covered health and unemployment, and
required individuals to pay into a fund alongside contributions from employer
and the state. The scheme was available to 1.4m people.
But it was not until 1948 that Britons
gained universal health coverage, with the establishment of the National Health
Service, free at the point of use and financed by the state. Often described as
the closest thing the UK has to a national religion, the NHS featured
prominently during the 2016 Brexit referendum. The Leave campaign promised to
divert savings from leaving the EU to the service.
China’s barefoot doctors
China’s Nationalist party opened a
westernised department of public health service in 1927, aiming to go
beyond the limitations of traditional medicine. The country’s revolutionary
government of 1949 took healthcare inspiration from the Soviet Union, which had
run a state healthcare system since 1922.
Chinese leader Mao Zedong advocated the
idea of “barefoot doctors” — farmers trained by community or county hospitals
and then sent to service rural populations.
In 1978, an international WHO conference
at Alma-Ata, in what is today Kazakhstan, praised the barefoot doctors and
identified primary care as essential for global public health. Today
the Chinese are struggling to restructure their system and widen access to
care.
Solutions for growing populations
By the middle of the 20th-century,
healthcare systems around the world were evolving.
President Harry Truman started a debate
over US public healthcare in 1945. This eventually resulted in the creation
under President Lyndon Johnson of two government programmes: Medicare and
Medicaid.
Medicare, established in 1965, covers
the elderly, while Medicaid caters for the unemployed and the poor.
Medicare coverage was extended in 1972
to cover the disabled and people with chronic kidney disease, and later under
President Barack Obama to include low-income families.
Mr Obama’s Affordable Care Act —
popularly know as Obamacare — was the subject of fierce criticism from
some opposition politicians, stoking misconceptions such as the notion that the
UK used “death panels” to decide which elderly people deserved care.
Obamacare created a state-run market for
people who did not get insurance from their employers and expanded Medicare for
low-income families, although by 2017 an estimated 28m Americans in 2017
remained uninsured.
Healthcare reform is a key issue in the
upcoming presidential race as some Democratic frontrunners call for “Medicare
for all”.
In India, Prime Minister Narendra Modi
in 2018 unveiled ambitious plans — dubbed ‘Modicare’ — to reform the
public health system in the second-most populous country in the world.
According to the Center for Global
Development, India is home to one-third of global maternal deaths and spends
just 1 per cent of gross domestic product on public health. Some 60m people
fall into poverty every year because of healthcare bills.
Modicare has been criticised for its
lack of funding and underemphasis on primary care services.
Sarah Hawkes, a professor of global
public health at University College London, says much could be learned from the
successes and failures of western healthcare systems.
“It’s very clear from the story of the
NHS that we can’t keep on [as we are],” she said. “The financial implications
of trying to treat ourselves out of a diabetic epidemic, for example, are so
vast that it’s impossible to imagine any financial system that would be able to
cope with that.”
At the same time, as Africa becomes one
of the world’s fastest growing continents, countries will need healthcare
systems robust enough to keep up with their expanding populations. African
nations could well leapfrog parts of the western experience, which for example
has belatedly involved placing more emphasis on prevention rather than
treatment.
Alongside improved diagnostics and
supply chains, universal health coverage will also enable people to hold
providers to account and monitor whether they are getting the services they are
entitled to, says Prof Hawkes.
“You can get across the notion that you
have a right to healthcare and it is not this discretionary gift from your
government. You hold government accountable and you can monitor what’s going
on. That’s a fundamental sea-change in the social contract.”
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