DRAFT: This module has unpublished changes.

Essay #1

( the formatted version Essay #1.docx )

 

Salma Yehia

Public Policy PO520

National Healthcare in Egypt

 

Introduction

 

            Health care is represented as drastically different systems with distinctive provisions depending on the country. Many wealthy nations offer universal healthcare, however usually health care systems are not as obviously clear-cut about how their system works. Politics plays a big role in what is included healthcare wise in a country based on certain political beliefs that alter how the citizens of the country receive the care. Many times, healthcare may be publically financed through taxes but delivered privately which complicates the system further. Political, cultural, social, and economic conditions also factor into how health care is delivered to citizens.

 

             There is not one healthcare system that is ideal for every country around the world. It should be customized to fit the conditions of the specific country and its people. However, we can learn the successes and failures of different public policies concerning health care around the world. Different policies may include increased education related to health, more widespread coverage in rural areas, increased accessibility to resources like hospitals and emergency care. Then, we can find some sort of system that would seem to work for any failing health care system in a specified country.

 

Background

 

            Healthcare is sometimes placed on the backburner of some countries agenda’s as it is seen as a less prominent issue. This should not be happening as the health of a country can determine productivity, and therefore economy, as well as general satisfaction of citizens that relates to country’s stability. There is one country in particular that has suffered authoritarian rule for over thirty years, recently dealt with a revolution, and debatably a military coup of sorts that resulted in the current presidency of Abdel Fattah El-Sisi. Egypt is a country with a currently complex healthcare system that is not working well for its citizens. There is grand dissatisfaction and unequal distribution of health provisions to underprivileged groups in Egypt.

 

            The governmental body that is responsible for governing Egypt’s healthcare system includes the Health Insurance Organization (HIO) and the Ministry of Health and Populations (MoHP). The Ministry of Health in Egypt provides two sorts of functions: one is under the realm of the administrative structure, Service delivery structure, important relevant statistics, Issue history and evolution. The other part is the Central Headquarter for planning, supervision, and program management. Egypt used to have the HIO as the provider to all Egyptians with insurance however it currently only covers government employees and school children. There are five sectors within the Central Headquarter and each is headed by an undersecretary which all report to the minister. [i] There are other players who contribute to health care in Egypt, and many other ministries operate their own health facilities that cater to their employees. [ii] The Ministry of Health and Population is responsible for all roles of providing healthcare including as a policy maker payer, provider, and regulator.

 

            Nowadays, Egyptians, for those who can afford it, would rather see private doctors for check-ups and other types of care[iii] In 2012, a new policy came out where the Ministry of Health unveiled a new universal healthcare law which provided every Egyptian with compulsory all inclusive health care coverage. The bill is aimed to provide full coverage for people in need of emergency medical care and it will be enforced with potential heavy monetary fines or potentially imprisonment if not accepted. [iv] However, the question is how these resources will be distributed evenly to all Egyptians including the many that live in rural areas of the country. Although there is no increase of costs with this law and the government will cover 20-30% of the poorest in Egypt, there are still gaps to how those who couldn’t afford it before but may not be in the poorest percentile will afford to pay for this care. Moreover, physical resources aren’t necessarily provided in certain areas needed in Egypt. What is even more inefficient is even those who are currently paying for private healthcare can stay on it but will also have to pay for the public healthcare. [v]

 

Argument

 

            The total expenditure on health as a percent of GDP in 2012 was 5% in Egypt. [vi] This low investment in healthcare has led to an imbalanced and a geographically fragmented system that is inadequate for the citizens of Egypt that has led many to turn to private care. After years of complaints, in February the Parliament’s Health Committee reported 65 per cent of Egyptians were unhappy with the country’s national health insurance scheme.[vii] The healthcare Index for Egypt is 59.02, which is nowhere near where it should be –the HCI is an estimation of the overall quality of the system including equipment, staff, doctors, costs, etc. [viii]

 

            Although there are some positive aspects to the current healthcare system in Egypt, there are too many structural issues that outweigh the scattered benefits that do occur. It is definitely good that roughly 90 percent of children were immunized and that

“in contrast to many other countries in the region, Egypt does not face a shortage of qualified staff but on the opposite upholds a large talent supply with regards to the various arms of the health care industry.” [ix]Although there is some good occurring, there is not enough money being spent to continue the great benefits. Only five percent of Egypt’s total budget is spent on healthcare. That is extremely low and creates a fragmented and unequal system that can’t fulfill its duties to its citizens. So, what happens is that many Egyptians end up spending from their pockets more than the country is spending on its citizens. These two charts below visualize what is being described:

 

 

            Even if there were proper funding, the money wouldn’t be allocated properly. This is because one of the largest problems is that the Ministry of Health and Population is burdening itself with too many roles—from planning budgeting, allocation, regulation, monitoring, evaluation, and delivery. The ministry lacks the proper structure to be able to monitor over all of this since the structure of the health system is vertically organized and centralized with little interaction between different providers of healthcare.[x] So, what ends up happening is that the policies passed don’t reflect the health needs of citizens. This can’t continue to happen especially if the Egyptian government continues to think of itself as a democracy – people should be deciding how they want to be governed/what policies to enact, and officials are the ones responsible for making it happen.

 

            Egypt’s current pluralistic style of healthcare is not working and needs to be fixed. There are many ways to attack the problem but obviously the first questions that the Egyptian citizens and the government must work together to find is whether or not universal healthcare is something plausible at this current stage. A universal healthcare system requires some sort of transfer of wealth from those who have to other who do not. However, when Egypt is considered lower middle-income country it seems that the country is not ready for such a commitment. Healthcare is something that must progress in stages. Just like government structures grow and adjust through long periods of time, one cant rush the process by doing what Egypt did in 2012 and passing a law requiring compulsory national healthcare on every citizen—whether or not citizens can afford it or want it. If it is compulsory then Egypt needs a more strategic system to deal with the money issue that arises for citizens.

 

            Another crucial but less talked about point is the important role that education plays in the realm of healthcare. If we want to fix the fundamental issue of health in Egypt, we can do it through a stronger education system. By having more qualified people as well as an educated population, more people will be willing to join the system, exploit its resources, and stand up for what they deserve as citizens of a democratic country. For example, women who don’t receive free prenatal care and care when their children are young tend to have an increased need for healthcare because their children are having more medical and learning issues in the long-run which means that the state has to deal with those issues and it becomes a cycle of inadequately providing healthcare at the appropriate times for its citizens. If they had the proper education beforehand, there could have been preventative measures put forth. However, the system is currently prescriptive rather preventative and this is not acceptable.

 

Egypt’s Future

 

            If we want Egypt to become stable again, we must realize that health care is a right that should be guaranteed to all citizens. Moreover, Egypt may be in a better situation than many other African countries. However, it is not just or fair for the Egyptian people to live in such a way, afraid of doctors who don’t care about their patients, and afraid to speak up for their rights. Egypt has plentiful amounts of resources but the government needs to make them more accessible to marginalized groups. That is why a reformed education is vital for improvements in Egypt to be made. The core values and structure of a country diffuse and expand through the educational system of a country. If people are able to gain a unique educational experience that benefits them in a multifaceted way, there will be more innovative, healthy and productive job force that will improve the economy and move it beyond the industrial phase which many underprivileged countries face guaranteeing them jobs. This is not only about a more productive workforce but better quality of doctors that can get the job done the first time, so that less health issues persistent in the long run.

 

            Post Revolution Egyptians crave freedom, equality, and better living conditions. Proper healthcare is an integral part od this process. Everyone should be provided equal access, equal opportunity, and equal quality. However, this will take time. Fundamental changes and policies need to be enacted before we can reach close to those stages. It is not about making appealing promises, but it is about creating many realistic small changes that can get the Egyptian peoples aspirations translated into an  actuality.

 

[xi]

 

DRAFT: This module has unpublished changes.

Final Group Essay

 

International Public Policy: Healthcare Systems and Models

 

Belinda Schwartz

Calvin Saenz

Salma Yehia

Shannon Watts

Stuart Ross

 

1: INTRO

 

It’s difficult to imagine a more pressing focus of public policy. The global reaction to this year’s Ebola outbreak reminds us of the necessity of healthcare, and of its disparity among world populations. From a US perspective, and following in the wake of Obamacare, the nation has become more aware of the issue of healthcare and its varieties. This report will outline the function of some established healthcare systems of states, as well as attempt to formulate a “best of all systems” institution.

 

The role of healthcare institutions within states are enormous, though varied around the globe - in part due to great disparity in state capacity. In contemporary history, much of the gap in health indicators has widened since the 1980’s as a consequence of AIDS, which hit Africa hard. Geography also contributes; the idea of tropics as spreaders of disease, and the theory of the effects of vertical/horizontal spreads on both technological advancement aided via latitude geography and climate disparity increased via longitude are of concern. Perhaps, though, the most major hurdle in the implementation of effective healthcare is war, and sadly this is something many parts of the world have struggled to avoid. Governments do, however, have roles that they can play in the health of their citizens. In this day and age, health risks are no longer localized; a disease outbreak in one region of the world has the potential to reach every corner of our increasingly interconnected globe. Contemporary history provides us with examples of effective global healthcare policy; our future presents greater opportunity.

 

Public health is arguably the most important factor of state capacity. Over the last century, public health has lead to increased life expectancies, worldwide reduction in infant and child mortality, and the elimination or reduction of many communicable diseases. Investing in public health has the potential to help everyone; the failure to do so could put everyone at risk.

 

This report attempts to discuss established global healthcare models, list their advantages and disadvantages, and ultimately their opportunities and complications, to help us theorize the beginnings of a new, global health system.

 

2: INFORMATION

 

Type 1: Beveridge/National Health Insurance Model

 

Background Information

The Beveridge Model is a type of health care system that is based on the ideal of universal coverage of all citizens which is provided by a central government—some refer to it as “socialized medicine”.  The system is financed through general tax revenues and the providers are controlled or owned by the government. The government also controls the service distribution and payments. Commonly, capitalist democracies are the ones who utilize this type of system most frequently. Countries such as Great Britain, Denmark, Spain, Sweden, New Zealand, and Hong Kong have functioning health care systems that resemble the Beveridge Model. The reason for the model’s popularity among socialist countries is the fact that the Beveridge model is based on the removal of profit motive from healthcare on the basis that it works against adeptness and equality. [i]

 

Although the model functions differently depending on the country, most countries under this system have some key characteristics. First is the belief that healthcare is a human right rather than a privilege. Moreover, it advocates the ability for citizens to have full access to healthcare regardless of their ability to pay, and primary care is at the center. Government ownership over the operation of the healthcare and national government responsibility for delivering equal care are central to the model. [i]

 

Advantages and Disadvantages

Countries that practice the Beveridge Model tend to have strong health care programs with a strong emphasis on primary care. The reason behind the vitality of primary care is that it can contribute to increasingly preventative service, less hospitalizations and use of emergency divisions, as well as lowered overall healthcare costs. Although there is a low cost per capita and lower percentage of GDP spending, there is no reduction in quality. Everyone contributes to the health of the country through taxes, which increases equality of coverage, access, and care. [i]

 

Disadvantages that occur within the system are usually due to the tradeoffs that must occur in any type of healthcare system. A state that is based on welfare means that high taxes are a must. Universal healthcare means that there are also fewer specialized options. Rather, broad services are offered and there are fewer choices available to the patients. Increasingly long waiting times and decreased access to specialists are also burdens on the patient. Lastly, it becomes difficult for the state to have access to a lot of the newest technologies because there is a struggle to hold down costs –so that citizens don’t have to pay more taxes than they do already. [i]

 

 

Example Country- Denmark

Denmark, like many Western European socialist countries, has a universal, compulsory national health care system. But what makes Denmark’s system unusual, is that there is little place for private health care or private companies to do anything. The system is financed and administered by the government, and the funding comes from general, direct taxes. As a socialist country, Denmark has one of the highest tax rates in the world, and those high taxes help pay for a relatively effective health care system and a number of other public goods. The population’s satisfaction with the Danish

Health system is very high, but the system could benefit perhaps even further with incentives for private sector development.

 

The structure of the tax system that is used to pay for healthcare could theoretically make some people unhappy or could be seen as inherently inequitable in almost any other cultural context. In the US, many people opposed the Affordable Care Act because they thought either some people didn’t need healthcare or it wasn’t the government’s responsibility to make it compulsory. Luckily, Denmark has very different cultural attitudes towards insurance –namely, they see it as a necessity and a right for everyone.

 

Around 20% of the population has private supplementary health insurance, which is only designed to cover the cost of co-pays for prescriptions and specialist care. In 1994, the ratio of general practitioners to patients was 29 per 10,000. In 2010, 93% of inpatients and 96% of outpatients were satisfied with their visit. Overall, Denmark’s healthcare system is remarkably well liked and has succeeded well over time.

 

Future of the Model

The Beveridge Model holds values for human life and health—that healthcare is a right and not a privilege. It tries to create a system that is based on dual values of equality and quality. Yet, this type of system is somewhat idealistic and although the government policies argue for important values, the implementation of the model lacks consistency in upholding a fair system. High taxation does not accommodate for the poor and the system also may fail to satisfy the needs of aging populations because of less specialized healthcare. We hope to see ways for countries that operate within this system to reduce costs while improving outcomes—potentially by investing in more up-to-date health related technologies.

 

References

[i] http://healthmatters4.blogspot.com/2010/12/beveridge-model.html

http://money.cnn.com/2013/04/01/pf/taxes/top-income-tax/

http://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf

http://www.civitas.org.uk/pdf/Denmark.pdf

http://www.itup.org/Reports/Fresh%20Thinking/Health_Care_Systems_Around_World.pdf

http://www.europarl.europa.eu/workingpapers/saco/pdf/101_en.pdf

 

Type 2: Bismarck Model

 

Background Information

There are many variations in the Bismarck model, but a few details remain the same throughout: nonprofit insurance, government regulation, and universal coverage.  For many versions of the model (such as in Germany, where it was created) the burden of medical costs are placed on its working population through payroll deduction. This means that everyone receives full medical benefits, but those who work pay for the health care system. In other cases, such as Switzerland, everyone pays in for their health insurance, regardless of whether they are working or not. What defines the Bismarck model is that there are third party non-profit insurance companies (sickness funds). These sickness funds are paid in different ways.

 

The use of non-profit insurance companies along with heavy government regulation stops healthcare costs from increasing beyond their utility margin. Within this model there are private doctors and hospitals, but non-profit insurance companies cover everyone to some extent. The tight government regulation to lower costs keeps the insurance system in check. Countries that exhibit the behavior of the Bismarck Model include Germany, Switzerland, France, Belgium, Netherlands, and Japan.[1]

       

This model is a means by which countries can provide and guarantee universal health care coverage for their citizens. Although each country has different implementation methods, they all require insurance. There are certain traits that are commonly seen in countries that follow the Bismarck model. Primarily, there are short waits, low costs, and quality care. More often than not, there is tight regulation of insurance that is sold through non-profits and government regulation of prices. [2]

 

Advantages & Disadvantages

Universal coverage is one of the biggest advantages of the Bismarck system. Everyone has health insurance, sometimes regardless of whether or not they are paying into it. Either way, all citizens have their medical costs covered. Another positive is that there are low costs due to non-profit insurance and government regulation (price fixing). There is also the earmarking of resources towards medical care. This leads to the medical field not having to play politics to compete with other government expenses since the money for medical care comes from companies/employees explicitly for payment to sickness funds. On another encouraging note, there is no exclusion for pre-existing conditions because everyone is required to pay into sickness funds; therefore everyone is also covered no matter their health status. Short lines are also common within the Bismarck model because of ready access to and funding for medical treatment. Overall, there is high quality medical treatment to the point where many foreigners travel to countries with Bismarck model systems to receive care.

 

However, the Bismarck system has its flaws. Despite mandating only nonprofit health insurance systems and keeping caps on prices for premiums and copays, the price of health care is steadily rising in some countries with this model. The government may provide price ceilings on health insurance, but in order to keep the system sustainable, they also must provide price floors. Therefore, while the government is spending relatively little (to GDP) on health care, the price is being transferred to the resident.

 

This is due to government regulation; the costs may not be as low as they would be if they were subject to free market competition. Furthermore, the cost of care to patients may increase in the near future since it is difficult to continue to cut costs on the government side. Instead, the insurance companies may ask for more money from the companies/employees who are paying, transferring the cost to the client. Another issue is that non-profit insurance companies may not be as efficient as if they were incentivized by profit margins.

 

Example Country-Switzerland

Switzerland is an unusual example of the Bismarck system because the people pay health insurance companies directly, and not through salary tax.  However, about 30% of people in Switzerland receive some sort of aid to afford the insurance. Theoretically, health care prices would be kept low because the insurance companies are still able to be competitive by varying how much their premiums cost versus how much out-of-pocket expenses cost. Basic health insurance does not cover everything, therefore insurance companies can make money off of supplementary plans.

The results of the system create a country that has one of the highest life expectancies in the world (82.39 years) and a low infant mortality rate. Within the country, there is relatively low expenditure on health care by the government, but the cost might be transferred to the individual. A problem that has arisen is that prices for basic health plans have risen 5% every year. In Switzerland, 100% of people have basic health insurance although there is still some inequality - those with more money can purchase the supplementary coverage. Regardless, many consider Switzerland’s health care system as a prime example of mixing capitalism and socialism.

 

Future of the Model

Critics of the Bismarck Model say that this system lacks the cost-cutting benefits of for-profit, market-driven insurance systems. However, countries with healthcare systems modeled after the Bismarck system have shown to be more efficient in their expenditures than countries like the US who lack definitive structure to their healthcare systems.

 

References:

http://whqlibdoc.who.int/whf/1994/vol15-no4/WHF_1994_15(4)_p323-328.pdf

http://www.ecu.edu/ah/upload/Kulesher-Forrestal-2014-International-Models-of-Health-Systems-Financing.pdf

 

Type 3: National Coverage Model / The National Health Insurance Model

Background Information

The National Coverage Model, sometimes referred to as the “one player” system, utilizes private sector healthcare providers (doctors and hospitals). The general public provides money (through taxes) for a publicly run insurance program that in return pays those providers (the private doctors and hospitals). This model functions as a blend of both the Bismarck and Beveridge model. Similar to the Bismarck system, it has an insurance-based policy and it resembles the Beveridge model in that it has a single-payer system with the government having a monopoly on medical funding. Some of the countries that fall under this model include Canada, Taiwan, and South Korea. The system uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. The single payer, the government, has favorable market power to use for negotiating lower prices of medical services and drugs. This is why places like Canada have a system with cheap drug prices that lure people to medical tourism. With no profit incentives, these insurance programs are cheap and the administrative sector is easy to navigate. [3]

 

Advantages & Disadvantages

Since there is no profit, and therefore no need for marketing, there is also a lack of financial motive to deny claims. These universal insurance programs also tend to be cheaper and much simpler administratively than American-style for-profit insurance. There is only one medical insurance provider in the National Healthcare Model and so prices are very low because the government is able to negotiate heavily with pharmaceutical companies. Moreover, regulation can be efficient, and trustworthy. No money is wasted on marketing or advertising of medications in a public system. Even less money is wasted to employ administrative workers to maneuver the bureaucracy of a patchwork system of for-profit payers (such as in the US). Lastly, but equally advantageous, is the fact that doctors have greater autonomy over patient care.

 

However, disadvantages may include problems with access and waiting times. In systems of publicly funded healthcare—which is free at the point of use—there are still private options. (In Canada, that accounts for approx. 30%) Not all medical services fall under the public coverage - for example optical and dental care are only covered privately and with inflated prices as a result. Another issue is that these public systems open the door to medical tourism. Ultimately, there is a tradeoff to universal care such as limitation of services covered by the national insurance and a limited volume of services/procedures.

 

Example Country-Canada

Rather than having a single national health care plan, the country has a program with 13 interlocking health plans across its regions—all of which share common basic features and coverage for Canadian citizens. The provincial governments are responsible for “the management, organization and delivery of health services for their residents”.[4]

 

The results of the implementation are seen through the numbers:

1.     The GDP spent on healthcare in Canada is 10.4% of the national budget.

2.     The total health expenditure per capita is $4,080.

3.     The life expectancy is 80.7 years.

4.     The public health expenditure per capita is $2,863.[5]

 

Future of the Model

It seems that few countries across the world utilize this method of health care, but those who do are finding success in its methods. The future of the National Coverage Model seems to include a merging of other health care models. The end result of the model depends on how the money is collected and how the services are distributed. Each country differs in its strategy of execution and potentially this model could start to pop up in more countries after seeing the success occurring in Canada.

References

[1]http://www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php

[2]http://healthmatters4.blogspot.com/2011/01/bismarck-model.html

[3]http://pnhpcalifornia.org/wp-content/uploads/2011/04/International-Comparison.pdf

[4]http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php

[5]http://pnhpcalifornia.org/wp-content/uploads/2011/04/International-Comparison.pdf

[i]http://healthmatters4.blogspot.com/2010/12/beveridge-model.html

 

Type 4: Out-of-Pocket Model

 

Background Information

The out-of-pocket-model is the most basic of all four systems as it is a “pay-to-play” type system which depends on paying full price (out-of-pocket) for health care as the countries within this system are too poor and disorganized to provide health care fully for their citizens. In the rural areas within places like China, South America, and Africa, millions live their whole lives without seeing a doctor or visiting a health care facility. Many times, since we live in the US, we fail to realize that only 40% of the world’s 196 countries have established health care systems. Therefore, a vast amount of countries exhibit the traits of this model. According to 2011 World Bank data, the average global out-of-pocket expenditure on healthcare is 69.1%. This means that of total global healthcare spending, the vast majority is spent by patients out-of-pocket.

 

Advantages & Disadvantages

One advantage is that the percentage of GDP spent on health care is low which means the countries can invest in other issues. Citizens pay lower taxes overall since they are not required to contribute to the health of all their fellow citizens. However, the advantages of this type of system are bleak. This system was not intentionally created but is rather the leftovers, mistakes, and flawed results from other types of systems that seem to forget the lower classes of their communities.

 

One of the endless disadvantages is that because families must pay out-of-pocket and provide for their loved ones, there is an increasingly delayed retirement rate that adds to the cycle of health issues. Also, increased health risks occur because not many will be willing to pay for such expensive costs. Therefore, they find unsafe home remedies that only aggravate the problem and decrease the overall health of the country.

 

Example Country-Pakistan

The country of Pakistan struggles to provide adequately for its citizens. It has 40 million low income households that depend on out-of-pocket health care for medications, diagnostic tests, labs, etc. The average Pakistani household spends $30 per day on healthcare. The healthcare system in the country is dysfunctional with little access to quality care. The high price tag of health care has led many to avoid seeking medical attention which creates a tradeoff between health and poverty. Approximately 25% of the country's population lives in cities and those numbers continue to grow. However, this has some serious impacts such as the growth of slums and illegal settlements because of high city prices, which has in turn increased health risks. Thousands are forced into small living areas without proper sanitation which has led to people being increasingly susceptible to transmittable diseases. Therefore, a cycle begins to occur where those who are sick must pay out-of-pocket for health care which leads to poverty. They then must live in dangerous conditions which then makes them sick again and this time they don't seek medical attention because they can’t afford it. This leads to more spreadable diseases across the country that decrease the overall national level of health.

 

Future of the Model

Many countries do not simply fall within this model cleanly. Although the countries provide health care, it is not for everyone and it is the poor who end up dealing with the out-of-pocket system.  The hope is that this type of model vanishes in the near future as governments around the world begin to realize that equal access to healthcare is a human right.

 

3: CHALLENGES

 

No healthcare system is perfect, and will likely always face limitations. Even the most robust health care institutions are susceptible to breakdown from external factors. Medical and technological advancements progress at rates quicker than most measures of public policy can handle, particularly in slow, heavy bureaucratic institutions - if Obamacare is illustrative of anything, it’s that.

 

The following is a list of some possible challenges or threats to these healthcare systems, and suggestions for possible solutions.

 

  1. Epidemic/pandemic/natural disasters and other forms of widespread catastrophe

Problems: In the case of a national epidemic, how will each of these systems fare? In the Beveridge model, everyone is already covered, so theoretically everyone would have access to care. Barring oversaturation, this means that hopefully the epidemic would be dealt with swiftly and effectively. In terms of the Bismarck model, in some cases it would depend on how much unemployment there is - in Germany, health insurance is paid through salary, so if the epidemic occurs in the middle of a large period of unemployment, then the healthcare system might not have enough support to function properly.  In the case of Switzerland, everyone would get basic coverage, but people who can afford supplementary insurance might get treated more quickly and effectively. Related to this would be the out-of-pocket system, which would lead to only the rich getting treatment and the poor getting little to no treatment.

Solutions: Perhaps in countries where not everyone has access to health insurance, there could be a policy where in the case of an epidemic, a specific program gets shut down and the funds are diverted to pay to administer health care to everyone for a temporary period of time. Each country could decide for itself which program gets temporarily shut down. It should obviously be something non-essential.  

2. Terrorist activity, political sabotage, biological warfare

Problems: The occurrence of biological warfare is not outside the realm of possibility. Closely linked to chemical warfare - sadly used most recently by the Assad regime in Syria’s civil war - the threat is real.

Solutions:

  • Increase Political oversight - a wing of the United Nations to focus on biological warfare.

  • Install a non-state actor “watchdog” group on biological warfare activity.

  • Foster peace through cultural exchange programs and education.

  • Implement an Iron Dome-like defence system for biological weapons.

  • Produce disarmament treaties.

  • Enforce economic sanctions.

3.  Aging populations

Problems: There are a few ways that an aging population can affect the health care system. The older you get, the more medical attention you need. It’s just a fact of life. In countries where all citizens are covered by health insurance, an aging population threatens to oversaturate the system. In countries where not everyone is covered, you risk having a large group with serious health issues who can’t afford to have them taken care of.

Some countries have health insurance systems where the younger generation technically pays for the older generation. For example, in Germany, health insurance is a tax on people’s salaries.  Essentially, those in the workforce pay for those not in the workforce - the retired, for example.  This could result in a problem if the retired population is larger than the working population - there might be more money being spent than coming in.  This is a problem currently occurring within the US Social Security System, as the Baby Boomer generation ages into retirement.

Solutions:

  • Kill all the old people after a certain age. That solves the problem, but there might be some ethical considerations.

  • Raise the retirement age. The longer people work, the longer they are putting money into the health insurance system.

  • Notify senior citizens about cheaper living opportunities in other countries. Word on the street is it’s currently a buyer’s market in Iran! Who doesn’t want to retire to a warmer climate?

  • Make older people pay a higher portion of taxes as they age or as they use the system more or both.

  • More government funding for old age care.



4. Overabuse of the system

Problem:  Overabuse and oversaturation are a concern for the Bismarck, Beveridge, and National Coverage models, because virtually everyone is covered under these systems. In the case of the Out-of-Pocket model, oversaturation is generally not an issue since not everyone has access to basic health care.

Solutions:

  • Incentivize using the system as little as possible.  For example, in Switzerland, every year you do not need medical attention (hospital or doctor visit), your health insurance premium gets lowered.

  • Work more proactively than reactively with regards to healthcare, for instance, enact policy for cheaper fruit and vegetables in supermarkets.

  • Give people financial incentives for leading a healthy lifestyle like getting rebates for gym memberships, or penalties for sunbed use or smoking. Over the last few years this appears to have started to occur more organically in the private sector. For instance, CVS’ decision to no longer stock cigarettes and tobacco. Further measures of corporate social responsibility might evolve towards a more health and wellbeing centered approach.

  • State-sponsored flu-shots and other preventative care measures might provide some solution - although the start-up costs would be a preliminary drain on the finances of the system.

  • Divert more public money to medical research. This could create increasingly efficient health care solutions without increasing total spending on health care. Also, by merging medical research into the health care system, there is more room for long term improvements in wellness in the country.

5. Infrastructure

Problems: Some countries do not have access to filtered water or good plumbing. Some things that might seem unrelated actually have a large impact on health - such as a lack of paved roads, which could deter ambulances from reaching large communities of people. Furthermore, there may not be enough hospitals or clinics. Even simple infrastructure problems can create problems, such as having “pull” handles to exit a bathroom.

Solutions:

  • Improve access to filtered water and good plumbing.

  • Enforce existing road laws and educate people on driving on the road with respect to ambulances. Make sure ambulances have access to all communities, either by paving roads or inventing an “off-road” ambulance.

  • Make push-to-exit bathroom doors the norm to slow the spread of germs.

  • Build more community walk-in clinics for easier access to care than hospitals or private, small doctor’s offices.

6. Unequal access to healthy food options or exercise opportunities

Problem: Food deserts result when there are more fast food restaurants than supermarkets. This leads to not enough access to healthy food options, like fresh fruits and vegetables, which could lead to health issues like obesity or diabetes. However, even if access to these foods exist, they may not be affordable to everyone. Furthermore, residents of the country may not be provided with enough access to exercise opportunities.

Solutions:

  • Implement health initiatives, like Michelle Obama’s “Let’s Move!” program. This incorporates education about healthy eating and exercising practices and provides healthier food options to children (such as in their school cafeterias).  

  • If countries don’t have a SNAP-like program (AKA Food Stamps), they could try implementing one. Countries that already have SNAP-like programs can create provisions to improve it - such as making food stamps acceptable at farmers markets.

7. Cultural Norms

Problems: There are norms that exist within cultures that are conducive to unhealthy practices.  Some of these norms lead to unsanitary conditions. Foreign Policy Magazine published an article about a cultural norm in India which dictates the use of defecating outdoors. The magazine notes: “Open defecation is one of the world's most stubborn problems. And the inability to adopt even Victorian-era sanitation is keeping India from being a superpower.”  It is not just that there is a lack of physical toilets and plumbing systems, it is that in some areas it is not even the cultural norm to use them.  

Alternatively, a culture could include certain negative attitudes towards healthy practices, which might be seen as “weak,” such as washing hands or eating fruits and vegetables.

Solutions: Promote healthier cultural norms, perhaps through ad campaigns. Celebrities telling you to wash your hands could have a lot of influence. Alternatively, charge fines for unsanitary practices.

8. Lack of education about healthy practices

Problem: Sometimes a population is simply uneducated about best health practices.

Solutions: Create nationwide PSAs educating the public on best health practices, such as the importance of handwashing, exercising, and keeping a healthy diet. Implement an education policy that requires schools to teach health or nutrition classes.

 

4: HEALTH CARE FOR THE FUTURE

 

What about the possibility and framework of a global healthcare system?

 

With what could be viewed as a trend of supranational institutions such as the European Union, might we envision healthcare models operating on a larger scale? If we take the view that health care issues in one area of the world are no longer just confined to that region, perhaps a global system of healthcare might prove valuable in the long-run. This, inevitably, would likely have to operate on more socialistic grounds, and would therefore require a change in mindset towards a more egalitarian view. With the bulk of the world’s pharmaceutical firms congregated in the West, humanitarian measures would have to be encouraged. A system such as this, full as it is of challenges, might work to maintain more global stability if we all have more to lose from political disruption and war.

 

In line with drastic change to healthcare models and systems, we believe investing much more in issues of mental health might yield a significant return on investment. Mental health is too often neglected in our society, and needs more of our attention. Research suggests that physical ailments are often worsened by mental issues and stress.

 

A global healthcare system may organically solve the challenges of population demographic disparities. It could go some way to offset the accompanying problems of aging populations, if many regions of the world are the inverse, as is true in the developing world.

 

5: CONCLUSION

 

The four major systems presented above, are, of course, only generalized categories. But they give us a framework to understand the theories behind established healthcare systems. Each nation’s healthcare system is different, as all public policy is context-dependent. No country fits perfectly within a specific model, and in reality implementation has created messy, mixed systems. Every approach also has different tradeoffs; no system is perfect. The main tradeoff in all systems is between controlling cost and outcome and ensuring universality. But as universal coverage becomes more of an established norm, the distinctions between the systems matter less and less. We believe that universal coverage is the ideal; but beyond that, there are a number of ways to achieve a successful healthcare system. As it is, the Beveridge, Bismarck, and National Health Insurance Models are starting to merge. Even countries like Germany, which pioneered the Bismarck model, are making their systems more Beveridge-like by adding government funds to the social insurance pool. Continued pressure on healthcare systems by demographic changes will further merge the models. Countries that rely on social insurance will have to adapt to an aging population and a decreasing workforce. As healthcare evolves further to be viewed as a right of citizenship by everyone, the distinctions between the models become irrelevant, and all countries can move towards better, more affordable healthcare for everyone.

 

DRAFT: This module has unpublished changes.