The COVID-19 crisis: debates around the world for the universal health model

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The UK National Health Service (NHS), which has been a source of inspiration worldwide, faces new challenges and the need for reform. Photo: AFP.

“The pandemic has highlighted the importance of having a solid health system and universal health coverage”, has repeatedly stated the director general of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus. Now, achieving that goal is a very complex mission. In a work published by the Overseas Development Institute (ODI), Anthony McDonnell, Ana Urrutia and Emma Samman analyze the restrictions that 49 countries have faced when implementing this type of model.

“In the early phases of system expansion, government intervention to provide health services tends to cover only a limited portion of the population, generally made up of politically organized groups, such as workers in the formal sector of the economy”, explain the authors. “Once governments achieve the goal of universality, the excluded sectors become the focus of their policies,” they add, while warning that “when countries achieve universal health policies, they are subjected to social and political pressures that seek to ensure the continuity of the system ”.

COVID-19 highlighted the difficulties of the health sector to face an emergency unprecedented in the last century. The debate on health services then returned to the scene.

NHS: THE BRITISH MODEL AND ITS REFORMS

Structured in 1948 on the basis of the famous report produced six years earlier by the commission led by William Beveridge, the National Health Service (NHS) it has become a benchmark for universal health coverage. The NHS employs 1,511,400 professionals and is the fifth largest employer in the world, including the private sector of the economy. Beyond some specific reforms, it was necessary to wait until the arrival of Margaret Thatcher to power in the 80s for what Laura Lima Quintana, Mónica Levcovich and Ana Rita Díaz-Muñoz describe – in a work published in 2012 by the Sanatorio Güemes Foundation– as “the greatest change in organization and management in the entire history of the NHS”.

This reform took place at the end of the Thatcher government and was incorporated in the National Health Service and Community Act Care of 1990, which introduced into the NHS “an internal market or quasi-market”, in which “a division between the purchasing function, in charge of the health authorities, and the provision function, a role played by the newly formed NHS trusts” was promoted. The goal was for these trusts to compete with each other for service contracts. Subsequently, the system was reorganized: the district health authorities were replaced by trusts of primary care, which became “responsible for the provision of primary care”, replacing regional health authorities with strategic health authorities (Strategic Healthcare Alliance). All these changes implied, according to the authors of the report, “a marked increase in the participation of the private sector in the provision of services to the NHS”.

The changes in the NHS, incorporated at the end of the Thatcher government, were reflected in a marked increase in the participation of the private sector in the provision of services to the health system.

Even before the outbreak of the COVID-19 outbreak, which hit the British healthcare system hard, the NSH was at the top of the UK political agenda. The current Conservative Prime Minister, Boris Johnson, commissioned his Health Minister, Matt Hancock, to implement a reform of the system that would have a broad social consensus. Once the critical moment of the pandemic has passed, Hancock is preparing to present his reform plan before the end of the year.

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BRAZIL: CHRONICLE OF AN UNEQUAL COUNTRY

Across the Atlantic, the Unified Health System (SUS) He has just turned 30 and has been subjected to a litmus test with the COVID-19 pandemic. Emerged in 1990 with the sanction of the Organic Health Law, in line with the 1988 Constitution, SUS coverage reaches around 80 percent of the Brazilian population, while the private health subsystem covers the remaining 20 percent, which is geographically concentrated in the southeast of the country. For the former vice president of the Federal Council of Medicine (CFM) of Brazil, Carlos Vital Tavares Corrêa Lima, the problem with SUS is that it has become a “complex system subject to the will of the government.”

The pandemic exposed the strong social inequalities and the limits of the Brazilian health model.  Photo: AFP.

The pandemic exposed the strong social inequalities and the limits of the Brazilian health model. Photo: AFP.

In his book, SUS: the challenge of being unique, Carlos Octávio Ocké-Reis, researcher at the Institute for Applied Economic Research (IPEA), warns that “in Brazil, unlike what happens in other countries that have adopted universal health care systems, the share of general taxes in the financing of the sector has always been residual ”. To effectively guarantee the “universalization” of access to health for the population, SUS needs to “diversify its sources of financing: on the one hand, to avoid problems derived from macroeconomic fluctuations; and, on the other, considering the tiny size of the Brazilian formal labor market, to counteract the reduction in its financing base based on payroll ”.

Despite the attempt to refinance the system, in an interview granted in 2018 to the digital portal of the Humanitas Unisinos Institute (IHU), Ocké-Reis himself lamented the “Financial strangulation” of the system, referring in particular to the “financing of its human resources, a fundamental dimension to improve the quality of health care”. In that sense, he questioned the fiscal adjustment measures implemented in recent years, among which he cited the constitutional amendment approved by Congress in 2016, during Michel Temer’s government, which established a freeze on public spending for the next 20 years, a measure that is currently being questioned before the Supreme Federal Court (STF) by trade unions and political forces of the opposition led by the Workers’ Party (PT).

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ISRAEL: HIGH QUALITY UNIVERSAL COVERAGE

With a long history of attracting talent and promoting its scientific-technological system, Israel also boasts an enviable public health model and coverage that reaches 100 percent of the population.. The model was implemented in 1995, after the approval of the National Health Insurance Law, which obliges citizens to choose between one of the four health providers –Kupat Jolim– that exist in the country.

The objective, as Zeev Rotstein, director of the prestigious medical organization Hadassah, explained to DEF, was “to move towards a system similar to that of the United Kingdom”. How is the system financed? “We Israelis pay our taxes to the government and it is the government that allocates resources to providers on a per capita basis, which takes into account age and a number of other health factors. It is not a pure model, but a hybrid system that has proven to work very well ”, he completed. The possibility of choosing between different Kupat Jolim has made it possible to maintain a high quality of performance.

Israel boasts an enviable public health model with coverage that reaches one hundred percent of the population.  Photo: AFP.

Israel boasts an enviable public health model with coverage that reaches one hundred percent of the population. Photo: AFP.

This was illustrated by David Chinitz, a professor at the School of Medicine of the Hebrew University of Jerusalem, in an article published on the Tabletmag.com portal: “Citizens can change the providers of their health plans every year. Although the percentage of those who opt for new providers is low, the providers work hard to keep their policyholders satisfied and to attract new clients. The competition is for an improvement in the quality of the service: “Israel’s health indicators, such as life expectancy and infant mortality, are among the best in the world, without prejudice to the fact that there are still gaps between different ethnic groups and Social classes, however, the latter have less to do with difficulties in accessing the system for economic or geographical reasons, and are, rather, attributable to other factors, such as educational level.

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Therefore, the Ministry of Health and service providers are responsible for developing programs aimed at closing these gaps. The efforts have proven to be successful, although there is still a long way to go. ” “Israel is spending 7.5 percent of its GDP on health and its system is equitable, practical and crystalline; in it, the rich and the poor have access to the same services “, Zeev Rotstein pointed out to us, while detailing that “The basket of medical services established by law ranges from transplants to chronic medication and hospitalization, and is periodically updated by an independent professional committee”.

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