DOI

70  Indian Journal of Public Health Research & Development, February 2020, Vol. 11, Number:
No. 02 10.37506/v11/i2/2020/ijphrd/194755

Health Coverage Across the Globe: A Contemporary Scenario

Vinoth Gnana Chellaiyan1, Hanitha Rajasekar2, Neha Taneja3

1
Assistant Professor, Department of Community Medicine Chettinad Hospital and Research Institute Rajiv Gandhi
Salai, Kelambakkam, Chennai, Tamil Nadu, 2Post graduate (MBBS), 3Assistant Professor,
Amity Institute of Public Health, Amity University

Abstract
Context: Health was declared as fundamental human right by WHO constitution of 1948. The major key
role playing factor in HAQ rankings is the universal health care programme and health schemes which
are initiated and ran by the government. Health care provision is incredibly complex and many nations
around the world spend considerable resources trying to provide it. Developed countries have their own
insurance scheme which benefits its population and meets their health care needs. No uniform one-size-
fits-all operational model exists when it comes to the successful implementation of a scheme. For instance,
multinational insurers who are successful in one country have met failure in other countries. Developing
country like India must try to improve their health care system by following certain initiatives incorporated
by other countries. Low income countries like Africa and Nepal need to take extra measure to improve
health insurance program and to provide quality care to their people. It is evident that there are an enormous
number of ways that health care insurance programs vary around the world. There is a need to identify the
characteristics of the most effective systems and the most equitable ones which could serve as a framework
by all countries.

Keywords:  Health for all, Health coverage across the globe.

Introduction treatment, rehabilitation and palliation) of sufficient

quality to be effective while also ensuring that the use
Health is a state of complete physical, mental and
of these services does not expose the user to financial
social well-being, and not merely the absence of disease
hardship.3 To achieve UHC, a country must address legal
or infirmity.1 Health was declared as fundamental human
coverage and rights, health workers shortages, extension
right by WHO constitution of 1948.2 The major key role
of health care shortages and quality of care.4 Health
playing factor in HAQ rankings is the universal health
care provision is incredibly complex and many nations
care programme and health schemes which are initiated
around the world spend considerable resources trying
and ran by the government.2 Universal health coverage
to provide it.5 The strength of the case for investing in
(UHC) ensures that all people have access to needed
health varies among countries.6 The return on investment
health services (including prevention, promotion,
is likely to be highest for emerging economies: They
can obtain significant improvements in health outcomes
(eg life expectancy) through modest increases in health
Corresponding Author: expenditures.6 The basic idea of this review is to provide
Dr. VinothGnanaChellaiyan: an insight on health coverages across various countries
MD Assistant Professor,Department of Community and there path towards universal health coverage.
Medicine Chettinad Hospital and Research Institute Health coverage in various countries: Many
Rajiv Gandhi salai, Kelambakkam, Chennai:603103 countries have their own insurance scheme which
Tamil Nadu, India. benefits its population and meets their health care needs.
Mob No: 9944894554 No uniform one-size-fits-all operational model exists
e-mail: drchellaiyan@gmail.com when it comes to the successful implementation of a
 Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02  71
scheme. It is not just standard processes or manuals or Canada has a universal single-payer, sponsored
actuarial formula or stabilised systems that can work health insurance system called Medicare which is
seamlessly across geographies such that the success is administered independently by the thirteen provinces
assured.7 and territories. Every citizen and permanent resident is
automatically covered. As of 2012, Canada spends about
High income countries: High income countries 11% of GDP on healthcare expenditures covering about
according to World Bank are United States, Germany 70% of healthcare expenditure.2
and Singapore, Canada, Japan and Gulf countries.
Important principle of The affordable care act of 2010 In Gulf countries major healthcare challenges has
or OBAMA care in United states is to improve quality hampered the efforts towards ensuring UHC across
of care which is achieved by establishing new agencies, the region. Mandatory health insurance is one of the
boards, commissions and other Government entities8; measures adopted to achieve UHC. Qatar has initiated
The 2010 Affordable Care Act (ACA) dramatically the upgradation of health care services by launching an e-
changed many features of the US health care system and health program. Saudi Arabia is digitalizing its hospitals
should greatly reduce the number of Americans who are and PHC patient medical records through healthcare
uninsured. information and management systems society (HIMSS).
UAE in 2011 had launched integrated electronic medical
The German government sponsors mandatory record system to link public hospitals and clinics
universal insurance coverage for everyone, including across Dubai and the Northern emirates through health
temporary workers residing in Germany.9 The German information system- Wareed12
system uses a unique point-based global budgeting
system to control annual health careexpenditures Middle income countries: China, India and Mexico
whereby the targeted expenditures are achieved by are middle income countries. Chinese government
ensuring that total payments to all providers of a given has established a multilevel medical security system
specialty are equal to the total budget for that specialty in including universal health care system, commercial
a year.10If salary of German residents is less than 59400 medical insurance and a medical charity aid. Over
euros per year or 4950 euros per month then membership 90% of the population has basic insurance coverage in
is made mandatory. It covers in patient hospitalisation, China. Three insurance schemes available in China as
OP services as well as dental care. of 2011 is Urban employee basic medical insurance,
Urban resident basic medical insurance and new rural
Singapore has a unique-to-the-world health care cooperative medical system. Chinese government health
system where the dominant form of insurance is care covers both sectors of population groups equally
mandatory self-insurance supported by sponsored inorder to work on urban rural disparity.13 In Mexico
saving, although complementary and special insurance the government run system operates Clinics and hospital
programs are also central to their system.11 It provides throughout the country in Mexico to provide health at
UHC through a combination of government subsidies, low price.14 Whereas in India according to model based
multi-layered healthcare financing schemes and private estimate by WHO through public and private sector is
individual savings all at national level. It provides estimated to be INR 1,713 / Capita / Year between 2014–
Government subsidy 80% of total cost in public hospitals 2015. Average medical expenditure for hospitalization
and primary care polyclinics. It is supported by 3M’s in urban patient has increased to 126% and rural patient
system namely Medisave, Medishield and Medifund. to 160% and same year GDP / Capita grew by 121% .15
Japan has a mandatory insurance system which Need for health insurance: India is presently in a
is comprised of an employment-based insurance for state of health transition facing a shift from infectious
salaried employees, and a national health insurance for diseases to non-communicable diseases that are now
the uninsured, self-insured and low income, as well as emerging as the leading cause of mortality. According
a separate insurance program for the elderly.10 Health to National Health Accounts (2014-15) 62.6% of
insurance benefits designed to provide basic medical total health expenditure in India (2.4% of GDP,
care to everyone are similar. They include ambulatory Rs. 2394 per capita) by householdis Out of pocket
and hospital care, extended care, most dental care and expenditure15which is defined as expenses that patient
prescription drugs. or family pays directly to health care provider without
72  Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02
a third party (Insurer, State) is limited withappropriate 4 years with total value of 4 lakh, in case of certain
health insurance.16People having no access to any form procedures it will be raised 1.5 lakh per annum.23 In
of health insurance scheme are being forced to make 2013 Sanjeevani Swasthya Bima Yojana was launched
OOPE pushing 60 million Indians to poverty each year.17 as a comprehensive health insurance scheme for citizen
of Dadra Nagar Haveli and Daman and Diu. Under this
Although India has been witnessing a staggering scheme premium for BPL families will be borne by the
growth in the health insurance sector, still only 15% of UT Administration and for those families with income
the population is protected by medical care insurance of 1 lakh- 2 lakh 50% will be by UT administration and
coverage and 5% of the population buy a plan voluntarily 50% by their own.24 Mukhyamantri Swasthya Bima
of their own accord which suggests that Indian insurance Yojana was launched in 2016 in Uttarakhand for all BPL
industry has still a long way to go. The reason behind and APL families (except those on govt. salary or govt.
such a low acceptability is not the affordability factor, pension or in tax payer category). It provided a cover
but the lack of awareness and unwillingness on the part of Rs. 50000 per eligible families and in same wake
of the potential buyers. The likelihood of utilising health second phase with a base cover of Rs. 50000 covering
care services increases with genuine health insurance 1206 diseases and critical cover package of Rs. 125000
scheme in place. Such schemes should be focused on covering 458 diseases.25
achieving a two-way objective, to tell people how
imperative is it to get a health care insurance and to build Nationwide health insurance (2003-2018):
the trust and credibility of insurers among them.18Global At National level, health insurance schemes were
disease burden in India 2016 report suggests that deaths implemented between 2003 -2018. Universal health
due to communicable, maternal, neonatal and nutritional insurance scheme was launched in 2003 and available
diseases is 27.5% and Non communicable diseases is for individuals as well as in a group. Age criteria 5
62% in men and 52% in women; if each citizen is insured to 70 years and children between 3 months to 5 years
nearly 89.5% of disease burden could be averted.19 A are eligible if one of the parent is covered. It gives
recent data suggest that 80% of hospitals are in urban area hospitalisation benefit of INR 30000 per family per
though it comprises of only 31% of country’s population policy inclusive of maternal benefit. Total expenses for
and availability of qualified physician in urban area is any one illness is limit to INR 15000 excluding maternal
11.3 per 10000 population when compared to 1.9 per benefits and also covers accident and disability.26
10000 population in rural area. 65% of rural population Rashtriya Swasthya Bima Yojana in 2013 was different
have no access to essential medicines and cannot afford from the previous policy with regards to target group
to medical expenditure.20Health insurance scheme are which included BPL families and defined categories of
designed to provide employment to rural poor besides unorganised workers. RSBY has been the only scheme
creating rural infrastructure so that urban-rural disparity in India launched on a Pan India basis, which aimed at
in the country could be reduced.21 universal health coverage.27-29 Beneficiaries are entitled
to hospitalisation coverage of Rs 30000 per annum for
State based health insurance schemes (2007- most of diseases that require hospitalisation. Additional
2017): Some states have its own health insurance scheme transport expenses are also provided to the beneficiary.28
for its people and they are explained in detail. Aarogyasri
scheme was launched in 2007 (continued as Dr NTR Under RSBY health protection mission/ Pradhan
Vaidya Seva (2015) AarogyaRaksha scheme (2017). It Mantri Rashtriya Swastya Suraksha Mission later
is a unique community health insurance scheme being renamed as Pradhan Mantri Jan Arogya Yojana was
implemented in Andhra pradesh. It provides financial launched in 2018 at Ranchi Jharkhand. It provides
protection upto 2 lakhs to BPL families in a year for coverage of 5 lakh/family/yr and benefits 10.74 crore
treatment of serious ailments requiring hospitalisation families; 8.03 in rural and 2.33 in urban areas through
and surgery.22Chief Minister comprehensive health a network of empanelled health care providers. Key
insurance scheme was launched in 2012 in Tamil Nadu. feature of the scheme is that the beneficiaries can
It provided cover for all major ailments and ensured avail of services anywhere in India and there is no
advanced healthcare for low income and unorganised compromise on family size and age.28 Budget allocation
group. Its aim was to benefit 1.34 crore families with is approximately 12000 crores and 60:40 is the ratio for
annual income of 72000 or less. The sum assured fund transfer from central and state government. Target
under the scheme is 1 lakh every year for a period of group is poor, deprived rural families and identified
 Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02  73
occupational category of urban workers’ families as per C, Abd-Allah F, Abdela J, et al. Measuring
Socio economic caste census 2011. All enrolled families performance on the healthcare access and quality
under Rashtriya Swasthaya BimaYojana (RSBY) not index for 195 countries and territories and selected
featured in the targeted groups as per SECC data has subnational locations: A systematic analysis from
also been included.30 the global burden of disease study 2016. Lancet
2018;391:2236-2271.
Low Income Countries: Most of the African
3. World Health Organization [homepage on
countries and Nepal belong to low income group. In
the Internet]. Health financing for universal
Nepal to provide affordable care, quality health services,
coverage>What is universal coverage; [updated
easy access and health security coverage Social health
2018 December 12; cited 2018 December 15].
security development committee was established. It
Available from: https://www.who.int/universal_
works by raising funds from healthy people and spending
health_coverage/en/
the same for needy.31In Ghana rapidly expanding
National program is run by the government. In Nigeria 4. The Lancet. Rural health inequities: data and
most of the schemes are run by private investors and decisions. The Lancet. 2015;385(9980):1803.
shareholders. In Tanzania and Uganda some programs 5. Health care around the world [Homepage on
are functioning through their own hospitals and clinic by Internet]. [cited 2018 April 13]. Available from:
employing their own staff on regular basis. Government www.globalissues.org
must take extra measures in these low income countries 6. Delivering universal health coverage- A guide for
to improve health insurance program and to provide policymakers [Homepage on Internet]. [cited2018
quality health care to their people.32 April 13]. Available from: https://www.imperial.
ac.uk
Conclusion
7. How Ayushman Bharat could be different details–
It is evident that there are an enormous number of [Internet] [cited 2019 January 5] Available from:
ways that health care insurance programs vary around https://www.livemint.com
the world. There is a need to identify the characteristics 8. Manchikanti L, Helm Ii S, Benyamin RM, Hirsch
of the most effective systems and the most equitable JA. A critical analysis of Obamacare; affordable
ones which could serve as a framework by all countries. care or Insurance for many and coverage for few.
In accordance to health for all agenda set by Alma Ata Pain Physician. 2017 Mar; 20:111-138
declaration in 19781 every country is struggling to
9. Health insurance options in Germany. [Homepage
provide an efficient health care system to its people.
on Internet]. [cited 15 December 2018].Available
Health has become a basic need with emerging health
from: https://www.howtogermany.com
care challenges. Health care delivery system in each
country aims to reach the ultimate goal of universal 10. Forthcoming in Culyer, Anthony (ed.) Encyclopedia
health coverage, with effective utilisation of resources of Health Economics, Elsevier Press., Inc. 2014.8
and by strategic planning this goal can be achieved in all 11. Singapore: International health care system
countries across the globe. profiles. [Homepage on Internet].[cited 2018
December 5]. Available from: https://international.
Conflict of Interest: Nil commonwealth.fund.org
Source of Funding: Self 12. Tawfiqkhoja, Salman Rawaf et al. Health care
in Gulf cooperation council countries: A review
Ethical Clearance: It is a Review article, Human of challenges and oppurtunities. Cureus.2017
subjects were not interviewed and examined. Ethical Aug;9(8)
Clearance is not available
13. Yu H. Universal health insurance coverage for 1.3
billion people: what accounts for China’s success?
Reference
Health Policy. 2015;119(9):1145–1152.
1. WHO (1978). Primary health care: report of the 14. Four countries with the best health care in the world.
International Conference on Primary Health Care, International living. [Homepage on Internet].[cited
Alma-Ata, USSR Health for all, Sr.No.1. 2018 December 5]. Available from: https://www.
2. Fullman N, Yearwood J, Abay SM, Abbafati cnbc.com/
74  Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02
15. Nandi S, Schneider H, Dixit P. Hospital utilization https://www.easycounter.com/report/vbch.dnh.nic.
and out of pocket expenditure in public and private in
sectors under the universal government health 25. Mukhyamantri Swasthya Bima Yojana (MSBY)
insurance scheme in Chhattisgarh State, India: Uttarakhand [Homepage on Internet]. [cited
Lessons for universal health coverage. PLOS ONE. 2018 December 15]. Available from: https://
2017;12(11):e0187904. mukhyamantri-swasthya-bima-yojana-msby/
16. www.arthrapedia.in. 2018 [Homepage on Internet]. 26. Universal Health Insurance Scheme: Features,
Out-of-pocket expense; [cited 2018 December 5]. Reviews & Charges [Homepage on Internet]. [cited
Available from: https://en.wikipedia.org/ 2018 December 15]. Available from: https://www.
17. Balarajan Y, Selvaraj S, Subramanian S. coverfox.com/health-insurance/universal-health-
Health care and equity in India. The Lancet. insurance-scheme/
2011;377(9764):505-515. 27. Health insurance in India – The need for public
18. Health Insurance in India – The Need for Public awareness. [Homepage on Internet]. [cited 2018
Awareness. [Homepage on Internet]. [cited January 5]. Available from: https:www. Policy
2019 January 5]. Available from: https://www. bazaar.com/health insurance
policybazaar.com/ 28. Pareek M. Ayushman Bharat-National Health
19. National Health Accounts (NHA) – Ministry of Protection Mission a way towards Universal Health
Health and Family Welfare. NHA – Estimate for Cover by reaching the bottom of the pyramid to
India 2014-2016 [Homepage on Internet]. [cited be a game changer or non-starter. Int J Adv and
2018 December 15]. Available from: https:// Innovative Res. 2018; 7(7):2278-7844
mohfw.gov.in 29. RSBY govt plans and scheme update. [Homepage
20. Urban rural conditions concept disparity. on Internet].[cited 2018 December 5]. Available
[Homepage on Internet]. [cited 2018 December from: http://www.rsby.gov.in/about_rsby.
15]. Available from: http://dspace.vpmthane.org aspxhttps://sarkariyojana.com;
21. Press Information Bureau [Homepage on Internet]. 30. Dhaka R, Verma R, Agrawal G, Kumar G.
Pib.nic.in.2018; [cited 2018 December 15]. Ayushman Bharat Yojana: a memorable health
Available from: http://pib.nic.in/ initiative for Indians. Int J Community Med Public
22. Aarogyasri Health Care Trust [Homepage on Health 2018;5:3152-3.
Internet]. [cited 2018 December 15]. Available 31. Nepal. Government of Nepal health insurance
from: http://aarogyasri.telangana.gov.in/ board. [Homepage on Internet].[cited 2018
23. Chief Minister’s Comprehensive Health Insurance December 5]. Available from: https://shs.gov.nic
Scheme [Homepage on Internet].[cited 2018 32. Carapinha JL, Ross-Degnan D, Desta AT, Wagner
December 15]. Available from: http://www.tnhsp. AK. Health insurance system in five sub-Saharan
org.2005-2012 African countries: Medicine benefits and data
24. Directorate of Medical & Health Service for decision making. Health policy. 2011; 99(3):
[Homepage on Internet]. Easycounter.com. 193‑202
2018 [cited2018 December 15]. Available from: