For the second part of the series, we will be focusing on accessibility to healthcare—a key aspect in realising global health. PwC envisions accessibility to healthcare as it relates to two aspects—first, being able to access the fundamental healthcare services with consideration of one’s economic situation (i.e. income), and second, having necessary infrastructure in place to provide the service. Essentially, if either is lacking, healthcare itself cannot be accessed to those in need. This essay will deep dive into the first aspect, through exploring the importance of ‘Universal Health Coverage (UHC)’, and how Japan can contribute to establishing UHC.
Importance of practising UHC
As outlined in the previous instalment in this series (1: Footprints of global health), global health is a multidisciplinary field that promotes the health of the overall population. As the world accelerates in becoming more borderless and urbanised, global health is crucial in providing health for all through strong collaboration among nations. One key scheme that exemplifies this is Universal Health Coverage (UHC)—an area in which Japan excels.
In the Global South, most healthcare expenditures are borne by individuals, leading to approximately 100 million people living in poverty as a result of such costs*1. Excessive healthcare cost burdens cause health disparities, further fuelling inequalities in access to healthcare in countries and regions facing poverty. To overcome poverty and inadequate access to healthcare, it is essential to prioritise UHC and build a sustainable and inclusive healthcare system.
History of UHC
As defined by the World Health Organization (WHO), UHC is a scheme where ‘all people have access to the full range of quality health services they need, when and where they need them, without financial hardship’*2. It aims to offer comprehensive support designed to address health disparities caused by factors such as financial hardship.
UHC was first adopted in the Global North through different methods in the 20th century*2, and became widely recognised when the WHO, as a part of the Alma Ata Declaration in 1978*2, emphasised the importance of achieving health equity. Although important, achieving UHC is not easy, especially in the Global South, which faces many challenges. However, now with UHC being recognised as one of the SDG 2030 goals, all countries have begun to consider the dissemination of UHC. In fact, the WHO has defined a scoring mechanism to measure the prevalence of UHC in each country, which encapsulates four major indicators (Diagram 1). The UHC scoring framework encapsulates not only the incidence rates of specific diseases, but also includes indicators such as service capacity and access to healthcare, to enable a comprehensive evaluation of the UHC scheme.
Source: SDG indicators metadata repository (updated 24 January 2023) (8)
In the latest UHC score (2021), the UHC score (worldwide) was 68/100, an improvement from 2000, when the score was 45/100. However, the pace of improvement has slowed in more recent years, with no improvement in scores between 2019 and 2021. The change in UHC scores over time shows that the number of countries scoring less than 40/100 is decreasing; however, the number of countries scoring above 60/100 is growing at a discouraging rate, indicating a lack of well-established UHC schemes (Diagram 2).
Whilst many factors contribute to the slowdown of UHC score, the current focal point is on the ‘economic support’—a necessity for establishing UHC. Before going into the specific challenges and the roles in which Japan can play in disseminating UHC, it is important to understand in more detail the different UHC models and their tie-ins with the fundamental healthcare system established within each country, covered in the next section.
Cross-country analysis of UHC
UHC models correlate strongly with the country’s healthcare system, resulting in each country having unique models (Diagram 3). With that said, the model can be grouped together into three types. All models have merits and drawbacks from different perspectives; hence, when considering UHC dissemination, it is important to understand the countries’ situation to find the best-fit model.
Beveridge model
Examples: UK, Sweden
Healthcare services are provided mostly free of charge, without any insurance payments, and all financed through taxes. Medical facilities are mainly public, and healthcare practitioners are employed by the government as civil servants. However, the budget allocated for healthcare has been limited in the past in accordance with the country’s financial situation, resulting in healthcare practitioner strikes and restriction of patients’ access to medical facilities.
Bismarck model
Examples: Japan, Germany, France
Healthcare services are provided using insurance premiums as a financial resource. Insurance premiums are set according to income, so that even low-income citizens can receive equal access to healthcare services with a low premium burden and a low counter burden, which can be seen as a merit. In addition, since the system is not affected by the financial situation of the government, stable medical services can be provided to patients. On the other hand, the financial disparity between health insurers may lead to differences in health services (including preventative health services), resulting in an unequal accessibility to healthcare services.
Out-of-pocket model
Examples: US
Public healthcare services are only available for the elderly, the disabled, low-income individuals and children, whilst the rest of the population in principle receive healthcare services by purchasing private insurance. Private insurance, however, is inadequate in providing healthcare services to all citizens, as there is a disparity in the services available depending on the income, as well as many citizens not opting to purchase private insurance due to high costs.
Source: Ministry of Health, ‘2022 Report on International Situation’
Japan’s role in UHC establishment
As outlined in the ‘History of UHC’, improvements in UHC dissemination are decelerating over the years. The reason varies across countries, but when reflecting on the UHC score per region, more than half of the countries have UHC scores below 60/100 in Sub-Saharan Africa, East Asia & the Pacific and South Asia (Diagram 4).
Within these regions mentioned above, there are countries belonging to the Global South that are facing a variety of challenges towards healthcare. As reported by the WHO and WBG, one key challenge to highlight is the economic issue, where there is an increasing ratio of healthcare costs to the cost of living. Whilst UHC scores may be improving, the percentage of countries with healthcare costs accounting for more than 10% of the cost of living is increasing over time. Additionally, when comparing figures from 2000 and 2019, the ratio is worsening, highlighting the necessity of financial support to address the economic issue. Whilst international organisations and some countries as outlined by the World Bank*3 are already providing support to address the economic issues in the Global South, to achieve a sustainable healthcare system in the Global South will require strong establishments of UHC. To do this, as outlined in the previous section, it is important to firstly understand the situation of the country holistically, and determine the best UHC system to implement.
As mentioned above, in order to establish a sustainable UHC model, it is necessary to learn from other countries’ models, in which Japan can serve to play as a ‘leader’ amongst the nations. Why? Japan has a UHC score of 83/100, which is 15 points higher than the global score of 68/100. It is also the first country in the G7 to set the promotion of UHC as a major theme, at the G7 Ise-Shima Summit and G7 Kobe Health Ministers’ Meeting in 2016 at the summit level. In addition, the Japanese government has recently set up the UHC Knowledge Hub*4—an accumulation of information on various UHC schemes. Japan can play a key role in sharing this information with those global communities in need. However, establishing UHC takes an immense amount of time and effort to ensure the system is accessible to all citizens. To ensure healthcare services are provided seamlessly over time, corporations from not only the government but also private sectors are needed. One example of support from the private sector is the Patient Assistance Program (PAP), in which pharmaceutical companies can provide free medications to those in need. Essentially, this program allows for healthcare services to be provided to those in need, even when the maturity level of the UHC system may be low. As for pharmaceutical companies that PwC supports, it has shown needs in establishing PAP, where PwC has supported researching competitors’ PAP schemes, developing policies and designing PAP in depth across multiple nations.
In summary, this series looked into the history of UHC, specific examples of UHC models around the world, challenges faced in its establishment, and specific initiatives to address these challenges. UHC is integral in a global society where borderlessness and urbanisation accelerate, and should be a focal point for not only Japan but in all countries to realise successful global health practices. The next series to follow will explore in more depth the topic of ‘healthcare infrastructure’—the other remaining aspect for providing sustainable access to healthcare. Considering the healthcare infrastructure, especially in the Global South, healthcare services and providers are critical areas where Japan can provide support. The current state analysis and issues around healthcare infrastructure, along with measures with consideration of geopolitical factors, will also be considered.
