A 'World Health Insurance'

Could international solidarity be achieved to attain such a goal?

In a recently published article, a team from Médecines Sans Frontières have suggested a 'World Health Insurance' to help provide healthcare for people in poorer nations (see box). Over 50% of the 42 countries carrying that healthcare burden would be European.

Gunter Danner MA PhD, studied history, economics and international relations...
Gunter Danner MA PhD, studied history, economics and international relations in
Great Britain, South Africa and the USA.
Today, he is personal advisor on socio-political and economic affairs to the CEO of Techniker Krankenkasse, which is Germany’s third largest not-for-profit health fund.
In addition, Dr Danner is Deputy Director of the permanent liaison bureau of the joint associations of German statutory social insurance in Brussels. He also regularly lectures on socio-economic subjects, specialising in the international comparison of social security systems in France, Germany, Switzerland and Sweden.
Along with major research on questions arising from EU-developments and enlargement, Dr Danner also participates in PHARE/TACIS projects for social reform in all East European countries, including Russia.

We asked Gunter Danner MA PhD to examine the broader implications for these countries if they became legally bound to contribute to such a scheme.

From a Euro centrist’s point of view, true global solidarity and a ‘World Health Insurance’ are rather unusual topics. For innumerable years calls for less, rather than more, social protection have been the norm. Consequently, in Western Europe most healthcare systems are permanently battling against shrinking funds and a noticeable decrease in political relevance. Recent international research has presented the idea of ‘health’ as a human right, enshrined by international treaties and perhaps some day legislation. However, in practice such rights might be quite difficult to ensure. No insurance, no matter whether statutory or private, can guarantee ‘health’ to any individual. However, it can ensure that people in need will receive some treatment, irrespective of their own solvency.

Thus the practical value of a health insurance for a sick individual is influenced by, for example, the generosity and decency of the scope of benefits offered, the availability of medical care and the ability of the insured to pay his or her dues as contributions or taxes.

Even throughout the EU this reality shows vast differences. Many systems are almost paper tigers, making illegal co-payments inevitable. Lots of the 27 different healthcare models are under-funded. Therefore, increasing out-of-pocket payments are quite normal.  Productivity does not always guarantee quick treatment rather than lengthy waiting lists. Even Central and East European Countries, with mostly poor public systems, ask for heavy contributions. Backhanders may have to be added on top.

Such contributions will be hard to get in Third World countries. Universal coverage – if possible not just on paper – is thus almost non-existent. The idea of a universal health fund, subsidised by ‘rich’ countries and allotting funds to those considered ‘poor’, therefore runs the risk of mixing up different levels of action.  Nobody, not even Brussels, has ever insured a Member State. Health insurance is logically aimed at the individual, not the Government. In the eyes of many, paying Governments to do or to leave something has not lived up to expectations as far as the creation of a better quality of life in economically challenged countries is concerned. Consequently, the additional ‘burden sharing’ of a ‘World Health Insurance’ (Author’s note: the term ‘insurance’ is misleading since no insurance principle – social or based on risks assessment – is involved) might ask the UK for an additional US$4.4 billion; France for US$2.6 billion, and Germany for US$2.9 billion. (It remains an open question, why  Britain, with  her problematic NHS, should pay roughly the same as the US, or one third more than France or Germany, with their still far more generous systems of healthcare). Given the pressures on their own systems, local voters might not like this idea at all.

On the other hand, the widening gulf between well-to-do countries and those where most people are forced to live in appalling conditions should not be brushed aside simply for reasons of local populism. Questions to be answered are still perhaps more complicated than just another call for more money to alleviate poverty gaps between Governments. Indeed, by concentrating existing means on health and other basic services of general interest, much might be achieved. Yet, the sometimes tragic political conditions in receiving countries may render this quite difficult
(The history of the arms’ race among poor countries does not speak in favour of many local Governments). Initially, public awareness in donating countries ought to be changed from the prevailing scepticism to a positive socio-strategic vision. Thus structural development aid, locally provided, double and triple checked against corruption, is of the essence. After all, millions of weary Western taxpayers rather than a few devoted Third World activists must be convinced that indeed more cash is needed and will do some good.

This calls for a well-balanced approach. More basic help and change should be made directly available to the suffering on the spot. Any anonymous global institution telling others what they have to do could add to the problems rather than bring about a solution.  At home, a new approach to social issues in so-called ‘rich’ countries under a growing demographic strain is important. Even here, injustice and poverty are unfortunately rising, albeit less horrifying than elsewhere.

The proposition
In their article published in Plos Medicine (vol. 3, issue 12,  2006. Pp.2174), Médecines Sans Frontières (MSF) members Gorik Ooms, Katharina Derderian and David Melody questioned: ‘Do we need a ‘World Health Insurance’ to realise the right to health?’

Although international recognition that health should be considered a human right has grown, the authors point out that far less attention has been paid to any legal obligation to provide international assistance. They suggest two major reasons why many countries avoid their obligation to provide such healthcare assistance:

1. The concept of shared responsibility. ‘Poor states can blame rich states for not honouring their obligation to provide assistance, thus leaving poor states with insufficient means to meet their core obligations. Rich states can blame poor states - and each other -for not doing enough,’ the MSF team points out.

2. The notion of ‘progressive realisation’, i.e. recognition that economic, social, and cultural rights cannot be fully realised in a short period. ‘This allows states to claim that they are doing, or have done, everything they can,’ the authors suggest. 

They then argue that a ‘world health insurance’ could solve both those problems by defining rights and duties for both rich and poor states. But how could such an insurance scheme work?
Ooms et al. cite the example of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The creation of this fund, they say, ‘…demonstrates the merits of ambitious thinking: the provision of anti-retroviral therapy to people living with AIDS, previously dismissed as unsustainable, became widely accepted as soon as the Global Fund provided a long-term funding perspective. Other health interventions deserve a similar approach’.

The team’s suggested framework for a world health insurance involves rich states paying a fair contribution and poor states having the right to assistance for healthcare needs that they cannot finance themselves. The WHO has estimated that a state needs to spend at least $35 per person per year to finance adequate levels of healthcare. Ooms et al suggest that rich countries should be obliged to assist those countries unable to reach this financial outlay alone.

Their original article can be accessed at: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030530

08.03.2007

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