L e a d e r s h i p , r e s o u r c i n g a n d g o v e r n a n c e Civil society contribution is also highlighted in achieving UHC (Oxfam, 2013). The key civil society responsibilities include: • Increasing collaboration to exert collective pressure on governments and other stakeholders to push for a UHC approach that enshrines the values of universality, equity and solidarity • Holding governments to account by engaging in policy dialogue, monitoring health spending and service delivery, and exposing corruption • Drawing attention to cases where influential donors are promoting inequitable health financing mechanisms and hold them to account • Working together with civil society to call for urgent action on global tax evasion and avoidance Formal sector unions should act in solidarity with workers in the informal economy and advocate for universal and equitable health care. Conclusion A brief review of the history of UHC shows that, in the countries of origin of modern medicine, over the 18th and 19th centuries health services were available either as charity from voluntary institutions or on payment to providers. Disease, destitution and widespread epidemics, however, forced local bodies to intervene in ways that were considered preventive – isolation, institutionalisation, fumigation and other sanitary measures – or through labour and health legislation (Rosen, 1993). The late 19th and early 20th century saw the evolution of other ways of payment, such as small mutual benefit societies, like the workers’ contributory funds, later joined by some employers, and limited national as well as private insurances for special groups. In Britain, World War II was instrumental in the achievement of the NHS, free at the point of delivery and paid for out of general taxation, as proposed by the Beveridge Committee. Germany and France, on the other hand, continued to follow Bismarck’s insurance-based system, while other European countries mixed private provisioning with one or the other of state-led NHS models. The two extremes were the USA and Canada. In contrast, the movement for UHC in the USA was repeatedly defeated. It only conceded medical insurance for the elderly, and later the poor, in the 1960s, keeping a large population from receiving state insurance coverage. Following the oil shocks and other crises of the 1970s, most Western countries protected their public expenditures in health, keeping it at six to eight per cent of their gross domestic product (UNDP, 2005). Canada’s Health Act 1984 re-asserted its political 110 Commonwealth Health Partnerships 2015 commitment to free and universal basic health services through a single payee insurance system administered by the public authority. It specifically discouraged financial contributions by patients, either through user charges or extra-billing (billing patients over and above the insured amount for basic services). US President Barak Obama made UHC his election agenda, and his electoral success reflects the assertion of the marginalised and the popularity of the idea of UHC among democratic Americans. What is interesting for us in this historical experience of the West is the fact that within the welfare capitalist framework: a) there was no one model of provisioning medical care; b) that the state played a very crucial role in provisioning, financing and regulating even if it was not the only provider; c) that even through the economic crisis, state spending on health care was protected; and d) that socioeconomic, political and cultural factors play an important role in shaping a country’s strategy for UHC. The question is, how have these been impacted by shifts in approach over time and what are the challenges for the future? Endnotes 1 For the text of the General Assembly International Covenant on Economic, Social and Cultural Rights, see www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx Accessed 10 April 2015. 2 European Observatory on Health Care Systems, 2000. References Oxfam, 2013. Universal Health Coverage: Why health insurance schemes are leaving the poor behind. Oxfam briefing paper 176. Available at: www.oxfam.org/sites/www.oxfam.org/files/bp176- universal-health-coverage-091013-en_.pdf Accessed 9 April 2015. Rosen, G., 1993. A History of Public Health. Baltimore and London: Johns Hopkins University Press. UNDP (United Nations Development Program), 2005. Human Development Report. New York: Oxford University Press, p. 284. DR SUNDARAMARULRHAJ MD, FRCP is past president of the Commonwealth Medical Association and the Indian Medical Association. He is an adjunct professor of medicine, Dr MGR Medical University, Chennai. DR R. V. ASOKAN is a senior physician and member of the Indian Medical Association. DR ROSHAN HEWAPATHIRANA is a PhD fellow in the Department of Informatics, University of Oslo, Norway; and visiting lecturer at the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.
Commonwealth Health Partnerships 2015
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