Socialization of Medicine - IV

Socialization of medicine can be achieved through mandatory prepayments by taxation, increasing public spending for healthcare financing, reducing out-of-pocket expenditures, consolidating risk pools, improving efficiency of supply chains, breaking the link between entitlement and contributions and aligning procurement with benefits for the population

After having explained the difference between the terms, ‘social medicine’, ‘socialized medicine’ and ‘socialization of medicine’ in the previous columns, this concluding piece on the topic will attempt to explore the possibilities of achieving socialization of medicine in our local socio-political and national contexts with a view to lay a roadmap for overcoming the statistics of inequitable access to a staggering 65% of our total population. Here the term “socialization” has been used in the specific context that everything in an egalitarian society is made and achieved by the cooperative and collaborative efforts of its people and citizens, as envisioned under the conventional ideology of ‘socialism’. Main aim behind public ownership of universal healthcare is to ensure social justice, security and solidarity so that the healthcare services are responsive to the needs and aspirations of the general population and such services are distributed equitably among all sections of the society. This essentially means that the universal health coverage to all the people in a nation or a community has to be funded by the people themselves rather than by the government alone in order to make it sustainable and successful for ever. External funding or government funding alone can sustain such an initiative only for a limited period, not for ever. Ideally pooling of resources from the government, households, taxpayers, NGOs (wherever available) and insurance providers (wherever in loop) can expand the scope of coverage to a vast segment of the population for an extended period. 

In order to make substantial progress in our march towards socialization of medicine that is synonymous to universal health coverage (UHC), we need to evolve our health-financing systems, eliminate or substantially reduce direct out-of-pocket payments by the people at the point of delivery and widen progressive mandatory prepayments through various forms of taxation, including compulsory social health insurance contributions based on one’s ability to pay though the services have to be provided equitably to all the citizens irrespective of their paying capacity. This was also envisaged in a resolution adopted by the World Health Assembly in its 64^th meeting held on May 24, 2011 that calls for a mechanism to pool the risks and resources among the population in order to subsidize the cost of services and avoid catastrophic health-care expenditures and impoverishment of individuals particularly the poor and marginalized sections of the society while seeking the needed healthcare (WHA, 2011). While managing the transition of our healthcare system to universal coverage, all options available need to be thoroughly weighed, analyzed and developed in consonance with the specific epidemiological, macroeconomic, sociocultural and political context of each state of the country. 

First step in the process will be to promote the efficiency, transparency and accountability of our health-financing governing systems. This will be logically followed by the establishment and strengthening of our institutional capacity in order to generate regional evidence and effective, evidence-based policy decision-making on the design and implementation of universal health coverage systems, that includes tracking the flows of healthcare expenditures through the application of standard accounting frameworks. Additionally, we need to ensure that our overall resource allocation strikes an appropriate balance between health promotion, disease prevention, health-care provision and rehabilitation. Wherever feasible we need to take advantage of existing opportunities for collaboration between public and private providers and health-financing organizations, albeit under an overarching government-inclusive stewardship (WHA, 2011). It is hard to achieve UHC if the entitlement of citizens depends solely on individual contributions made by them because those who are most in need will remain without adequate coverage in such a regime. It will be difficult to collect direct taxes like income tax or mandatory health insurance contributions where a high proportion of the population does not have regular, salaried employment. Therefore, we need to weaken or even break the link between entitlement and contributions and place greater reliance on general budget revenues sourced mainly from indirect taxes, designed to be progressive and persistent in nature (WHA. After many years of trying to expand coverage for the informal sector with a government-run and subsidized contributory voluntary health insurance program, Thailand abandoned this approach in 2002, introducing a scheme that is funded entirely from general tax revenues (Prakongsai et al, 2009). 

Sufficient government funding or public financing is critical to subsidize the costs of care for the poor and sick populations. This requires increasing public spending on health, either by prioritizing health financing in national budget allocations, expanding the overall level of public revenues through progressive and sustainable mechanisms and expenditures, or implementing a combination of the two. For instance, Mexico ’s commitment to move toward UHC was reflected in an increase in public spending on health by an average of 5% annually from 2000 to 2006 (Garcia-Diaz et al, 2011). Similarly, enhancements in public health spending by Turkey between 1995 and 2010 contributed immensely towards significant improvements in their service delivery besides improved access for the underserved and rural populations (worldbank.org). There is need to build and consolidate pools that cover people of different economic strata and health statuses to enable the redistribution of resources since the fragmentation of risk pools inhibits our ability to distribute prepaid funds for health in accordance with the need. Attempts at splitting health insurance schemes for civil servants or formal sector workers by countries like Thailand and Mexico before extending explicit coverage to the rest of the predominantly poor population has proved dearly and their governments have been forced to spend more resources to gradually equalize the benefits across the population. 

One important measure required to ensure successful implementation of UHC is to improve efficiency of our pharmaceutical supply chains with a view to conserve our limited resources and ensure their better utilization for achieving UHC. It has been estimated by the World Health Organization that 20% and 40% of health expenditures are wasted in most countries as a result of spending on branded medicines rather than purchasing their generic versions. Effective purchasing of health services can improve efficiency and save funds that can be reinvested to increase the coverage and quality of healthcare. Such strategic purchasing involves shifting from conventional bureaucratic resource allocation processes towards data-driven approaches that use information about the service provider’s performance or health service needs of the population they serve (Kutzin et al, 2009). While health system financing is an essential component of UHC, progress toward UHC also requires coordinated actions across the pillars of the health system with particular attention to strengthen human resources for health. 

Therefore, socialization of medicine embraces a system wherein entire population of a nation contributes significantly as per their income, social status and resources towards health system financing through a just and rationalized taxation system so that poorer and marginalized segments of the society get adequately covered for their healthcare expenditures and do not suffer catastrophic expenditures leading to their impoverishment or deprivation of needed care. In the process taxpayers themselves get adequately covered for a considerable number of services and extent of costs while visiting healthcare centres thereby getting rid of the stresses causes by such out-of-pocket expenditures at the point of delivery. Thus by socialization we mean centralization of resource pooling and decentralization of service provision, wherein an affluent section of the society bears the healthcare burden of the deprived, under-privileged and marginalized sections just like we have the system of “zakat” being practiced in Islam wherein all affluent muslims contribute and pool a meagre 2.5% of their total savings for extending financial help to the poor and downtrodden sections of their community. Socialization of medicine through UHC implies that all people have access, without any discrimination, to the needed promotive, preventive, curative, palliative and rehabilitative basic health services and essential, safe, affordable, effective and quality medicines. This can be achieved by making important policy choices and inevitable trade-offs between the way pooled funds are used to extend coverage to those individuals who previously were not covered, to services that previously were not covered or to reduce the out-of-pocket payments needed for each service (WHR, 2010). These dimensions of coverage reflect a set of policy choices about benefits and their rationing that are among the critical decisions facing any country in its reform of health financing systems towards UHC. 

In Jammu and Kashmir healthcare is mainly provided to the people by the government health institutions. Though there are a few hospitals in private sector too but they do not function 24/7 and have no accident and emergency department. Surgeries are performed at private hospitals by doctors on call that too mostly during daytime only. That makes it easier for the government to acquire full control over the healthcare system through socialization of medicine in a manner similar to that of NHS in UK. Government can impose a 3-5% cess on total payable income tax just like education cess that is in vogue at present and thereby insure all its citizens for socialized, universal healthcare so that nobody has to pay out-of-pocket for his healthcare and medicines and suffer any impoverishment due to their unaffordable costs. However, the trade-off between the extent of services to be covered, percentage of population to be covered and the extent of costs to be covered by the government shall have to be worked out in consonance with our local financial, budgetary and psycho-social circumstances, disease incidence, morbidity and mortality patterns, per capita annual income and overall expenditure on healthcare by the government. Further all financial allocations for health-related expenditures shall have to be pooled centrally and distribution of goods and services decentralized to the maximum extent possible. UK model can be studied and adopted in a well-organized and systematic manner owing to the fact that it adopted socialized medicine way back in 1948 and has evolved enormously since then (concluded).