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

Health is a state of complete physical, mental and
social well-being, and not merely the absence of disease
or infirmity.1 Health was declared as fundamental human
right by WHO constitution of 1948.2 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.2 Universal health coverage
(UHC) ensures that all people have access to needed
health services (including prevention, promotion,
Corresponding Author:
Dr. VinothGnanaChellaiyan:
MD Assistant Professor,Department of Community
Medicine Chettinad Hospital and Research Institute
Rajiv Gandhi salai, Kelambakkam, Chennai:603103
Tamil Nadu, India.
Mob No: 9944894554
e-mail: drchellaiyan@gmail.com
quality to be effective while also ensuring that the use
of these services does not expose the user to financial
hardship.3 To achieve UHC, a country must address legal
coverage and rights, health workers shortages, extension
of health care shortages and quality of care.4 Health
care provision is incredibly complex and many nations
around the world spend considerable resources trying
to provide it.5 The strength of the case for investing in
health varies among countries.6 The return on investment
is likely to be highest for emerging economies: They
can obtain significant improvements in health outcomes
(eg life expectancy) through modest increases in health
expenditures.6 The basic idea of this review is to provide
an insight on health coverages across various countries
and there path towards universal health coverage.
Health coverage in various countries: Many
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
 Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02  71
scheme. It is not just standard processes or manuals or
actuarial formula or stabilised systems that can work
seamlessly across geographies such that the success is
assured.7
High income countries: High income countries
according to World Bank are United States, Germany
and Singapore, Canada, Japan and Gulf countries.
Important principle of The affordable care act of 2010
or OBAMA care in United states is to improve quality
of care which is achieved by establishing new agencies,
boards, commissions and other Government entities8;
The 2010 Affordable Care Act (ACA) dramatically
changed many features of the US health care system and
should greatly reduce the number of Americans who are
uninsured.
The German government sponsors mandatory
universal insurance coverage for everyone, including
temporary workers residing in Germany.9 The German
system uses a unique point-based global budgeting
system to control annual health careexpenditures
whereby the targeted expenditures are achieved by
ensuring that total payments to all providers of a given
specialty are equal to the total budget for that specialty in
a year.10If salary of German residents is less than 59400
euros per year or 4950 euros per month then membership
is made mandatory. It covers in patient hospitalisation,
OP services as well as dental care.
Singapore has a unique-to-the-world health care
system where the dominant form of insurance is
mandatory self-insurance supported by sponsored
saving, although complementary and special insurance
programs are also central to their system.11 It provides
UHC through a combination of government subsidies,
multi-layered healthcare financing schemes and private
individual savings all at national level. It provides
Government subsidy 80% of total cost in public hospitals
and primary care polyclinics. It is supported by 3M’s
system namely Medisave, Medishield and Medifund.
Japan has a mandatory insurance system which
is comprised of an employment-based insurance for
salaried employees, and a national health insurance for
the uninsured, self-insured and low income, as well as
a separate insurance program for the elderly.10 Health
insurance benefits designed to provide basic medical
care to everyone are similar. They include ambulatory
and hospital care, extended care, most dental care and
prescription drugs.
Canada has a universal single-payer, sponsored
health insurance system called Medicare which is
administered independently by the thirteen provinces
and territories. Every citizen and permanent resident is
automatically covered. As of 2012, Canada spends about
11% of GDP on healthcare expenditures covering about
70% of healthcare expenditure.2
In Gulf countries major healthcare challenges has
hampered the efforts towards ensuring UHC across
the region. Mandatory health insurance is one of the
measures adopted to achieve UHC. Qatar has initiated
the upgradation of health care services by launching an e-
health program. Saudi Arabia is digitalizing its hospitals
and PHC patient medical records through healthcare
information and management systems society (HIMSS).
UAE in 2011 had launched integrated electronic medical
record system to link public hospitals and clinics
across Dubai and the Northern emirates through health
information system- Wareed12
Middle income countries: China, India and Mexico
are middle income countries. Chinese government
has established a multilevel medical security system
including universal health care system, commercial
medical insurance and a medical charity aid. Over
90% of the population has basic insurance coverage in
China. Three insurance schemes available in China as
of 2011 is Urban employee basic medical insurance,
Urban resident basic medical insurance and new rural
cooperative medical system. Chinese government health
care covers both sectors of population groups equally
inorder to work on urban rural disparity.13 In Mexico
the government run system operates Clinics and hospital
throughout the country in Mexico to provide health at
low price.14 Whereas in India according to model based
estimate by WHO through public and private sector is
estimated to be INR 1,713 / Capita / Year between 2014–
2015. Average medical expenditure for hospitalization
in urban patient has increased to 126% and rural patient
to 160% and same year GDP / Capita grew by 121% .15
Need for health insurance: India is presently in a
state of health transition facing a shift from infectious
diseases to non-communicable diseases that are now
emerging as the leading cause of mortality. According
to National Health Accounts (2014-15) 62.6% of
total health expenditure in India (2.4% of GDP,
Rs. 2394 per capita) by householdis Out of pocket
expenditure15which is defined as expenses that patient
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
health insurance.16People having no access to any form
of health insurance scheme are being forced to make
OOPE pushing 60 million Indians to poverty each year.17
Although India has been witnessing a staggering
growth in the health insurance sector, still only 15% of
the population is protected by medical care insurance
coverage and 5% of the population buy a plan voluntarily
of their own accord which suggests that Indian insurance
industry has still a long way to go. The reason behind
such a low acceptability is not the affordability factor,
but the lack of awareness and unwillingness on the part
of the potential buyers. The likelihood of utilising health
care services increases with genuine health insurance
scheme in place. Such schemes should be focused on
achieving a two-way objective, to tell people how
imperative is it to get a health care insurance and to build
the trust and credibility of insurers among them.18Global
disease burden in India 2016 report suggests that deaths
due to communicable, maternal, neonatal and nutritional
diseases is 27.5% and Non communicable diseases is
62% in men and 52% in women; if each citizen is insured
nearly 89.5% of disease burden could be averted.19 A
recent data suggest that 80% of hospitals are in urban area
though it comprises of only 31% of country’s population
and availability of qualified physician in urban area is
11.3 per 10000 population when compared to 1.9 per
10000 population in rural area. 65% of rural population
have no access to essential medicines and cannot afford
to medical expenditure.20Health insurance scheme are
designed to provide employment to rural poor besides
creating rural infrastructure so that urban-rural disparity
in the country could be reduced.21
State based health insurance schemes (2007-
2017): Some states have its own health insurance scheme
for its people and they are explained in detail. Aarogyasri
scheme was launched in 2007 (continued as Dr NTR
Vaidya Seva (2015) AarogyaRaksha scheme (2017). It
is a unique community health insurance scheme being
implemented in Andhra pradesh. It provides financial
protection upto 2 lakhs to BPL families in a year for
treatment of serious ailments requiring hospitalisation
and surgery.22Chief Minister comprehensive health
insurance scheme was launched in 2012 in Tamil Nadu.
It provided cover for all major ailments and ensured
advanced healthcare for low income and unorganised
group. Its aim was to benefit 1.34 crore families with
annual income of 72000 or less. The sum assured
under the scheme is 1 lakh every year for a period of
4 years with total value of 4 lakh, in case of certain
procedures it will be raised 1.5 lakh per annum.23 In
2013 Sanjeevani Swasthya Bima Yojana was launched
as a comprehensive health insurance scheme for citizen
of Dadra Nagar Haveli and Daman and Diu. Under this
scheme premium for BPL families will be borne by the
UT Administration and for those families with income
of 1 lakh- 2 lakh 50% will be by UT administration and
50% by their own.24 Mukhyamantri Swasthya Bima
Yojana was launched in 2016 in Uttarakhand for all BPL
and APL families (except those on govt. salary or govt.
pension or in tax payer category). It provided a cover
of Rs. 50000 per eligible families and in same wake
second phase with a base cover of Rs. 50000 covering
1206 diseases and critical cover package of Rs. 125000
covering 458 diseases.25
Nationwide health insurance (2003-2018):
At National level, health insurance schemes were
implemented between 2003 -2018. Universal health
insurance scheme was launched in 2003 and available
for individuals as well as in a group. Age criteria 5
to 70 years and children between 3 months to 5 years
are eligible if one of the parent is covered. It gives
hospitalisation benefit of INR 30000 per family per
policy inclusive of maternal benefit. Total expenses for
any one illness is limit to INR 15000 excluding maternal
benefits and also covers accident and disability.26
Rashtriya Swasthya Bima Yojana in 2013 was different
from the previous policy with regards to target group
which included BPL families and defined categories of
unorganised workers. RSBY has been the only scheme
in India launched on a Pan India basis, which aimed at
universal health coverage.27-29 Beneficiaries are entitled
to hospitalisation coverage of Rs 30000 per annum for
most of diseases that require hospitalisation. Additional
transport expenses are also provided to the beneficiary.28
Under RSBY health protection mission/ Pradhan
Mantri Rashtriya Swastya Suraksha Mission later
renamed as Pradhan Mantri Jan Arogya Yojana was
launched in 2018 at Ranchi Jharkhand. It provides
coverage of 5 lakh/family/yr and benefits 10.74 crore
families; 8.03 in rural and 2.33 in urban areas through
a network of empanelled health care providers. Key
feature of the scheme is that the beneficiaries can
avail of services anywhere in India and there is no
compromise on family size and age.28 Budget allocation
is approximately 12000 crores and 60:40 is the ratio for
fund transfer from central and state government. Target
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
Socio economic caste census 2011. All enrolled families
under Rashtriya Swasthaya BimaYojana (RSBY) not
featured in the targeted groups as per SECC data has
also been included.30
Low Income Countries: Most of the African
countries and Nepal belong to low income group. In
Nepal to provide affordable care, quality health services,
easy access and health security coverage Social health
security development committee was established. It
works by raising funds from healthy people and spending
the same for needy.31In Ghana rapidly expanding
National program is run by the government. In Nigeria
most of the schemes are run by private investors and
shareholders. In Tanzania and Uganda some programs
are functioning through their own hospitals and clinic by
employing their own staff on regular basis. Government
must take extra measures in these low income countries
to improve health insurance program and to provide
quality health care to their people.32
Conclusion
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.
In accordance to health for all agenda set by Alma Ata
declaration in 19781 every country is struggling to
provide an efficient health care system to its people.
Health has become a basic need with emerging health
care challenges. Health care delivery system in each
country aims to reach the ultimate goal of universal
health coverage, with effective utilisation of resources
and by strategic planning this goal can be achieved in all
countries across the globe.
Conflict of Interest: Nil
Source of Funding: Self
Ethical Clearance: It is a Review article, Human
subjects were not interviewed and examined. Ethical
Clearance is not available
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