Medicalization of global health 4: The universal health coverage campaign and the medicalization of global health

The Reality of Cost Sharing in Japan

Financial pressure on younger generation is mounting in Japan, a super-ageing society with staggering economy. The revision on the co-insurance rate for 70-74 with "Standard" category was implemented to mitigate such pressure, seeking better balance across generations in sharing the burden of healthcare cost. It raised the rate from 10% to 20% over the period of five years from 2014 to 2018. This report examined how it changed the share of cost sharing (cost sharing as percentage to total healthcare expenditure), among the 70-74 with "Standard" category in Citizens Health Insurance programme in 44 prefectures. It specifically focused on change in the population's actual share of cost sharing (ASCS) that better reflect the genuine amount of payment actually made by the patients themselves. The average ASCS increased from 7.28% (2013) to 10.78% (2019), resulting wider gap from the statutory planned share of cost sharing (i.e., the statutory co-insurance rate of 10% in 2013, and 20% in 2019). Also found was increased variance among prefectural ASCS, which may suggest a possibility of un-designed effect by the revision, of encouraging a move towards ability and willingness to pay. In terms of cost containment effect, Japan needs to consider various non-conventional options, including review of the current use of healthcare resources. First and foremost, however, the true state of cost sharing should be recognized in terms of ASCS and shared more widely as a reality. Such effort is essential in discussion of how to keep embracing the country's life line, UHC.

The cost-effectiveness of sexual and reproductive health and rights interventions in low- and middle-income countries: a scoping review

Sexual and reproductive health and rights (SRHR) are an essential component of universal health coverage (UHC). In determining which SRHR interventions to include in their UHC benefits package, countries are advised to evaluate each service based on robust and reliable data, including cost-effectiveness data. We conducted a scoping review of full economic evaluations of the essential SRHR interventions included in the comprehensive package presented by the Guttmacher-Lancet Commission on SRHR. Of the 462 economic evaluations that met the inclusion criteria, the quantity of publications varied across regions, countries, and the components of the SRHR package, with the majority of publications reporting on HIV/AIDS, reproductive cancer, as well as antenatal care, childbirth, and postnatal care. Systematic reviews are needed for these components in support of more conclusive findings and actionable recommendations for programmes and policy. Further evaluations for interventions included in the remaining components are needed to provide a stronger evidence base for decision-making. The economic evaluations reviewed for this article were inherently varied in their applied methodologies, SRHR interventions and comparators, cost and effectiveness data, and cost-effectiveness thresholds, among others. Despite these differences, the vast majority of publications reported the evaluated SRHR interventions to be cost-effective.

Engaging globally with how to achieve healthy societies: insights from India, Latin America and East and Southern Africa

The way healthy societies are conceptualised shapes efforts to achieve them. This paper explores the features and drivers of frameworks for healthy societies that had wide or sustained policy influence post-1978 at global level and as purposively selected southern regions, in India, Latin America and East and Southern Africa. A thematic analysis of 150 online documents identified paradigms and themes. The findings were discussed with expertise from the regions covered to review and validate the findings.

Globally, comprehensive primary healthcare, whole-of-government and rights-based approaches have focused on social determinants and social agency to improve health as a basis for development. Biomedical, selective and disease-focused technology-driven approaches have, however, generally dominated, positioning health improvements as a result of macroeconomic growth. Traditional approaches in the three southern regions previously mentioned integrated reciprocity and harmony with nature. They were suppressed by biomedical, allopathic models during colonialism and by postcolonial neoliberal economic reforms promoting selective, biomedical interventions for highest-burden diseases, with weak investment in public health. In all three regions, holistic, sociocultural models and claims over natural resources re-emerged. In the 2000s, economic, ecological, pandemic crises and social inequality have intensified alliances and demand to address global, commercial processes undermining healthy societies, with widening differences between ‘planetary health’, integrating ecosystems and collective interests, and the coercive controls and protectionism in technology-driven and biosecurity-driven approaches.

The trajectories point to a need for ideas and practice on healthy societies to tackle systemic determinants of inequities within and across countries, including to reclaim suppressed cultures; to build transdisciplinary, reflexive and participatory forms of knowledge that are embedded in and learn from action; and to invest in a more equitable circulation of ideas between regions in framing global ideas. Today’s threats raise a critical moment of choice on which ideas dominate, not only for health but also for survival.

Four Ironies of Self-quantification: Wearable Technologies and the Quantified Self

Bainbridge's well known "Ironies of Automation" (in: Johannsen, Rijnsdorp (eds) Analysis, design and evaluation of man-machine systems. Elsevier, Amsterdam, pp 129-135, 1983. https://doi.org/10.1016/B978-0-08-029348-6.50026-9) laid out a set of fundamental criticisms surrounding the promises of automation that, even 30 years later, remain both relevant and, in many cases, intractable. Similarly, a set of ironies in technologies for sensor driven self-quantification (often referred to broadly as wearables) is laid out here, spanning from instrumental problems in human factors design (such as disagreement over physiological norms) to much broader social problems (such as loss of freedom). As with automation, these ironies stand in the way of many of the promised benefits of these wearable technologies. It is argued here that without addressing these ironies now, the promises of wearables may not come to fruition, and instead users may experience outcomes that are opposite to those which the designers seek to afford, or, at the very least, those which consumers believe they are being offered. This paper describes four key ironies of sensor driven self-quantification: (1) know more, know better versus no more, no better; (2) greater self-control versus greater social control; (3) well-being versus never being well enough; (4) more choice versus erosion of choice.

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

BACKGROUND

Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access.

METHODS

This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.

RESULTS

The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability.

CONCLUSION

The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Challenges and opportunities towards the road of universal health coverage (UHC) in Nepal: a systematic review

BACKGROUND

Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal.

METHOD

We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart.

RESULTS

We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC.

CONCLUSION

To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.

The Medicalization of Health and Shared Responsibility

Public, occupational and environmental health are relatively novel disciplines compared to the ancient history of medicine. Their development, together with a more insightful knowledge of the human pathophysiology (this more usual term is the one used in the article itself), have progressively expanded the field of investigation of medicine to environmental, behavioural and genetic factors that favour the development of certain medical conditions. As a result we have developed numerous additional strategies to monitor health and prevent disease, including interventions in anticipation of diseases themselves when patients are still healthy or in a grey area of increased risk. New developments related to genomics and distributed point of care technologies will exacerbate a process of medicalization of health. This process is profoundly re-shaping how medicine interacts with the general population, states and policy makers and has implications for healthcare system design and individual health choices.

Universal Health Coverage's evolving location in the post-2015 development agenda: Key informant perspectives within multilateral and related agencies during the first phase of post-2015 negotiations

In 2001, technocrats from four multilateral organizations selected the Millennium Development Goals mainly from the previous decade of United Nations (UN) summits and conferences. Few accounts are available of that significant yet cloistered synthesis process: none contemporaneous. In contrast, this study examines health's evolving location in the first-phase of the next iteration of global development goal negotiation for the post-2015 era, through the synchronous perspectives of representatives of key multilateral and related organizations. As part of the Go4Health Project, in-depth interviews were conducted in mid-2013 with 57 professionals working on health and the post-2015 agenda within multilaterals and related agencies. Using discourse analysis, this article reports the results and analysis of a Universal Health Coverage (UHC) theme: contextualizing UHC's positioning within the post-2015 agenda-setting process immediately after the Global Thematic Consultation on Health and High-Level Panel of Eminent Persons on the Post-2015 Development Agenda (High-Level Panel) released their post-2015 health and development goal aspirations in April and May 2013, respectively. After the findings from the interview data analysis are presented, the Results will be discussed drawing on Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality.The Lancet2007; 370: : 1370-79) agenda-setting analytical framework (examining ideas, issues, actors and political context), modified by Benzianet al.(2011). Although more participants support the High-Level Panel's May 2013 report's proposal-'Ensure Healthy Lives'-as the next umbrella health goal, they nevertheless still emphasize the need for UHC to achieve this and thus be incorporated as part of its trajectory. Despite UHC's conceptual ambiguity and cursory mention in the High-Level Panel report, its proponents suggest its re-emergence will occur in forthcoming State led post-2015 negotiations. However, the final post-2015 SDG framework for UN General Assembly endorsement in September 2015 confirms UHC's continued distillation in negotiations, as UHC ultimately became one of a litany of targets within the proposed global health goal.

Medicalization of global health 2: The medicalization of global mental health

Once an orphan field, 'global mental health' now has wide acknowledgement and prominence on the global health agenda. Increased recognition draws needed attention to individual suffering and the population impacts, but medicalizing global mental health produces a narrow view of the problems and solutions. Early framing by advocates of the global mental health problem emphasised biological disease, linked psychiatry with neurology, and reinforced categories of mental health disorders. Universality of biomedical concepts across culture is assumed in the globalisation of mental health but is strongly disputed by transcultural psychiatrists and anthropologists. Global mental health movement priorities take an individualised view, emphasising treatment and scale-up and neglecting social and structural determinants of health. To meet international targets and address the problem's broad social and cultural dimensions, the global mental health movement and advocates must develop more comprehensive strategies and include more diverse perspectives.

Medicalization of global health 1: has the global health agenda become too medicalized?

Medicalization analyses have roots in sociology and have critical usefulness for understanding contemporary health issues including the 'post-2015 global health agenda'. Medicalization is more complex than just 'disease mongering'--it is a process and not only an outcome; has both positive and negative elements; can be partial rather than complete; and is often sought or challenged by patients or others in the health field. It is understood to be expanding rather than contracting, plays out at the level of interaction or of definitions and agenda-setting, and is said to be largely harmful and costly to individuals and societies. Medicalization of global health issues would overemphasise the role of health care to health; define and frame issues in relation to disease, treatment strategies, and individual behaviour; promote the role of medical professionals and models of care; find support in industry or other advocates of technologies and pharmaceuticals; and discount social contexts, causes, and solutions. In subsequent articles, three case studies are explored, which critically examine predominant issues on the global health agenda: global mental health, non-communicable disease, and universal health coverage. A medicalization lens helps uncover areas where the global health agenda and its framing of problems are shifted toward medical and technical solutions, neglecting necessary social, community, or political action.