Universal health coverage and equal access in Sweden: a century-long perspective on macro-level policy.

BACKGROUND: When today's efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden's long and ongoing journey towards universal health coverage and equal access to healthcare. METHODS: The focus is on macro-level policy. A document analysis is divided into three broad eras (1919-1955; 1955-1989; 1989-) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. RESULTS: Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system's Achilles' heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden's welfare 'exceptionalism', or is a temporary decline remains to be assessed in the future.

Social Democratic Solidarity and the Welfare State: Health Care and Single-Tier Universality in Sweden and Canada.

Although it is not generally done, it is useful to compare the history of the evolution of universal health coverage (UHC) in Canada and Sweden. The majority of citizens in both countries have shared, and continue to share, a commitment to a strong form of single-tier universality in the design of their respective UHC systems. In the postwar era, they also share a remarkably similar timeline in the emergence and entrenchment of single-tier UHC, despite the political and social differences between the two countries. At the same time, UHC was initially designed, implemented, and managed by social democratic governments that held power for long periods of time, creating a path dependency for single-tier Medicare that was difficult for future governments of different ideological persuasions to alter.

Beautiful Harmony of the Japanese Precious Healthcare Legacies for the New Imperial Era.

The new Imperial era, Reiwa, started in May, 2019. After World War II, Reiwa is the third Imperial era following Showa and Heisei. In each era, we had specific healthcare problems in cardiovascular medicine and implemented preventive strategies against them. Furthermore, nationwide healthcare policies such as a universal healthcare insurance system (kaihoken) and health check-up system largely contribute to overcoming these problems. Here, we summarize the specific issues in cardiovascular medicine and nationwide strategies policies against them in each era. We also describe what we should do in the new Imperial era from the cardiovascular viewpoint.

Political Accommodations in Multipayer Health Care Systems: Implications for the United States.

Current interest in a single-payer approach to universal health care coverage in the United States has also triggered interest in alternative multipayer approaches to the same goal.An analysis of experiences in Germany, the Netherlands, Switzerland, and Israel shows how the founding of each system required a distinctive political settlement and how the subsequent timing, content, and course of the reforms were shaped by political circumstances and adjustments to the founding bargain in each nation.Although none of these systems is directly transferable to the United States, certain parallels with the American context suggest that a multipayer approach might offer a model for universal coverage that is more politically feasible than a single-payer scheme but also that issues associated with risk selection and other potential inequities would remain.

The Rise and Fall of "Universal Health Coverage" as a Goal of International Health Politics, 1925-1952.

The UN Sustainable Development Goals of 2015 have restored universal health coverage (UHC) to prominence in the international health agenda. Can understanding the past illuminate the prospects for UHC in the present? This article traces an earlier history of UHC as an objective of international health politics. Its focus is the efforts of the International Labor Organization (ILO), whose Philadelphia Declaration (1944) announced the goal of universal social security, including medical coverage and care. After World War II, the ILO attempted to enshrine this in an international convention, which nation states would ratify. However, by 1952 these efforts had failed, and the final convention was so diluted that universalism was unobtainable. Our analysis first explains the consolidation of ideas about social security and health care, tracing transnational policy linkages among experts whose world view transcended narrow loyalties. We then show how UHC goals became marginalized, through the opposition of employers and organized medicine, and of certain nation states, both rich and poor. We conclude with reflections on how these findings might help us in thinking about the challenges of advancing UHC today.

From health for all to universal health coverage: Alma Ata is still relevant.

With increasing adoption of universal health coverage (UHC), the health for all agenda is resurgent around the world. However, after a promising start the first time in 1978, the health for all agenda fizzled over the next decade. This commentary discusses the origin of the health for all agenda in the 1970s and the influence of global politico-economic forces in shaping that agenda, its demise and the resurgence in the form of UHC in the twenty-first century. We discuss UHC's focus on finances and the increasing role of market economy in health care, and the opportunities and risks UHC poses. We conclude by saying that UHC's greater focus on finances is prudent, but in order to achieve its promise, UHC needs to regulate the market based provision of healthcare, and incorporate more of the people and community centered ethos of its earlier iteration from 40 years ago.

The development and impact of primary health care in China from 1949 to 2015: A focused review.

High-quality primary health care (PHC) services are associated with better health outcomes and positive health equity. Providing PHC services to all inhabitants is one of the Chinese government's health care objectives. However, an imbalance between people's increasing health needs and effective health service utilization exists in China. The objective of this review is to identify evidence for PHC development in China and to summarize the challenges as a reference for the future improvement of China's PHC system. Literature searches related to China's PHC were performed in PubMed, Web of Science, China National Knowledge Infrastructure, and Wan-fang databases. Related data were collected from the China Statistical Yearbook on Health and Family Planning 2003-2016, the China National Health Accounts Report 2015, and An Analysis Report of National Health Services Survey in China, 2013. The PHC network and the population's health have improved in China in recent years, with general practitioners as "gatekeepers" who have gradually taken the initiative to offer health services to residents. The limitation of input and shortages of resources and skilled health care providers may restrict the sustainable development of China's PHC system. Therefore, policy support from the government is necessary.

Overcoming social segregation in health care in Latin America.

Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin America's longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.

Historical account of the national health insurance formulation in Kenya: experiences from the past decade.

BACKGROUND: Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya. METHODS: We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework. RESULTS: The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system. CONCLUSION: The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.

Bonhoeffer and universal health care as a human right.

Bonhoeffer gave a theocentric basis for human rights, as God is the ground of ethics. In our earthly world, the "ultimate" must be prepared by what is "penultimate." That includes humanity's natural life and bodily wholeness, leading to human duties crafted by human reason. Nowadays, biblical texts should not be used as partisan weapons attacking government provision of health care, since all Scripture (even the Law) is seen as a Christ-centered focus on human redemption. Thus, Bonhoeffer implies a right to universal health care, but leaves entirely open which practical structures may best provide it.

The Brazilian health system: history, advances, and challenges.

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Universal health coverage as a global public health goal: the work of the International Labour Organisation, c.1925-2018.

We examine the efforts of the International Labour Organisation (ILO) to extend medical care under social security, through international conventions, advocacy and technical assistance. We consider the challenges faced by the ILO in advancing global health coverage through its labourist, social security model. The narrative begins in the interwar period, with the early conventions on sickness insurance, then discusses the rights-based universalistic vision expressed in the Philadelphia Declaration (1944). We characterize the ILO's postwar research and technical assistance as "progressive gradualism" then show how from the late-1970s the ILO became increasingly marginalized, though it retained an advisory role within the now dominant "co-operative pluralistic" model.