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The UN on September 23 is holding a high-level meeting at the General Assembly in New York on universal health coverage

The event, led by Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, aims to garner commitments to sustain investment in health and accelerate progress towards universal health coverage across the world.

Universal health coverage is defined by the WHO as giving everybody access to health services that are of sufficient quality to be effective, without inflicting financial hardship as the price to pay for it.

The concept is not a new one: it could be argued its origins lie in ancient Egypt.

Beginnings of universal health coverage

Scrolls dating back more than 3,000 years resurfaced in 2015, revealing workers in the Egyptian town of Deir el-Medina in the flourishing Nile River Valley enjoyed paid time off and home visits from a workplace doctor.

UNITED STATES - CIRCA 1957: A painting from a series made for schools of the history of the medical profession. (Photo by Buyenlarge/Getty Images)
As ancient Egypt thrived there is evidence of the beginning of a health care system © Buyenlarge/Getty Image

Chancellor Otto von Bismarck’s attempts to unify German states included the Sickness Insurance Act of 1883, forcing companies to offer insurance to employees through a scheme where both paid into a fund. 

The system expanded to eventually include accidents in 1884, disability in 1889 and unemployment insurance in 1927. 

GD7EXM Furst Otto von Bismarck (1815-1898) in der Reichstagssitzung vom 6. Februar 1888 - Prince Otto von Bismarck (1815-1898) in the Reichstag session of February 6, 1888 Berlin Painter : Henseler, Ernst 1852-1940 Germany
Otto von Bismarck in the Reichstag in 1888 © Peter Horree / Alamy
(Eingeschränkte Rechte für bestimmte redaktionelle Kunden in Deutschland. Limited rights for specific editorial clients in Germany.) Nurses and paramedics taking care of 'injured' people in a paramedical training- 1897- Photographer: Zander & Labisch- Published in: 'Berliner Illustrirte Zeitung' 23/1897Vintage property of ullstein bild (Photo by Zander & Labisch/ullstein bild via Getty Images)
Nurses and paramedics taking care of 'injured' people as part of their training in 1897 © Zander & Labisch/ullstein bild via Getty Images

In 1911, Britain passed the National Insurance Act. This covered health and unemployment, and required individuals to pay into a fund alongside contributions from employer and the state. The scheme was available to 1.4m people. 

But it was not until 1948 that Britons gained universal health coverage, with the establishment of the National Health Service, free at the point of use and financed by the state. Often described as the closest thing the UK has to a national religion, the NHS featured prominently during the 2016 Brexit referendum. The Leave campaign promised to divert savings from leaving the EU to the service. 

LONDON, UNITED KINGDOM - JUNE 30: Thousands of demonstrators take part in a march followed by a rally outside Downing Street in central London to celebrate the 70th anniversary of the National Health Service. Protesters call for an end to austerity policies which lead to underfunding and staff shortages in the NHS, and demand that it remains publicly owned and accessible to everyone. June 30, 2018 in London, England. (Photo credit should read Wiktor Szymanowicz / Barcroft Media via Getty Images)
Thousands of demonstrators take part in a march in central London to celebrate the 70th anniversary of Britain’s National Health Service © Barcroft Media via Getty Images
LONDON, ENGLAND - JULY 18: A 'Vote LEAVE' battle bus is parked outside the Houses of Parliament in Westminster by the environmental campaign group Greenpeace before being re-branded on July 18, 2016 in London, England. The bus which was used during the European Union (EU) referendum campaign and had the statement "We send the EU £350 million a week let's fund our NHS instead" along the side was today covered with thousands of questions for the new Prime Minister Theresa May and her government about what a 'Brexit' might mean for the environment. (Photo by Jack Taylor/Getty Images)
A 'Vote Leave' campaign battle bus parked outside the Houses of Parliament in Westminster © Jack Taylor/Getty Images

China’s barefoot doctors

China’s Nationalist party opened a westernised department of public health service in 1927, aiming to go beyond the limitations of traditional medicine. The country’s revolutionary government of 1949 took healthcare inspiration from the Soviet Union, which had run a state healthcare system since 1922. 

Chinese leader Mao Zedong advocated the idea of “barefoot doctors” — farmers trained by community or county hospitals and then sent to service rural populations. 

A medical team (Barefoot Doctors) led by communist party member Ma Yi is active in the Wuchih Mountains area, serving the peasants of the Li nationality. Performing acupuncture. China. 1968. Cultural Revolution. (Photo by: Sovfoto/Universal Images Group via Getty Images)
Barefoot doctors serve people in the Wuchih mountain area of rural China in 1968 © Sovfoto/Universal Images Group via Getty Images

In 1978, an international WHO conference at Alma-Ata, in what is today Kazakhstan, praised the barefoot doctors and identified primary care as essential for global public health. Today the Chinese are struggling to restructure their system and widen access to care.

Solutions for growing populations

By the middle of the 20th-century, healthcare systems around the world were evolving. 

President Harry Truman started a debate over US public healthcare in 1945. This eventually resulted in the creation under President Lyndon Johnson of two government programmes: Medicare and Medicaid.

Medicare, established in 1965, covers the elderly, while Medicaid caters for the unemployed and the poor. 

Medicare coverage was extended in 1972 to cover the disabled and people with chronic kidney disease, and later under President Barack Obama to include low-income families.

President Lyndon Johnson signing Medicare Bill, Independence, Missouri, Harry Truman looks on, 30 Jul 1965. (Photo by: Universal History Archive/Universal Images Group via Getty Images)
President Lyndon Johnson signing the Medicare Bill as former president Harry Truman looks on in 1965
MAY 31 1966 Mr. and Mrs. George Whitehead, 4063 W. Eledorado Place, Sigh For Medicare Mrs. Amy Chester, Security claims representative, assists as deadline nears. Credit: Denver Post (Denver Post via Getty Images)
A couple signs up for Medicare in 1966 © Denver Post via Getty Images
(Original Caption) Regina, Saskatchewan: This is an overall taken at the Legislative Buildings this afternoon as thousands of people marched on protesting the governments stand in the Medicare crisis.
Thousands of people protest against Medicare in 1962 © Bettmann Archive
An elderly woman shows her gratitude to President Lyndon B. Johnson for his signing of the Medicare health care bill in April 1965. (Photo by © CORBIS/Corbis via Getty Images)
An elderly woman shows her gratitude to President Lyndon Johnson for signing the Medicare bill into law

The US remains an anomaly among industrialised nations for lacking a universal healthcare system. 

Mr Obama’s Affordable Care Act — popularly know as Obamacare — was the subject of fierce criticism from some opposition politicians, stoking misconceptions such as the notion that the UK used “death panels” to decide which elderly people deserved care.

Protesters with 'death panel' Obamacare signs.
Protesters with 'death panel' and anti-Obama signs © Marc Nozell
WASHINGTON, DC- Jan. 25: President Barack Obama delivers his State of the Union address to a joint session of the U.S. Congress. (Photo by Scott J. Ferrell/Congressional Quarterly/Getty Images)
President Barack Obama addresses a joint session of US Congress © CQ-Roll Call, Inc via Getty Imag

Obamacare created a state-run market for people who did not get insurance from their employers and expanded Medicare for low-income families, although by 2017 an estimated 28m Americans in 2017 remained uninsured.

Healthcare reform is a key issue in the upcoming presidential race as some Democratic frontrunners call for “Medicare for all”.

UNITED STATES - APRIL 10: From left, Sens. Kirsten Gillibrand, D-N.Y., Bernie Sanders, I-Vt., and Jeff Merkley, D-Ore., conduct an event to introduce the
Bernie Sanders introduces the Medicare for All Act of 2019

In India, Prime Minister Narendra Modi in 2018 unveiled ambitious plans — dubbed ‘Modicare’ — to reform the public health system in the second-most populous country in the world. 

According to the Center for Global Development, India is home to one-third of global maternal deaths and spends just 1 per cent of gross domestic product on public health. Some 60m people fall into poverty every year because of healthcare bills. 

Modicare has been criticised for its lack of funding and underemphasis on primary care services.

Nand Lal Mandhji, holds a letter about the Ayushman Bharat Medical Scheme, known as 'Modicare' as he sits outside his home with his family in Marwan village in the eastern state of Bihar, India, June 20, 2019. Picture taken June 20, 2019. REUTERS/Alasdair Pal - RC1252E27050
Nand Lal Mandhji holds a letter about 'Modicare' in the eastern state of Bihar in India © Reuters
RANCHI, INDIA - SEPTEMBER 23: Prime Minister Narendra Modi gives a health card to beneficiaries as he launches Ayushman Bharat-National Health Protection Scheme, at Prabhat Tara Ground, at Dhurwa, on September 23, 2018 in Ranchi, India. Prime Minister Narendra Modi launched the Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY)' scheme, deemed as the world's largest government-funded healthcare programme covering over 50 crore beneficiaries. (Photo by Parwaz Khan/Hindustan Times via Getty Images)
Prime Minister Narendra Modi with a health card at the launch of the Ayushman Bharat-National Health Protection Scheme in Ranchi, India © Hindustan Times via Getty Images

Sarah Hawkes, a professor of global public health at University College London, says much could be learned from the successes and failures of western healthcare systems.

“It’s very clear from the story of the NHS that we can’t keep on [as we are],” she said. “The financial implications of trying to treat ourselves out of a diabetic epidemic, for example, are so vast that it’s impossible to imagine any financial system that would be able to cope with that.”

At the same time, as Africa becomes one of the world’s fastest growing continents, countries will need healthcare systems robust enough to keep up with their expanding populations. African nations could well leapfrog parts of the western experience, which for example has belatedly involved placing more emphasis on prevention rather than treatment.

SIx months old Lordina Dadzie receives the new malaria vaccine at the Breman-Amanfopong community clinic. The Breman Amanfopong community begins the Malaria Vaccine Implementation Programme (MVIP) to introduce the new malaria vaccine RTS,S to young children. The new malaria vaccine begins its phased implementation in Ghana in six regions and it is expected to end in 2021. Malaria accounts for about 30% of reported OPD cases in the Asikuma-Odoben-Brakwa District. May 1, 2019. Breman-Amanfopong, Central Region-Ghana. WHO/Francis Kokoroko 2019
Mother and baby attend a vaccination clinic in Ghana © WHO/Francis Kokoroko

Alongside improved diagnostics and supply chains, universal health coverage will also enable people to hold providers to account and monitor whether they are getting the services they are entitled to, says Prof Hawkes. 

“You can get across the notion that you have a right to healthcare and it is not this discretionary gift from your government. You hold government accountable and you can monitor what’s going on. That’s a fundamental sea-change in the social contract.”

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About this Special Report

World leaders have committed to introduce universal health coverage by 2030 as part of the UN’s Sustainable Development Goals but, as our three-part report explores, there is a still a long way to go.

The next part will publish on Wednesday October 16

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