HEALTH care is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. Access to adequate health care is a global problem in low, middle-income, and high-income countries.

What does it mean to access health care? Health care access is the ability to obtain health-care services such as prevention, diagnosis, treatment, and management of diseases, illnesses, disorders, and other health-impacting conditions. For health care to be accessible, it must be affordable, convenient, and of acceptable quality. The World Health Organization (WHO) has long believed that health care is a fundamental right. The best way to pursue this is universal health care. Reports in 2019 suggested that up to half the world’s population did not have access to essential medical services. Further estimates indicate that medical costs put 100 million people into severe poverty every year.

Universal access to health care

The goal of the WHO is universal health care, in this scenario, there should be no “out-of-pocket costs” for those seeking care. The universal health-care programme of the WHO tracks “catastrophic health care spending” to identify persons with inadequate access to health care. This is defined as patients who spend more than 10 per cent of their household budget on medical services. The aim would be that this population should be less than 20 per cent of a country’s population. In 2018, as part of the millennial developmental goals, it targeted increasing access to health care by one billion persons worldwide by the year 2023, primarily by increasing access to universal health care. In the first month of 2023, the goal has not been reached and, in fact, the increase has only been 160 to 200 million individuals. Given that health care provision requires economic resources, it is not surprising that countries with the lowest gross domestic product (GDP) per capita have the highest rates of inadequate access to health care.

There is a clear association between rising levels of GDP per capita and a greater proportion of the population that can access health care. This is a vexing problem in lower-income countries where access to health care is limited for many people because of the associated costs of seeking care. In many countries, there is limited access to third-party health care payers, and the regulatory environment that compels third-party payers to honour their agreements is weak. There is some good news among the bad, however. Although starting from a weak base, the most significant increases in access to care were seen on the African continent, where several countries experienced a more than 30 per cent increase in the population who did not require catastrophic health care spending. As the COVID-19 pandemic and worldwide inflation subside, we may see significant increases in health care access.

Role of the Government in facilitating access to health care

Access to health care starts at the country or government level. Health-care services can be provided through the Government entirely, such as when a government funds health care, builds hospitals and clinics, employs medical personnel, and is responsible for the health-care system in its entirety. A classic example may be Cuba.

Most countries, including Jamaica, have a mixture of public and private provision of health-care services, with government-provided or public health care accessible for the population at large and a private health-care market for those who wish to access it.

The degree to which the private market supplies health care varies quite significantly among nations. In the United Kingdom, the National Health Service (NHS) plays the leading role in health-care delivery, but there is access to private care, which is paid for directly or through commercial insurance. The Canadian system is one in which the Government funds most health care costs, but much of the care is delivered by private actors. The United States is a country where the private market plays a more significant role than many others. Most US health care is privately funded, except for government intervention for defined populations through the Centres for Medicare and Medicaid Services (CMS) and the Veterans Administration Hospital systems for veterans. Even when the Government underwrites care, it is primarily extended in private facilities.

Given that resources are finite, any country with a significant public aspect to health care will need to decide how much money can be spent each year. This must be done in conjunction with spending in other areas of similar or greater importance. For instance, the Government of Jamaica has to fund national security (including the police, customs, and immigration), the judiciary, the education system, national infrastructure, and health care. More money for health care means less money for these competing priorities. Given the rise in chronic diseases, the increasing use of technology in medicine, and the ageing of our population, the amount of money that needs to be spent increases over time. In an ideal world, these changes would be accompanied by a rise in the GDP and a rise in the percentage of the budget that can be directed toward health care. As a low-middle income country in 2019, Jamaica spent about 6.1 per cent of its budget on health care, with a per capita spending of only US$327 per person. Compare this with the United Kingdom, which in 2022 spent 11.9 per cent of its GDP on health care with a per capita spending of 3,840 pounds (US$4,696.26), or the United States, which spent 18.3 per cent of its GDP on health care in 2021 for a per capita spending of US$12,914.

The amount of money available to spend will dictate what services can be offered to the public. Primary care services such as vaccination, antenatal visits, outpatient management, and disease prevention are relatively inexpensive to provide and can be offered to a substantial proportion of the population at low cost. These measures also generally deliver significant improvements in public health and tend to be in the service mix of all countries. At the other extreme are services that are very expensive to provide, and which are utilised by a very small segment of the population. Some examples include bone marrow transplantation for childhood leukaemia, solid organ transplantation, and gene therapy for sickle cell disease. Given that resources are finite and limited, should we pay 200,000 US dollars for organ transplantation or vaccinate our school-age population? This is an extreme example, but the fact is that the Government must make trade-offs in deciding what services are to be provided and thus accessed by the population.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107