23rd Annual Session of the Seoul Model United Nations ​

Forum: World Health Organization (WHO) ​ Question of: Implementing Universal Health Coverage to improve ​ healthcare standards Student Officer: Alex Taehoon Kim, President ​ ​

Introduction

The Earth’s population has skyrocketed in the last century and is envisioned to reach 9.7 billion by 2050.1 This expeditious growth has brought copious important societal and economic problems. However, arguably one of the most crucial and urgent issues to be dealt with in modern times is the provision of healthcare and ensuring the wellbeing for all. Despite impressive technological advancements, mankind has yet to find a means to provide basic medical services to all of its citizens, especially in developing nations. With the rise of Newly Industrialized Countries (NICs) in recent decades, it is tempting for many nations to neglect improvements in healthcare standards in favor of rapid economic development. But one must acknowledge that economic growth takes place via the interdependence with healthcare improvements, not in spite of them.2 The correlation between health improvements and societal improvements is not to be overlooked.

An important step to achieving advancements in healthcare services is the implementation of Universal Health Coverage (UHC). Currently, there are 100 million people who are forced into extreme poverty (living on 1.90 USD or less per day) because of catastrophic health expenditure. 12% of the world’s population uses 10% or more of their budget on health services.3 According to an excerpt from the ministerial meeting between the World Bank and WHO in 2013, “only about 35% in public health facilities across the 27 developing countries with data” provided essential medicines.4 The implementation of UHC will enable individuals to

1Roser, Max, et al. “World Population Growth.” Our World in Data, 9 May 2013, ​ ​ ourworldindata.org/world-population-growth; Growing at a Slower Pace, World Population Is Expected to Reach 9.7 Billion in 2050 and Could Peak at Nearly 11 Billion around 2100 | UN DESA Department of Economic and Social Affairs.” United Nations, United Nations, ​ ​ www.un.org/development/desa/en/news/population/world-population-prospects-2019.html.

2Frenk, Julio. Health and the Economy: A Vital Relationship - OECD Observer, May 2004, ​ ​ oecdobserver.org/news/archivestory.php/aid/1241/Health_and_the_economy:_A_vital_relationship_.html. 3 “Universal Health Coverage (UHC).” World Health Organization, World Health Organization, ​ ​ ​ www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc). 4 WHO, and World Bank. “Background Document Towards Universal Health Coverage: Concepts, Lessons and Public Policy Challenges.” WHO/World Bank Ministerial-Level Meeting on Universal Health Coverage 18-19 ​

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23rd Annual Session of the Seoul Model United Nations ​ undergo adequate medical treatment, from crucial primary health services and palliative care to preventative measures and rehabilitation services, without the burden of financial ruin. Essentially, UHC is encapsulated by these three objectives: providing equitable, high quality, and affordable healthcare. It is historically fully rooted in the 1948 WHO constitution, in which health is declared to be a primary right for all, as well as the Alma-Ata declaration in 1978 where the Health for All agenda was established.5 Although providing health services free of cost for all citizens is indeed neither feasible nor sustainable, UHC allows people to receive quality healthcare without significant financial consequences. Many nations, therefore, have started to gradually recognize the importance of UHC, and UHC formally became part of the Sustainable Development Goals (SDG) adopted in 2015. Henceforth, all UN member states have been making efforts to implement UHC by 2030.6

In order to ensure nations are progressing in regards to the implementation, there needs to be a means to calculate or quantify the effectiveness of UHC. Currently, there are three main challenges when tracking UHC in a given country identified by the UN: “sourcing reliable data on a broad set of health service coverage and financial protection indicators,” “disaggregating data to expose coverage inequities,” and “measuring effective coverage, which not only includes whether people receive the services they need but also takes account the quality of services provided and the ultimate effect on health.”7 To mitigate these problems, household surveys and health facility data are in widespread use to accurately represent various groups with different socioeconomic levels, sex, and other factors. It is crucial to monitor both financial protection coverage and health services; this is because many nations with subpar medical services score higher on financial protection, as many of their citizens choose to forgo basic or essential health services.8 In order to track health services, the UN and WHO mainly focuses on reports on “reproductive and newborn health (family planning, antenatal care, skilled birth attendance),” “child immunization (three doses of diphtheria, tetanus and pertussis-containing vaccine), “infectious disease treatment,” and “non-health sector determinants of health.” To monitor financial protection, the UN focuses on reports on instances of Out-Of-Pocket payment, or

February 2013, WHO Headquarters, Geneva, Switzerland , WHO/World Bank, 18 Feb. 2013, ​ www.who.int/mediacentre/events/meetings/2013/uhc_who_worldbank_feb2013_background_document.pdf. 5 “What Is Universal Coverage?” World Health Organization, World Health Organization, 9 July 2019, ​ ​ www.who.int/health_financing/universal_coverage_definition/en/#:~:text=UHC%20is%20firmly%20based%20on,p rotection%20for%20the%20world's%20poorest. 6 United Nations. “Political Declaration of the High-Level Meeting on Universal Health Coverage.” ​ INAL-Draft-UHC-Political-Declaration.pdf, 23 Sept. 2019, ​ www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf. 7 Boerma, Ties, et al. “TRACKING UNIVERSAL HEALTH COVERAGE.” TRACKING UNIVERSAL HEALTH ​ ​ COVERAGE FIRST GLOBAL MONITORING REPORT, WHO, World Bank, Rockefeller Foundation, and the ​ Ministry of Health, Japan., Apr. 2015. 8 Boerma, Ties, et al.

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23rd Annual Session of the Seoul Model United Nations ​ catastrophic health expenditure (defined as spending 25% or more of the household budget on healthcare services).9

Despite clear guidelines outlined by the UN, many nations find it difficult to make progress in implementing UHC. This is most prevalent in Less Economically Developed Countries (LEDCs) due to rurality, poverty, or war. Although the global economic trends indicate that by 2030 demands for health workers will increase by 40 million, most of the demands will be created in wealthier, More Economically Developed Countries (MEDCs). Currently, there need to be 18 million more health service workers in LEDCs to achieve UHC in those areas.10 Urgent action must be taken or this problem will be exasperated.

Another major challenge when implementing UHC is the accrescent price of various drugs and medicines. This is a serious problem and cannot be attributed to the advent of newer, better drugs; even older brand-name oral and injectable drugs that have been out in the market for over a decade increases in price 9% and 15% respectively, annually.11 These results exemplify that inflation of branded medication prices can be traced back to manufacturers artificially increasing prices of drugs that are already available. While this does hinder the implementation of UHC, the challenge is determining the appropriate monetary value that pharmaceutical companies deserve–especially when the said companies prioritize returning their profit to various shareholders over developing innovative medicines.12 The lack of transparency displayed by the companies regarding how they derive at their price and profit margin, as well as the lacklustre “information on the patent status of essential medicines,” further complicates the countries’ assessment on their progress of the implementation of UHC.13

The implementation itself is not a simple task. Governments need to carefully self-evaluate their respective countries’ societal and economic position as well as consider their citizen demographics before determining their appropriate healthcare system. Various countries have taken different approaches to address this issue. Countries, such as the Netherlands, Japan, and Germany, have implemented a health insurance mandate system where citizens are required

9 Boerma, Ties, et al. 10 Kieny, Marie-Paule. “Universal Health Coverage: Unique Challenges, Bold Solutions.” World Health ​ ​ Organization, World Health Organization, 3 Aug. 2016, ​ www.who.int/mediacentre/commentaries/2016/universal-health-coverage-challenges-solutions/en/. 11 University of Pittsburgh. "Rising drug prices linked to older products -- not just newer, better medications." ScienceDaily. ScienceDaily, 7 January 2019. . 12 K​ ieny, Marie-Paule. 13 K​ ieny, Marie-Paule.

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23rd Annual Session of the Seoul Model United Nations ​ to be insured for hospital and outpatient medical treatment by law.14 15 16 The amount each person pays depends on their wealth. This system, known as the Bismarck model, eradicates unfairness and ensures UHC to all citizens.17 However, it should be noted that many LEDCs might not be able to afford to raise taxes enough to sustain such a system.

Another alternative is the Beveridge model, or “socialized medicine.”18 This type of UHC is widely used in Britain, Italy, New Zealand, and the whole of Scandinavia.19 Although this system requires the highest amount of taxation from the citizens, patients will never have to pay for medical care or treatment. Most doctors and institutions in this system are state-owned and state-run, more so than the aforementioned Bismarck model. While many criticize the Beveridge model as the system requires heavy involvement of the government on healthcare, it is undeniable that the goal of this system is to provide the best health services to the citizens.20

The final type of UHC is the National Health Insurance Model (NHI). NHI incorporates aspects of both Beveridge and Bismarck models and is widely used in South Korea, Taiwan, and Canada.21 In the NHI model, the providers of healthcare are entirely private, and the funds for these institutions are from taxation and the government.22 Although the NHI model is a UHC system, medical institutions from an NHI nation can require patients to wait before treatment, making the system relatively cheaper than Bismarck and Beveridge models.23 The government can also flexibly negotiate with pharmaceutical companies for better pricing in the interests of the citizens.24

14 T​ ikkanen, Roosa. “Germany.” Commonwealth Fund, 5 June 2020, ​ ​ www.commonwealthfund.org/international-health-policy-center/countries/germany#:~:text=Health%20System%20 Statistics&text=Health%20insurance%20is%20mandatory%20in,insurers%20known%20as%20sickness%20funds. 15 “Health Insurance in Japan.” Overview of the Health Insurance System Based in Japan, International Student ​ ​ Insurance, www.internationalstudentinsurance.com/japan-student-insurance/health-insurance-in-japan.php. 16 Ministerie van Algemene Zaken. “Compulsory Standard Health Insurance.” Health Insurance | Government.nl, ​ ​ Ministerie Van Algemene Zaken, 9 May 2018, www.government.nl/topics/health-insurance/compulsory-standard-health-insurance. 17 PNHP. “Health Care Systems - Four Basic Models.” Health Care Systems - Four Basic Models | Physicians for a ​ National Health Program, PNHP, ​ www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php. 18 Wallace, Lorraine S. “A view of health care around the world.” Annals of family medicine vol. 11,1 (2013): 84. ​ ​ ​ doi:10.1370/afm.1484 19 Pre-Meds, Global. “Health Care Systems: Differences Around the Globe.” Meds, 17 Sept. 2019, ​ ​ ​ www.globalpremeds.com/blog/2014/02/22/health-care-systems-differences-around-the-globe/#:~:text=Countries%2 0that%20operate%20their%20health,%2C%20Sweden%2C%20and%20New%20Zealand. 20 Pre-Meds, Global. ​ 21 Pre-Meds, Global. ​ 22 Wallace, Lorraine S. ​ 23 Wallace, Lorraine S. ​ 24 Pre-Meds, Global. ​

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Another type of healthcare is the private insurance model or the Out Of Pocket system (OOP), run by the developing world (China, India, the African continent) and the United States. It is mainly used by countries that are too impoverished or disorganized to establish a proper healthcare system. This model, consequently, is not UHC and not all citizens are covered in this system. The rich pay to receive quality healthcare; the poor die or just stay sick.25 It is in these nations within this category where UHC will hopefully be implemented by 2030.

The implementation of Universal Health Coverage is an arduous task for many. What the future holds for the quality of our healthcare depends on the actions of sovereign nations. While there certainly isn’t a one-size-fits-all solution to improving the provision of healthcare, many nations are beginning to progress in the right direction as they have realized the benefits of implementing UHC. But one thing is certain–there is a lot of work to do.

Definition of Key Terms

Universal Health Coverage (UHC)

The World Health Organization defines Universal Health Coverage as a system in which “all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also enduring that the use of these services does not expose the user to financial hardship.”26 In a nation, the implementation of UHC is crucial because it allows citizens access to quality, equitable healthcare without significant financial consequences. Universal Health Coverage might seem like a modern concept, but it has its roots all throughout history. Its origins go as far back as Ancient Egypt 3000 years ago.27 An ancient text, rediscovered in 2015, revealed that Egyptian workers in the town Deir El-Medina had personal physicians and even received rest days. The Egyptian state also allocated medical ingredients to be shared among workers, albeit not always equally.28 A more recent example of UHC happened in 1883, when the Sickness Insurance Act was introduced in unified Germany under Otto Von

25 Wallace, Lorraine S. ​ 26 WHO. “What Is Universal Coverage?” World Health Organization, World Health Organization, 9 July 2019, ​ ​ ​ www.who.int/health_financing/universal_coverage_definition/en/. 27 Swan, Esan. “Universal Health Coverage: an Illustrated History.” The Evolution of Healthcare Policy from ​ Ancient Egypt to the US Presidential Debates, Financial Times, 23 Sept. 2019, ​ www.ft.com/content/34084366-dadb-11e9-8f9b-77216ebe1f17. 28 Clark, Laura. “Some Ancient Egyptians Had State-Sponsored Healthcare.” Smithsonian.com, Smithsonian ​ ​ ​ Institution, 20 Feb. 2015, www.smithsonianmag.com/smart-news/some-ancient-egyptians-had-state-sponsored-healthcare-180954361/.

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Bismarck. This act, aimed to assist workers in case of injury or illness, subsequently expanded to incorporate accidents in 1884 and disability in 1889.29 Currently, 32 nations have achieved Universal Health Coverage. These nations include Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, the United Arab Emirates, and the United Kingdom.30 Many other nations are following suit as part of the Sustainable Development Goal.

The Beveridge Model The Beveridge Model is one of the four major schools of healthcare. Notable countries using this system are the United Kingdom, Spain, Italy, New Zealand, and most of Scandinavia. 31 It was developed by the British economist and social reformer William Beveridge in 1948.32 33 In this system, the government acts as a sole provider of healthcare, removing most privatization of health services and all market competition.34 In this regard, healthcare is treated like the police force or the public library as it is entirely supported by the government.35 Due to this underlying nature, the healthcare system does not necessarily focus on standard of living–rather, it seeks to maintain the minimum cost for healthcare for citizens without sacrificing the quality of medical services.36 Therefore, owing to the fact that the system is a single-payer national health system funded by all citizens via taxation (and other general revenues), the cost for medical services is generally low and usually free. Its main philosophy is that access to quality healthcare is a basic human right. With the Beveridge model, all citizens are guaranteed universal health coverage.37 The main criticism of this system is that since all citizens have access to healthcare, people will be placed in long waiting lists and those with life-threatening conditions will not be

29 Clark, Laura. ​ 30 Department of Health. Foreign Countries with Universal Health Care, ​ ​ ​ www.health.ny.gov/regulations/hcra/univ_hlth_care.htm. 31 Reid, Thomas Roy. “Four Basic Models of Health Care.” Health: The Big Picture, The Change Agent, Mar. 2009, ​ ​ ​ changeagent.nelrc.org/wp-content/uploads/2018/05/Four-Basic-Models-of-Health-Care.pdf. 32 Chung, Mimi. “Health Care Reform: Learning From Other Major Health Care Systems | Princeton Public Health ​ Review.” Princeton University, The Trustees of Princeton University, 2 Dec. 2017, ​ ​ pphr.princeton.edu/2017/12/02/unhealthy-health-care-a-cursory-overview-of-major-health-care-systems/#:~:text=Th ere%20are%20four%20major%20models,out%2Dof%2Dpocket%20model. 33 “History - William Beveridge.” BBC, BBC, www.bbc.co.uk/history/historic_figures/beveridge_william.shtml. ​ ​ ​ 34 Vera Whole Health. Global Healthcare: 4 Major National Models And How They Work, 17 July 2019, ​ ​ ​ www.verawholehealth.com/blog/global-healthcare-4-major-national-models-and-how-they-work. 35 Reid, Thomas Roy. ​ 36 Center for Economic Studies. “BISMARCK VERSUS BEVERIDGE: A COMPARISON OF SOCIAL INSURANCE SYSTEMS IN EUROPE.” CESifo DICE Report 4/2008, CESifo, Apr. 2008, ​ ​ www.ifo.de/DocDL/dicereport408-db6.pdf. 37 Chung, Mimi. ​

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23rd Annual Session of the Seoul Model United Nations ​ prioritized. Some also worry that the cost of care might increase as the system has to sustain an entire population.38 Another criticism is the perceived inability for nations with the Beveridge model to respond to a health crisis. The rationale is that since a health-related national emergency will certainly negatively affect the nation’s economy, funding to combat the crisis will decrease while the number of patients to treat due to the crisis will increase, thus creating a vicious cycle of lacklustre funding and more sick people.39 While the first criticism is a valid concern, it should be noted that no country on earth uses a healthcare model in its purest form; the systems are tweaked or mixed to match specific countries’ socioeconomic levels and circumstances. The second concern has proved to be more relevant, especially amidst the ongoing COVID-19 pandemic. Britain, for example, is using existing government reserves and monetary assistance from other countries to fund the NHS.40 The British government has also resorted to overdraft facility from the Bank of England due to financial pressure.41

The Bismarck Model The Bismarck Model, also known as the Social Health Insurance (SHI) Model, was developed by the first German chancellor Otto Von Bismarck upon the creation of Statutory Health Insurance and the implementation of the Sickness Insurance Act in 1883. At the time, Bismarck’s ambitions were to combat social unrest upon German unification as well as the growing Socialist influences in the nation. The Bismarck model, therefore, requires “compulsory membership among all of the population,” at least in principle.42 Everyone needs to contribute to the Social Health Insurance fund and the amount each person pays depends on their salary. These payments are referred to as “sickness funds” and are taken from taxation. However, private companies do exist for those who wish to have additional healthcare besides the basic sickness funds.43 These companies can own their own medical institutions or collaborate with both reputable public and private institutions to provide healthcare. Although they are private, they

38 Chung, Mimi. ​ 39 Kutzin, Joseph. “Bismarck Meets Beveridge on the Silk Road: Coordinating Funding Sources to Create a Universal Health Financing System in Kyrgyzstan.” World Health Organization, World Health Organization, 5 May ​ ​ 2009, www.who.int/bulletin/volumes/87/7/07-049544/en/. 40 Goodley, Simon. “UK Triples Coronavirus Response Fund for NHS and Public Services.” The Guardian, ​ ​ ​ Guardian News and Media, 13 Apr. 2020, www.theguardian.com/society/2020/apr/13/uk-triples-coronavirus-response-fund-for-nhs-and-public-services. 41 Elliott, Larry. “Bank of England to Finance UK Government Covid-19 Crisis Spending.” The Guardian, Guardian ​ ​ ​ News and Media, 9 Apr. 2020, www.theguardian.com/business/2020/apr/09/bank-of-england-to-finance-uk-government-covid-19-crisis-spending. 42 Carrin, Guy, and Chris James. “Social Health Insurance: Key Factors Affecting the Transition towards Universal Coverage.” World Health Organization, World Health Organization Geneva , Jan. 2005, ​ ​ www.who.int/health_financing/documents/shi_key_factors.pdf. 43 Nguyen, Angeline. “International Health Care Systems Part 3: The Bismarck Model.” Morning Sign Out, 5 Aug. ​ ​ 2017, morningsignout.com/international-health-care-systems-part-3-the-bismarck-model/.

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23rd Annual Session of the Seoul Model United Nations ​ are heavily regulated by the government and are non-profit.44 Unlike the Beveridge model, where the goal is to maintain a subsistence level, the goal of the Bismarck model is to ensure a high standard of living.45 The Bismarck model is also a multi-payer system. Notable nations that employ the Bismarck model include Germany, France, Japan, Switzerland, Netherlands, and Belgium.46 A common criticism of the Bismarck model is that the taxation rate, which everyone is required to pay by law, needs to be unnecessarily high to sustain healthcare that not everyone will use. Another criticism is that those who have tertiary services via private companies need to wait longer than those only with the sickness funds. This is because the system prioritizes on equity more than individual necessity.47 The two, again, are valid concerns but it should be noted different countries have various country-specific approaches to address those problems.

The National Health Insurance Model The National Health Insurance (NHI) Model combines certain aspects of the Beveridge model and the Bismarck model. In the NHI model, the government is the single-payer for healthcare (Beveridge model), and private institutions provide the medical services (Bismarck model). Notable countries that use the NHI model are Canada and South Korea.48 The NHI grants autonomy to private hospitals, while also “reducing internal complications with insurance policies.”49 In recent times, there has been a tendency for countries that use the Beveridge model or the Bismarck model to incorporate aspects of both models, creating distinct systems that resemble the NHI model found in Canada, Taiwan, and South Korea. This can be a potential model for the implementation of UHC in various developing nations, although all countries have varying levels of socioeconomic development.

Out of Pocket Model The Out of Pocket model is defined as “direct payments made by individuals to health ​ care providers at the time of service use.” This, however, does not include any fee for medical services that have been paid in advance. For example, government taxes or insurance fees are not counted within the Out of Pocket model, and neither is any “net of any reimbursements to the

44 Jose Colucci, MS. “United States: One Country, Five Different Healthcare Systems.” Design In Health, Design In ​ ​ ​ Health, 28 Feb. 2018, www.designinhealth.org/blog/2018/2/28/united-states-one-country-five-different-healthcare-systems. 45 Center for Economic Studies. ​ 46 PNHP. ​ 47 Nguyen, Angeline. ​ 48 Chung, Mimi. ​ 49 Chung, Mimi. ​

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23rd Annual Session of the Seoul Model United Nations ​ individual who made the payments.”50 The Out of Pocket model is used in most countries that are not industrialized and cannot afford to have a proper healthcare model. This system, unfortunately, is used in most of the world, but is most notable in Sudan, Nigeria, Vietnam, Cambodia, and India.51 In this model, the rich are able to pay for healthcare and the poor are left to die and is thus not a form of Universal Health Coverage. This model is the most disorganized and unregulated healthcare model out of the 4 existing ones as well. Many instances of the Out of Pocket model happen in rural areas where people do not have access to quality governmental medical services. In these rural areas, due to the unregulated nature of the Out of Pocket model, health workers (mostly village healers) make the majority of their revenue via user fees. This creates financial incentives on the business of protecting a fundamental human right, health, thereby encouraging perverse malpractices (i.e., cutting corners) and the implementation of exemption mechanisms on patients.52 Ironically, in the world’s poorest places, people contribute more to healthcare financially than people in developed nations. For instance, in Germany, only 10% of medical revenues are generated from household budgets. This is a stark contrast to the Democratic Republic of Congo, where 70% of medical revenues are from household budgets.53 There is a definitive correlation between catastrophic health expenditures and the use of the Out of Pocket model. Catastrophic health expenditures, as aforementioned, is defined as spending 25% or more of the household budget on healthcare services. Because of the ​ unregulated nature of the Out of Pocket model, it is no surprise that many are affected financially because of healthcare fees. To mitigate these problems, many countries have started to implement laws, regulations, and policy reforms on healthcare. Some strategies include “abolish[ing] user fees abolish user fees and charges in public health facilities,” “target[ing] and exempt[ing] specific population groups such as the poor and vulnerable, pregnant women and children from official payments,” and “target[ing] and exempt[ing] a range of health services such as maternal and child care from official payments and deliver them free of charge.54 Although nations have definitely made progress addressing this issue, it should be noted that all

50 WHO. “Out-of-Pocket Payments, User Fees and Catastrophic Expenditure.” World Health Organization, World ​ ​ ​ Health Organization, 6 Apr. 2018, www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/. 51 WHO. “Out-of-Pocket Expenditure as a Percentage of Total Expenditure on Health(%): 2014.” World Health ​ ​ Organization, Global Health Observatory, 2017, ​ gamapserver.who.int/gho/interactive_charts/health_financing/atlas.html?indicator=i5. 52 WHO. “Out-of-Pocket Payments, User Fees and Catastrophic Expenditure.” World Health Organization, World ​ ​ ​ Health Organization, 6 Apr. 2018, www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/. 53 WHO. “Medical Costs Push Millions of People into Poverty across the Globe.” World Health Organization, ​ ​ ​ World Health Organization, 8 Dec. 2010, www.who.int/mediacentre/news/releases/2005/pr65/en/. 54 WHO. “Out-of-Pocket Payments, User Fees and Catastrophic Expenditure.” World Health Organization, World ​ ​ ​ Health Organization, 6 Apr. 2018,

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23rd Annual Session of the Seoul Model United Nations ​ of these policies need political support from the people, the government, and various communities in the nation.

Primary care Primary care refers to the essential healthcare one receives and encompasses a general system that aids people with common symptoms and medical conditions. Although sometimes used interchangeably with primary healthcare, primary care is a more specific concept and focuses on individual medical systems, whereas primary healthcare focuses on medical services given to a certain population. Primary care might be sought when patients have mild flu or common cold. Medical workers in primary care are typically responsible for managing acute medical problems such as skin rashes, burns, asthma attacks, broken bones, pneumonia, and heart attacks. Primary care providers are usually nurse practitioners, doctors, and physician assistants, but can be geriatricians, pediatricians, and obstetrician-gynecologists. These providers are also responsible for coordinating with and directing patients to specialists for or different levels of care if it is necessary.55 In 1978, during the Alma-Ata Declaration, the six agendas of primary care were established: first contact accessibility, longitudinality, comprehensiveness, coordination, family centeredness, and community orientation. In 2001, WHO suggested implementing these domains internationally and their importance subsequently were agreed upon globally. Despite this, there is a clear imbalance between primary care providers and providers of other levels in many nations. In the US, for example, only 32% of total physicians and 39% of physicians currently practicing were in the primary care sector, with over 60% of physicians being specialists.56 This indicates that the value of primary care providers are severely underestimated. However, primary care is essential in a functioning healthcare model as about 80% of the general population only need services from primary care in one year, with 10 to 12% and 5 to 10% of the population needing secondary care and tertiary care, respectively.57 Primary care is a central part of healthcare, and no equity in a primary care sector means no equity in a healthcare model (i.e., no Universal Health Coverage).58

Secondary Care

55 Torrey, Trisha. “How the 4 Levels of Medical Care Differ.” Verywell Health, 16 Feb. 2020, ​ ​ ​ www.verywellhealth.com/primary-secondary-tertiary-and-quaternary-care-2615354. 56 U. S. Department of Health and Human Services, “Health Resources and Services Administration (HRSA),” 2011, About Health Centers: Program Requirements, http://bphc.hrsa.gov/about/requirements/index.html. ​ ​ 57 B. Starfield, “Is primary care essential?” The Lancet, vol. 344, no. 8930, pp. 1129–1133, 1994. ​ ​ 58 Shi, Leiyu. ‘The Impact of Primary Care: A Focused Review’. Scientifica, edited by P. J. Schluter et al., vol. ​ ​ ​ 2012, Hindawi Publishing Corporation, Dec. 2012, p. 432892, doi:10.6064/2012/432892. ​ ​

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Secondary care refers to healthcare provided by a specialist. Unlike primary care, secondary care is usually reserved for assistance needed in specific parts of the body or a specific condition/disease. For instance, secondary care providers can be psychiatrists, treating problems on psychology, cardiologists, treating problems on hearts, dermatologists, treating problems on skins, and endocrinologists, treating problems on hormones. Most people visit secondary care providers (i.e., specialists) when health concerns can not be solved in the primary level.59 In many nations, there are tensions between the generalists (primary care providers) and specialists (secondary care and tertiary care providers). There are various reasons for this: money, prestige, patient autonomy, and power. Furthermore, many laws inadvertently encourage these unhealthy and unnecessary competition. It is, however, paramount to acknowledge the importance of cooperation between the two for the improvement of health services and the implementation of universal health coverage.60

Tertiary Care Tertiary care is defined as when the patient is hospitalized and requires the highest level of expertise and medical instruments. At this level procedures like cardiac surgery, cancer treatment, hemodialysis, some plastic surgery and neurosurgery, as well as coronary artery bypass surgery are common.61 Many rural hospitals do not offer this level of healthcare. In such cases, patients will be redirected to a more urban hospital or any hospitals that provide specialized services. Although less than 10% of the general population needs tertiary care in a given year, it is important to ensure the quality of tertiary care for a truly excellent quality healthcare.62

Poverty Poverty is one of the main negative consequences of catastrophic health expenditure, usually caused by the lack of Universal Health Coverage. According to estimates made by the World Bank, “100 million people are being pushed into poverty” because they have to pay for medical fees.63 This goes directly against the UN declaration that health is a fundamental human

59 Torrey, Trisha. ​ 60 Pearson, S D. “Principles of generalist-specialist relationships.” Journal of general internal medicine vol. 14 ​ ​ ​ Suppl 1,Suppl 1 (1999): S13-20. doi:10.1046/j.1525-1497.1999.00259.x 61 eInsure. “The Difference Between Primary, Secondary and Tertiary Health Care.” EInsure, 24 Jan. 2017, ​ ​ www.einsure.com/blog/the-difference-between-primary-secondary-and-tertiary-health-care/. 62 B. Starfield. ​ 63 Aizenman, Nurith. “Health Care Costs Push A Staggering Number Of People Into Extreme Poverty.” NPR, NPR, ​ ​ 14 Dec. 2017, www.npr.org/sections/goatsandsoda/2017/12/14/569893722/health-care-costs-push-a-staggering-number-of-people- into-extreme-poverty.

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23rd Annual Session of the Seoul Model United Nations ​ right. Ultimately, achieving universal health coverage will also aid in achieving the first Sustainable Development Goal of “no poverty.”64

Timeline of Key Events

1883 - Germany implements Social Health Insurance Bill under Otto Von Bismarck Germany was unified under Prussian chancellor Otto Von Bismarck in January of 1871. After the unification, Bismarck, a conservative, was afraid of the growing influence of the Social Democratic Party as he was afraid that the party would weaken his political power. The growth of the party was because of the rapid industrialization of Germany; the party promised workers in the factories a better future. Bismarck, to combat this, introduced the Social Health Insurance Bill in 1883 to protect worker safety. Although the policy did draw from previous worker safety laws, this bill set the stone for subsequent policy changes leading to Universal Health Coverage in Germany and the rest of the world.65 With this bill, Bismarck introduced the concept of “sickness funds.” Workers financially contributed to a mandatory sickness fund that had specific benefits. These fees were often taken from wages. Although only 10% of German citizens were insured at the time, many industrial workers were guaranteed sick pay, free pharmaceuticals, and death benefits. This bill was eventually expanded to include all German workers– “agricultural and forestry workers in 1911, ​ civil servants in 1914, the unemployed in 1918, non-working wives and daughters in 1919, all primary dependents in 1930, all retirees in 1941, the physically disabled in 1957, students in 1975 and artists in 1981.”66 By the year 2000, Germany had achieved 88% enrollment on the Social Health Insurance (SHI) model. (It should be noted that the figure is not 100% because Germans who are wealthy enough are eligible for private healthcare and can opt out of the SHI system).67 This concept of sickness funds has been implemented in various countries and is still ​ in use today.

1912 - Norway becomes the first country to adopt Universal Health Coverage as a policy

64 UN. “About the Sustainable Development Goals – United Nations Sustainable Development.” United Nations, ​ ​ United Nations, www.un.org/sustainabledevelopment/sustainable-development-goals/#:~:text=The%20Sustainable%20Development %20Goals%20are,environmental%20degradation%2C%20peace%20and%20justice. 65 Bump, Jesse B. ‘The Long Road to Universal Health Coverage: Historical Analysis of Early Decisions in ​ Germany, the United Kingdom, and the United States’. Health Systems & Reform, vol. 1, no. 1, Taylor & Francis, ​ ​ Jan. 2015, pp. 28–38, doi:10.4161/23288604.2014.991211. ​ ​ 66 CTO Technologies. Bismarck and the Beginning of Universal Healthcare, XTENTION, 14 Nov. 2018, ​ ​ ​ www.ctotechnologies.co.uk/bismarck-universal-healthcare/. 67 Carrin, Guy, and Chris James. ​

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In 1912, the Norweigian government went through a sweeping change in their healthcare system. For one, the parliament ordered a substantial increase in primary healthcare providers from 161 to 372. The insurance mandate law, which was implemented in 1909 and covered one-third of Norweigian workers, was revamped to establish its own administration.68 This makes Norway the first country to implement UHC as a national policy.69

1938 - Japan and New Zealand establishes National Health Insurance and Social Security Act Imperial Japan enacted the National Health Insurance law in 1938. This law enabled rural workers and the general public to receive better healthcare than before, as it “prescribed that municipalities could be insurers of the national health insurance for the people living in their regions.”70 Some municipalities had the choice of not implementing the health insurance and not everyone was required to insure themselves. However, this law was gradually extended until, in 1961, everyone in Japan was required to enroll by law. Japan achieved Universal Health Coverage in 1961. Since the late 19th century, New Zealand had a reputation for effective worker-management that labelled the country “working man’s paradise.” However, this was challenged when the Great Depression severely affected the country’s economy in the 1930s. The New Zealand Labour Party, after winning the 1935 election, established the Social Security Act on September 14th, 1938, to combat high unemployment rates and to improve the standard of living.71 Following this act, New Zealand implemented UHC and started to provide free hospital care, medicine, general practitioners, and maternal practitioners to all New Zealand citizens. 72According to Keith Sinclair, a notable historian, New Zealand’s 1938 Social Security Act was the first-ever social security system in the world.73

April 7, 1948 - World Health Organization (WHO) goes into force

68 Hubbard, William H. “Public health in Norway 1603-2003.” Medical history vol. 50,1 (2006): 113-7. ​ ​ ​ doi:10.1017/s0025727300009480 69 De Jong, Charlie. “Universal Health Care and Temporal and Spatial Diffusion Patterns.” BSc_C_de_Jong.Pdf, ​ ​ ​ University of Twente, 7 Nov. 2011, essay.utwente.nl/61439/1/BSc_C_de_Jong.pdf. 70 National Institute of Population and Social Security Research. “Social Security in Japan 2014 Health Care.” IPSS, ​ ​ ​ 2014, www.ipss.go.jp/s-info/e/ssj2014/004.html. 71 New Zealand History. “Social Security Act Passed.” RSS, 7 Aug. 2017, ​ ​ nzhistory.govt.nz/social-security-act-passed#:~:text=14%20September%201938&text=The%20cornerstone%20of% 20the%20first,families%2C%20invalids%20and%20the%20unemployed.&text=Labour%20won%20the%201935% 20election,a%20reasonable%20standard%20of%20living. 72 French, Sian, et al. “Health Care Systems in Transition - New Zealand.” NewZeafront.pdf, European Observatory ​ ​ on Health Care Systems, 2001, www.euro.who.int/__data/assets/pdf_file/0008/95138/E74467.pdf. 73 Sinclair, Keith. A History of New Zealand. Wellington: Penguin Press, 1988. OCLC 154283103 ​ ​ ​ ​ ​ ​

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The World Health Organization went into force on April 7, 1948, in Geneva, Switzerland, 2 years after the WHO constitution was written. Since then, WHO has actively worked to aid countries in implementing UHC. Specifically, they “focus on primary healthcare to improve access to quality essential services,” “work towards sustainable financing and financial protection,” “improve access to essential medicines and health products,” “train the health workforce and advise on labour policies,” “support people's participation in national health policies,” and “improve monitoring, data and information.”74 On the constitution of the World Health Organization, signed on July 22, 1946, by 61 countries, it states

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”75

This was the first formal international declaration or recognition that health is a fundamental human right.

July 5, 1948 - Britain establishes the National Health Service (NHS) Upon the 1945 victory of the Labour Party, Britain established the National Health Service On July 5, 1948, creating NHS England, NHS Scotland, HSC Northern Ireland, and NHS Wales. The NHS’s core values reflect that of the Welsh health minister at the time, Aneurin Bevan, and encompasses 4 aspects: “meet the needs of everyone,” “be free at the point of delivery,” and “be based on clinical need, not ability to pay.”76 A leaflet was issued to households before the launch and contained these words:

“It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child-can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.”77

74 WHO. What We Do, World Health Organization, www.who.int/about/what-we-do. ​ ​ ​ 75 WHO. “Constitution.” World Health Organization, World Health Organization, ​ ​ ​ www.who.int/about/who-we-are/constitution#:~:text=The%20Constitution%20was%20adopted%20by,force%20on %207%20April%201948. 76 “Our Values.” NHS Graduates, www.nhsgraduates.co.uk/about-the-nhs/our-values/. ​ ​ ​ 77 Socialist Health Association. “The Start of the NHS 1948.” Socialist Health Association, 5 Sept. 2017, ​ ​ www.sochealth.co.uk/national-health-service/the-sma-and-the-foundation-of-the-national-health-service-dr-leslie-hil liard-1980/the-start-of-the-nhs-1948/.

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The NHS subsequently became the basis of the Beveridge Model, or socialized medicine, and was implemented in many other places–notably New Zealand, Denmark, and Hong Kong.78

December 8, 1966 - Canada passes National Medical Care Act On December 8th, 1966, the Candian House of Commons Passed the National Medical Care Act by a vote of 177 and 2. Within 5 years, everyone in Canada had access to publicly administered, quality, and universal healthcare. It was the first Universal Health Coverage implementation in North America. The Candian Universal Health Coverage has its roots in medicare that first appeared in the province of Saskatchewan, implemented on July 1st, 1962. Saskatchewan had a long history of social welfare, being a social democratic state with a mixed Socialist and Capitalist economy as well as a functioning welfare system by the 1950s. Despite fierce resistance against socialized medicine by prominent right-wing politicians and businessmen in the province, the Medicare system persisted. By 1964, no politician from Saskatchewan attacked UHC publicly as a result of the Liberal party victory in the provincial election. Pro-Universal Health Coverage (Medicare) forces subsequently spread throughout the country, leading to the adoption of the National Medicare Care Act by the federal government.79 Canadian Medicare evolved to form the NHI system, a model that was later implemented in places like Taiwan and South Korea.

September 12, 1978 - Alma-Ata Declaration adopted in Almaty, Kazakhstan The Primary Health Care International Conference, held in the Soviet Union (present-day Almaty, Kazakhstan), reaffirmed that health is a fundamental right and should be universal regardless of wealth, race, or religion by adopting the Alma-Ata Declaration. Some excerpts from the declaration include:

“The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

“The existing gross inequality in the health status of the people, particularly between ​ developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries.”

78 PNHP. ​ 79 Brown, Lorne, and Doug Taylor. “The Birth of Medicare.” The Birth of Medicare – Canadian Dimension, ​ ​ ​ Canadian Dimension, 3 July 2012, canadiandimension.com/articles/view/the-birth-of-medicare.

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“The people have a right and duty to participate individually and collectively in the planning and implementation of their health care.”80

The conference proved to be a major milestone in terms of ensuring quality healthcare for all and the implementation of UHC. All member states of WHO came together to reaffirm the importance of equity and accessibility in healthcare.

September 25, 2015 - General Assembly adopts “Transforming our world: the 2030 Agenda for Sustainable Development Goal” (recognize December 12 as UHC day) In 2012, the Rio de Janeiro United Nations on Sustainable Development conference was held. There, 17 Sustainable Development Goals (SDGs) were proposed to succeed the Millennium Development Goals (MDGs) that lasted until 2015.81 For three years, the UN worked with member states to draft goals that solved the shortcomings of the predecessor MDGs, notably the problematic “donor-recipient” relationship in foreign aid.82 Thus the 2030 SDGs were born with the focus of collective action. The goals were subsequently ratified by 193 countries and went into full force on September 25, 2015.83 The adoption of the SDGs is significant as the goals aid in the implementation of UHC everywhere. Article 3.8 of the SDG states

“Achieve universal health coverage, including financial risk protection, access to quality ​ essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

Overall, the adoption of SDG was a significant step forward in regards to implementing UHC everywhere.

September 23, 2019 - General Assembly holds a high level meeting “Universal Health Coverage: Moving Together to Build a Healthier World” On September 23, 2019, the General Assembly opened a debate on the topic of “Universal Health Coverage: moving towards to build a healthier world.” This was the first

80 WHO. “WHO Called to Return to the Declaration of Alma-Ata.” WHO Called to Return to the Declaration of ​ ​ Alma-Ata - WHO, World Health Organization, 5 Dec. 2017, ​ www.who.int/social_determinants/tools/multimedia/alma_ata/en/#:~:text=International%20conference%20on%20pr imary%20health,goal%20of%20Health%20for%20All. 81 UNDP. “Background on the Goals.” Background of the Sustainable Development Goals, ​ ​ www.undp.org/content/undp/en/home/sustainable-development-goals/background.html. 82 “UN DESA | DPAD | UN System Task Team on the Post-2015 Development Agenda.” United Nations, United ​ ​ ​ Nations, www.un.org/en/development/desa/policy/untaskteam_undf/report2.shtml. 83 “Transforming Our World: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform.” United Nations, United Nations, ​ ​ sustainabledevelopment.un.org/post2015/transformingourworld.

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23rd Annual Session of the Seoul Model United Nations ​ high-level conference on the topic of the implementation of UHC and the most crucial international political debate on the subject in the twenty-first century.84

Position of Key Member Nations and Other Bodies

Every member nation of the UN is in agreement that the implementation of UHC is beneficial for their respective citizens. Therefore, this section will focus on different models various countries employ and their shortcomings rather than focus on different viewpoints. This will provide basic knowledge for countries without UHC.

People’s Republic of China Whether or not China has UHC currently is debatable. On one hand, China has undergone massive reforms to widen access to healthcare for the entirety of its citizens in the past decades. In 2009, the Communist Party of China (CPC) promised all of its citizens that UHC will be achieved by year 2020.85 During the phase 1 of health reforms (2009-2011), the government focused on developing a health insurance program that ensured access to all citizens. The phase 2 (2012-) focused on health care delivery reforms, by restructuring public hospitals’ governance and pharmaceutical management, as well as the elimination of specialist-centric care that existed in the country prior to the reforms.86 In such a short period, CPC quadrupled its health spendings to ensure basic coverage for 95% of the population.87 This is great progress, considering only 30% of the population was insured in 2003. The Out of Pocket expenditure rate decreased exponentially from 60.7% in 2003 to 35.1% in 2017.88 On the other hand, China still lacks many aspects of UHC. For example, the average reimbursement rate of Out of Pocket payments made by inpatients is very low, with 48% for rural residents and 44% for urban residents. This means that the Chinese people, despite having a basic insurance plan, have to pay for their medical services half of the time. Moreover, there are certain regions that do not guarantee medical insurance, as regional and local governments are

84 President of the 73rd Session. “Universal Health Coverage - General Assembly of the United Nations.” Universal ​ Health Coverage - General Assembly of the United Nations , United Nations, 23 Sept. 2019, ​ www.un.org/pga/73/event/universal-health-coverage/. 85 Yip, Winnie, et al. 10 Years of Health-Care Reform in China: Progress and Gaps in Universal Health Coverage, ​ ​ THE LANCET, 28 Sept. 2019, www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32136-1/fulltext#seccestitle10. 86 Yip, Winnie, et al. ​ 87 Liu, Yuanli. “Is China Facing a Health Care Crisis?” The New York Times, The New York Times, 1 Nov. 2011, ​ ​ ​ www.nytimes.com/roomfordebate/2011/11/01/is-china-facing-a-health-care-crisis/chinas-health-care-reform-far-fro m-sufficient. 88 Knoema. “China Out of Pocket Expenditure as a Share of Current Health Expenditure, 1960-2018.” China - Out ​ ​ of Pocket Expenditure as a Share of Current Health Expenditure, Knoema, 2017, ​ knoema.com/atlas/China/topics/Health/Health-Expenditure/Out-of-pocket-expenditure-as-a-share-of-current-health- expenditure.

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23rd Annual Session of the Seoul Model United Nations ​ responsible for running the insurance system. This means that there are inter-regional disparities or inequities that might hinder the country’s progress in implementing UHC.89 Much like other countries, generalist or primary care providers are not prioritized in China, causing the primary care sector to lag behind that of secondary and tertiary care or specialists. This creates demands for big hospitals, which are difficult to sustain due to China’s huge population. Big hospitals in major metropolitan cities are often crowded, and “five-minute consultation time is [a] luxury.”90 The aging population and air pollution (problems prevalent in most of East Asia) are inhibiting the progress of Chinese healthcare. Overall, Chinese efforts in the past decade to implement UHC is commendable, and this model can be implemented in many other developing nations considering China often represents the developing world. Extrapolating from developments in previous years, China has the potential to develop a quality, functioning healthcare. However, China still has to undergo many improvements before it can boast its health system.

Republic of Korea Korea achieved UHC relatively later than many other developed nations in 1989.91 However, Korea’s real commendable achievement lies in the fact that following the 1977 amendment on the Medical Insurance Act, it fully implemented UHC in the short span of 12 years. In comparison, Germany took 127 years, Israel took 84, Austria took 79, and Japan took 36.92 In 1977, the Korean president Park Chung-Hee started to require workers to be mandated to have medical insurance. Eventually, this was expanded to government workers and private school teachers in 1979, rural residents in 1988, and all residents in 1989.93 Korea’s implementation of UHC can be a potential model for many developing countries, as it gave way to a functioning healthcare system in a short time. Today, Koreans have the 5th most efficient healthcare system and enjoy a quality National Health Insurance model available for all citizens. 94

89 Liu, Yuanli. ​ 90 Zhou, Viola. “Does China Have Universal Health Care? A Long (and Better) Answer.” Inkstone, Inkstone, 10 Oct. ​ ​ 2018, www.inkstonenews.com/health/china-translated-does-china-have-universal-health-care/article/2167579. 91 Lee, Jong-Chan. “Health care reform in South Korea: success or failure?.” American journal of public health vol. ​ ​ ​ 93,1 (2003): 48-51. doi:10.2105/ajph.93.1.48 92 Pearson, Mark, et al. “UNIVERSAL HEALTH COVERAGE AND HEALTH OUTCOMES.” ​ Universal-Health-Coverage-and-Health-Outcomes-OECD-G7-Health-Ministerial-2016.Pdf, OECD, 22 July 2016, ​ www.oecd.org/health/health-systems/Universal-Health-Coverage-and-Health-Outcomes-OECD-G7-Health-Minister ial-2016.pdf. 93 Lee, Jong-Chan. ​ ​ 94 Miller, Lee J, and Wei Lu. “U.S. Near Bottom, Hong Kong and Singapore at Top of Health Havens.” ​ Bloomberg.com, Bloomberg, 19 Sept. 2018, ​ www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-of-health-index-hong-kong-and-singapore-at-top.

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However, Korea suffers from numerous healthcare problems as it was developed so rapidly. For instance, Korea’s health system growth skews towards the specialists and neglects generalists. The Korean primary care system is estimated to be the weakest out of Organisations for Economic Cooperation and Development (OECD) countries, as the government focused heavily on the development of hospitals to combat growing populations in the 1980s.95 96 Several factors hinder the development in the primary care sector in the country: “the nominal patient ​ referral system without a gatekeeping function, fee-for-service schedule, overproduction of specialists and sub-specialties, and private sector dominance.”97 98 99 100 101 Korea’s extensive use of technologies has overloaded the NHI as well, creating inequities and inefficiencies in the healthcare system.102 40% of Health spendings in Korea is still by the OOP method.103 Although Korea does have a UHC system, it is important for the nation to constantly improve upon the existing healthcare system.

Japan The Japanese have one of the best healthcare systems in the world, as evidenced by the high level of life expectancy at 84 years. “Survival estimates after a diagnosis of breast, cervical or colorectal cancer are all high and 30-day case fatality after an ischaemic stroke is the lowest in the OECD.”104 Although Japan had achieved UHC relatively later than most developed countries in 1961, the SHI system that evolved from the 1938 Citizens’ Health Insurance (CHI) proved to be a massive success, placing Japan’s healthcare one of the world’s best. Japan’s implementation of UHC can be a model for many developing countries.

95 Ahn SH. Assessment of primary care level in Korea and comparison with the developed countries. J Korean Acad ​ ​ ​ Fam Med. 2001:483–97. 96 Jeong HS, Shin JW. Trends in Scale and Structure of Korea's Health Expenditure over Last Three Decades ​ ​ (1980-2009): Financing, Functions and Providers, J Korean Med Sci. 2012 May;27(Suppl):S13-S20. ​ https://doi.org/10.3346/jkms.2012.27.S.S13 97 Cho Y, Chung H, Joo H, Park HJ, Joh H-K, Kim JW, et al. (2020) Comparison of patient perceptions of primary ​ care quality across healthcare facilities in Korea: A cross-sectional study. PLoS ONE 15(3): e0230034. https://doi.org/10.1371/journal.pone.0230034 98 OECD. OECD Health Care Quality Review: Korea. Paris: Organization for Economic Cooperation and ​ Development Publishing, 2012. 99 Lee JY, Eun SJ, Ock M, Kim HJ, Lee HJ, Son WS, et al. General internists' perspectives regarding primary care ​ and currently related issues in Korea. Journal of Korean medical science. 2015;30:523–32. pmid:25931781. 100 Jung JW, Sung NJ, Park KH, Kim SW, Lee JH. Patients' Assessment of Community Primary and Non-primary ​ Care Physicians in Seoul City of South Korea. Korean journal of family medicine. 2011;32(4):226–33. pmid:22745858; PubMed Central PMCID: PMC3383130. 101 Lee JH, Choi YJ, Lee SH, Sung NJ, Kim SY, Hong JY. Association of the length of doctor-patient relationship ​ with primary care quality in seven family practices in Korea. Journal of Korean medical science. 2013;28(4):508–15. pmid:23580064; PubMed Central PMCID: PMC3617301. 102 Kwon S LT, Kim CY. Republic of Korea Health System Review. In: editor S K. Geneva, Switzerland: World ​ Health Organization; 2015. 103 Pearson, Mark, et al. ​ 104 Pearson, Mark, et al. ​

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The Japanese health system, however, is not without flaws. With a rapidly ageing population, Japan is spending more and more on healthcare to meet the demands of increasing numbers of senior citizens. In 2019, Japan spent 10.9% of their Gross Domestic Product (GDP) on health resources, well above the OECD average of 8.8%.105 Moreover, there is a doctor shortage in Japan that needs attention. Only 2.4 people out of 1000 are practising doctors–lower than the OECD average of 3.5.106 There is an obvious disparity between the number of huge hospitals in metropolitan areas and the number of doctors in urban cities. Some medical experts, such as Yusuke Tsugawa from Harvard University, even goes as far as to say that the Japanese longevity is not caused by excellent healthcare; rather, it is due to genetics, diet, cultural habits, and education.107 Overall, Japan has come a long way to establish a superb healthcare model. But there are certainly areas to be improved.

Federal Republic of Germany Germany achieved the implementation of complete UHC in 2009, when the country mandated the SHI multi-payer system for all citizens, 127 years after Otto Von Bismarck passed the Social Health Insurance Bill in 1883. Because its healthcare developed gradually with many trials and errors, Germany’s healthcare is regarded as one of the best in the world. Like most countries running the Social Health Insurance system, Germany has a multi-payer healthcare system. This is in sharp contrast to single-payer countries that use the Beveridge Model or the National Health Insurance Model. In Germany, most healthcare revenues are generated from employers and their employees, with surplus tax that contribute as well. With this SHI model, Germany has achieved quality healthcare for all. Much like other nations, German health system is not without country-specific flaws. As of 2018, 11.7% of German GDP was used in healthcare, higher than the EU average of 9.9%.108 Compared to the OECD average, Health expenditure per person in Germany is 33% higher as ​ well.109 110 This is caused by the overutilization of the labor market for medical revenues, leading to “a narrow financing base vulnerable to economic downturns and a shift to a service-oriented economy.”111 Another weakness the German healthcare faces is the lack of standardization in

105 OECD. “Health at a Glance 2019 - Japan.” Health-at-a-Glance-Japan-EN.pdf, OECD, 2019, ​ ​ ​ www.oecd.org/japan/health-at-a-glance-japan-EN.pdf. 106 OECD. ​ 107 Otake, Tomoko. Japan's Buckling Health Care System at a Crossroads, The Japan Times, 19 Feb. 2017, ​ ​ ​ www.japantimes.co.jp/news/2017/02/19/national/japans-buckling-health-care-system-crossroads/. 108 OECD. “Health at a Glance: Europe 2016.” Health-at-a-Glance-EUROPE-2016-Briefing-Note-GERMANY.pdf , ​ ​ 2016, www.oecd.org/germany/Health-at-a-Glance-EUROPE-2016-Briefing-Note-GERMANY.pdf. 109 Dietrich, Christoph & Riemer-Hommel, Petra. Challenges for the German Health Care System. Zeitschrift für ​ Gastroenterologie, 2012. 50. 557-72. 10.1055/s-0032-1312742. 110 33 OECD. Health at a Glance 2011: OECD Indicators. OECD Publishing (re- ​ trieved 29.2.2012) 2012 111 Dietrich, Christoph & Riemer-Hommel, Petra. ​

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23rd Annual Session of the Seoul Model United Nations ​ regards to testing pharmaceuticals, leading to overuse and a stale market without innovation.112 Hence, the German model is often described as a “mega-corporatist system.” Doctors also have financial incentive to carry out unnecessary operations and surgeries.113 Currently, reforms are too slow to mitigate these problems, as even the slightest change in policies can negatively affect stakeholders such as hospitals and sickness funds.114 Overall, the German healthcare system needs constant improvements, and beyond a simple reinforcement of UHC. But there is no denying that it is one of the best in the world that many nations can base their UHC upon.

United Mexican States Much like China, whether Mexico has fully implemented UHC is debatable. Some claim the nation implemented it in 2012, while others claim the insured healthcare is too basic to be qualified as UHC. However, what is indisputable is the fact that the nation is making significant and commendable efforts to implement UHC. In 2004, the government started an ambitious project called the “Seguro Popular (SP),” which eventually expanded to cover 52.6 million Mexicans in 2012. That is 47.7% of the Mexican population.115 30% of the population, comprised of employees and their families, are insured with Mexican Institute for Social Security (IMSS). The impoverishment percentage of health expenditure reduced from 3.3% to 0.8% in a decade. Although this amount of coverage is far from universal, it is a huge step from before the implementation of SP, as in the early 2000s half of the Mexican population had no medical insurance.116 However, Mexico suffers from many healthcare problems as well. Over the decades, many statistics indicate that Mexico has actually widened the gap between their healthcare and healthcare of developed nations. For instance, between 2000 and 2012, Mexico’s percentage among adults who are obese increased from 62% to 71%. 30% of patients die after a heart attack, and Out of Pocket payments make up 41% of total health expenditure as of 2017.117 118 “The healthcare system is highly fragmented with several vertically-integrated social insurer/ providers, each covering different parts of the population.” Essentially, the health model is

112 Dietrich, Christoph & Riemer-Hommel, Petra. ​

113 Knight, Ben. “German Hospitals 'Carrying out Unnecessary Operations': DW: 08.11.2017.” DW.COM, 8 Nov. ​ ​ ​ 2017, www.dw.com/en/german-hospitals-carrying-out-unnecessary-operations/a-41299019. 114 Dietrich, Christoph & Riemer-Hommel, Petra. ​ 115 Pearson, Mark, et al. ​ 116 Malkin, Elisabeth. “Mexico's Universal Health Care Is Work in Progress.” The New York Times, The New York ​ ​ ​ Times, 29 Jan. 2011, www.nytimes.com/2011/01/30/world/americas/30mexico.html. 117 Pearson, Mark, et al. ​ 118 Ríos, Ana María. “Out of Pocket Share of Health Spend in Mexico.” Statista, 11 Mar. 2020, ​ ​ www.statista.com/statistics/973612/mexico-out-of-pocket-percentage-health-expenditure/.

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23rd Annual Session of the Seoul Model United Nations ​ fragmented or disorganized based on regions, jobs, and age, with each system having different prices and different quality. This situation is exacerbated by the fact that Mexicans can not choose their health insurance on their own because the insurance is determined based on their jobs. Mexico only has 2.4 physicians out of 1000 people, well below the recommended number of 3.4.119 It is apparent Mexico has a long way until it achieves a functioning, quality healthcare system.

Republic of Colombia Much like Mexico and China, whether Colombia has achieved UHC is debatable. The country, however, is notable in its progress of improving healthcare and gradually implementing UHC. In 1997, the Colombian government started massive reforms on the healthcare system, and by 2013, they passed the Statutory Law, whereby all Colombians have access to basic healthcare. By 2014, 96% of the population were covered under a health insurance called Sistema General de Seguridad Social en Salud (SGSSS), and Out of Pocket expenditure decreased to 16% (lower than the current OECD average). In comparison, before the 1993 reforms, only 24% of the population had health insurance and Out of Pocket expenditure was over 50%. Consequently, Colombia’s life expectancy is gradually increasing. This progress is better than many developed countries.120 The Colombian system, in many ways, is similar to that of Germany. Both SGSSS and SHI are multi-payer insurance, creating revenues from both taxations and employers. However, unlike Germany, Colombia does not have as much resources to provide quality care for all. This is the key problem in the Colombian healthcare system: the lack of systematic guidelines for health quality standards. Colombia needs to train more specialists and provide better quality care for everyone. Still, it is undeniable that Colombia has one of the best healthcare systems in Latin America, and, in certain ways, have a more organized approach than many MEDCs. Colombia is a model to be followed for nations without UHC.121

Canada Canada has one of the best healthcare systems in the world. It has fully implemented UHC since the Medicare Act was passed in 1966 with the National Health Insurance model. The

119 Manatt Jones. Mexican Healthcare System Challenges and Opportunities.pdf, Manatt Jones, Jan. 2015, ​ ​ www.eluniversal.com.mx/english/oecd-mexican-healthcare-system-lagging-behind. 120 Pearson, Mark, et al. ​ 121 OECD. Colombia Still Faces Challenges to Improve Health Care Quality, 10 Dec. 2015, ​ ​ www.oecd.org/health/colombia-still-faces-challenges-to-improve-health-care-quality.htm.

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NHI is mostly funded with federal taxes and is responsible for healthcare for all. Out of Pocket payments are only 14%, and the average life expectancy is 82.5 years.122 123 Despite having one of the best healthcare system in the world, however, Canada suffers from lack of health coverage in all sectors, lack of physicians and medical instruments, expensive costs, and long waiting times. The Canadian Medicare healthcare model does not cover fees for dental health, vision health, and prescription drugs.124 Moreover, the Canadian health services are found to be extremely expensive; in 2016, “on an age-adjusted basis, Canada ​ ranked fourth highest for health-care expenditure as a percentage of GDP and 10th highest for health-care expenditure per capita.”125 In the same year, among 28 other nations with UHC, Canda ranked 26th on physician to population ratio, 27th on hospital beds per a thousand people, 22nd on number of MRI scanners, and 21st on CT scanners. Out of 10 countries with UHC, Canada placed worst (10th out of 10 countries) on average wait time per patient.126 Of course, this does not mean Canada has a subpar medical system; it just means that even the best healthcare systems have flaws that nations need to account for when implementing their UHC.

Kingdom of Thailand Thailand is currently in the process of implementing UHC. In 2001, the government launched the Universal Coverage Scheme (UCS or the 30-Baht Scheme) whereby all Thai citizens are covered with basic insurance. The UCS is a single-payer system financed entirely by tax revenues, similar to the British NHS. UCS, however, is not the only health insurance plan in the country–Civil Servant Medical Benefit Scheme (CSMBS), which has its origins in funding government employees and retirees, currently covers 7% of the population, and Social Security Scheme (SSS), originally intended to cover private sector employees, currently covering about 4.5% of the population.127 When the UCS was implemented, Thailand’s average life expectancy rose by 5 years. Infant mortality declined from 100 per 1000 births in the 1970s to 9.5 per 1000 births in 2017. Out of Pocket and catastrophic health expenditure declined drastically.128

122 Health System Tracker. “Out-of-Pocket Spending.” Peterson-KFF Health System Tracker, 19 May 2020, ​ ​ ​ www.healthsystemtracker.org/indicator/access-affordability/out-of-pocket-spending/. 123 MacroTrends. Canada Life Expectancy 1950-2020, 2020, ​ ​ www.macrotrends.net/countries/CAN/canada/life-expectancy#:~:text=The%20current%20life%20expectancy%20fo r,a%200.18%25%20increase%20from%202018. 124 Effective Public Healthcare Panacea Project. Canadian Health Care, 4 Mar. 2020, www.ephpp.ca/. ​ ​ 125 Barua, Bacchus. “Survey Reveals Canadian Health-Care Concerns.” Survey Reveals Canadian Health-Care ​ ​ Concerns | Fraser Institute, 27 May 2017, ​ www.fraserinstitute.org/blogs/survey-reveals-canadian-health-care-concerns. 126 Barua, Bacchus. ​ 127 Pearson, Mark, et al. ​ 128 OECD, Multi-dimensional review of Thailand (volume 1). Initial assessment. Health systems development in ​ ​ ​ Thailand: a solid platform for successful implementation of universal health coverage, 2018. Available from: ​

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One unique concern for the Thai healthcare system is the aging population. According to the World Bank, one fourth of the Thai population will be 65 year old or older in two decades.129 This creates a burden on the healthcare system, as an aging population means a shrinking workforce and thus less taxation. This is one of the main problems Thailand has to deal with in the near future. However, it is undeniable that Thailand is an excellent example of a developing nation with a successful healthcare system.

Suggested Solutions

The implementation of UHC should be individualized to serve different and unique positions each member state is in. That said, there are general guidelines to improving the provision of healthcare in most countries in current socioeconomic situations. First of all, it is important to acknowledge that health is a political issue and improving healthcare is a political choice. Although the concept of health literacy is relatively new among various political issues, it is ultimately the politicians and the government’s role of improving the country’s health standards. Therefore, education of health literacy is arguably the first step a nation has to undergo. This education needs to encompass everyone–governors, policymakers, physicians, and the general public. With a health conscious and literate populous, the country will steer towards the right direction in regards to implementing UHC and improving healthcare. Essentially, “it requires collective efforts from all stakeholders in policy, research, education and ​ practice” to improve health standards.130 There are 6 criteria in which health literacy can be judged on: equity, health information demands, healthcare costs, rates of chronic disease, health results, and numbers of people affected. In other words, health illiteracy can lead to exacerbation of existing inequities in healthcare standards, poor patient care as well as lacklustre communication between the patient and the doctor, overuse of unnecessary hospitalization which causes high costs, increasing rates of people with chronic diseases, poor health outcomes, and large number of people affected by poor health standards.131 132 It is evident that a strong emphasis on the education of health literacy https://read.oecd-ilibrary.org/development/multi-dimensional-review-of-thailand-volume-1_9789264293311-en#pag e18 129 World Bank. Thailand Economic Monitor - June 2016: Aging Society and Economy, June 2016, ​ ​ ​ www.worldbank.org/en/country/thailand/publication/thailand-economic-monitor-june-2016-aging-society-and-econ omy. 130 Sorensen, Kristine. Health literacy is a political choice. A health literacy guide for politicians.., 2016, ​ https://www.researchgate.net/publication/311455482_Health_literacy_is_a_political_choice_A_health_literacy_gui de_for_politicians 131 Sorensen, Kristine. ​ 132 Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in Europe: comparative ​ results of the European health literacy survey (HLS-EU). Eur J Public Health [Internet]. The Oxford University Press; Dec. 2015, http://www.ncbi.nlm.nih.gov/pubmed/25843827

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23rd Annual Session of the Seoul Model United Nations ​ is crucial to the improvement in the provision of healthcare. Nations without a UHC system need to closely observe nations that do to analyze their own unique situations and seek to implement UHC in the near future. Furthermore, in order to implement UHC, nations need to fundamentally examine and answer three basic questions: “who is covered,” “what services are covered,” and “how much financial protection do citizens have when accessing services?” In reality, however, it is quite difficult for nations to completely cover all three agendas as resources are limited. It should therefore be noted that education for the implementation of UHC is one of the top priorities nations should have in regards to improving healthcare. “Movement towards UHC is a process of progressive realization whereby the population understands that coverage with health services, service quality and financial risk protection will improve over time as more resources become available.”133 For nations already with UHC, improvement on the system is necessary. Common criticism of universal healthcare such as the long wait time and subpar quality needs to be addressed for a nation to improve their provision of healthcare. Many nations that have UHC also suffer from a rapidly aging population, further highlighting the importance of a strong healthcare system. UHC can not function without government intervention, through the form of either funding or taxation. Voluntary contributions alone can never finance a functioning universal healthcare. However, the problem is that many LEDCs might not be able to sustain such a system. The creation of a Non-Governmental Organization (NGO) or a UN affiliated organization dedicated to financing the implementation of UHC, or a massive reform on an existing organization (if such an organization exists) can be done to efficiently finance UHC in developing countries. This organization might also function as a platform or an intermediary between member states to discuss various strategies that can be employed to aid in the implementation of UHC. MEDCs that have already implemented universal healthcare might be able to finance LEDCs that are in the process of implementation. Implementing UHC has no one-size-fits-all solution due to different circumstances in different nations. Delegates are encouraged to specifically and thoroughly research ways to implement UHC in their own respective countries and then devise a generalized plan that would improve provision of healthcare for all.

133 Yates, Robert, and Gary Humphreys. “Arguing for Universal Health Coverage.” UHC_ENvs_BD.PDF, World ​ ​ Health Organization, 2013, www.who.int/health_financing/UHC_ENvs_BD.PDF.

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