Acknowledgements

Assessing the extent to which Universal Healthcare Policy is a key decider in managing the COVID-19: A comparative Study of the UK, the United States and The Netherlands

Acknowledgements

I would like to express my sincere gratitude to my supervisor Mr. John through whose support and guidance, this dissertation came to a successful completion. The rigorous guide and feedback has greatly enabled me to work through all the chapters of this dissertation. Lastly, I also appreciate my family for being there for me and ensuring that I had the both the material and emotional supported I really needed while working on this project. Thank you all.

Abstract

This policy report investigates the extent to which the Universal Healthcare Policy is key in the management of COVID-19 by doing a comparative study in the UK, the United States and the Netherlands. The study employed a qualitative research design characterized by comparative case study strategy, secondary data and thematic analysis technique. Firstly, this study establishes that Universal Healthcare Coverage (UHC) and the structure of UHC implemented by a country is not key in the management decisions of the pandemic as concerns testing and tracing programs. UHC however plays an important role in the effectiveness of such programs as the research establishes that countries which have no UHC policies in place such as the US, most likely have a considerable proportion of their population suffering from chronic illnesses which make them more predisposed to infections.

The study also establishes that UHC is important for the success of containment measures such as lockdowns. Thirdly, the research also establishes that UHC reduces proportion of the population with chronic illnesses and therefore is a key decider in the determination of the success of COVID-19 vaccinations. The term decider is used in the report to symbolize the main determinant, the causative agent, and the overall an outcome. The study also establishes that inequalities in most societies limit universal access to vaccinations. Just like the containment measures, this research also found out that the success of public education and awareness programs is also mediated largely by political influence and prior pandemic experience as well as the believability of scientific evidence supporting such programs. The reports recommends a reduction of political influence on the management of the pandemic. The report also recommends the implementation of UHC policies in countries that have so as to reduce the proneness of the population to the pandemic.

Contents

TOC o “1-3” h z u 1. Introduction PAGEREF _Toc81865666 h 11.1 Background to the study PAGEREF _Toc81865667 h 11.2 Research aims and objectives PAGEREF _Toc81865668 h 11.3 Research rationale PAGEREF _Toc81865669 h 22. Literature Review PAGEREF _Toc81865670 h 32.1 What is Universal Health Coverage PAGEREF _Toc81865671 h 32.2 Review of literatures on UHC implementation in UK, the Netherlands and the United States PAGEREF _Toc81865672 h 32.2.1 Review of literatures on Universal healthcare coverage in the UK PAGEREF _Toc81865673 h 32.2.2 Review of literatures on Universal healthcare coverage in the Netherlands PAGEREF _Toc81865674 h 52.2.3 Review of literatures on universal healthcare coverage in the United States PAGEREF _Toc81865675 h 72.3 Theoretical underpinning of the research Punctuated Equilibrium Theory (PET) PAGEREF _Toc81865676 h 83. Methods PAGEREF _Toc81865677 h 103.1 Data collection PAGEREF _Toc81865678 h 103.2 Data Analysis: Comparative case-study strategy PAGEREF _Toc81865679 h 114.Findings and discussions PAGEREF _Toc81865680 h 144.1 Findings PAGEREF _Toc81865681 h 144.1.1 Introduction PAGEREF _Toc81865682 h 144.1.2 Deployment of test and trace programs in the UK, US and Netherlands. PAGEREF _Toc81865683 h 144.1.3 Effectiveness of the containment measures such as lockdowns and the consistency with which these measures are implemented. PAGEREF _Toc81865684 h 194.1.4 Roll out of COVID-19 vaccinations PAGEREF _Toc81865685 h 214.1.5 Public education awareness and programmes aimed at guiding citizen behaviour PAGEREF _Toc81865686 h 264.2 Discussion of Findings PAGEREF _Toc81865687 h 274.2.1 UHC policy as a key decider in deployment of Covid-19 testing and contact tracing PAGEREF _Toc81865688 h 274.2.2 UHC as a key decider in implementation of containment measures such as lockdowns. PAGEREF _Toc81865689 h 304.2.3 UHC policy as a key decider in roll out of Covid-19 vaccination PAGEREF _Toc81865690 h 314.2.4 UHC as a key decider in implementing public education and awareness programmes PAGEREF _Toc81865691 h 334.3 Chapter Summary PAGEREF _Toc81865692 h 335. Conclusion PAGEREF _Toc81865693 h 345.1 UHC as a key decider in Covid-19 management (deployment of testing and contact tracing program) PAGEREF _Toc81865694 h 345.2 UHC as a key decider in implementation of Covid-19 containment measures PAGEREF _Toc81865695 h 355.3 UHC as a key decider in Covid-19 management (roll out of vaccination). PAGEREF _Toc81865696 h 365.4 UHC as a key decider in management of Covid-19 pandemic through public education and awareness programs PAGEREF _Toc81865697 h 365.5 Recommendations of the study PAGEREF _Toc81865698 h 37References PAGEREF _Toc81865699 h 39

1. Introduction1.1 Background to the studyAccording to Ndugga et al. (2021), the Covid-19 pandemic continues to have ravaging impact on the global economy and global population. The virus which was first reported in Wuhan, China, in late 2019, has rapidly become a global threat (WHO, 2021). More specifically, reports by the World Health Organisation reveals that, as of December 2020, close to 82 million had been infected with the virus with approximately 1.8 million succumbing (WHO, 2021). Experts state that this is a relatively conservative figure given the number of deaths that can be attributed to the virus both directly and indirectly is much higher (Ndugga et al., 2021). This is therefore an indication that Covid-19 is not only a global pandemic but also a public health crisis which also has severe economic impacts.

However, there have been differences in the progress made by different countries in as far as testing, contact tracing and Covid-19 vaccinations are concerned. A number of factors such as climatic conditions, age difference and how fast the government implement the pandemic containment strategies have been found to affect the progress made in testing, contact tracing and Covid-19 vaccinations (Zieff et al, 2020). Some scholars have also argued that UHC policies are key in the management decisions of pandemic as it ensure equity in access to healthcare and more coordinated response to the pandemic. Moreover, the policies ensure that people are not exposed to undue financial burden due to high cost of medications

On the contrary, some scholars have argued that UHC policy does not necessarily affect the management decisions of the pandemic. In fact due to increase to access to COVID-19 healthcare due to elimination of financial barriers, there is an increase in general efficiency and wastefulness associated with bureaucratic and government-run agencies (Zieff et al, 2020).

It is therefore against this background that the current policy seeks to assess the extent to which the Universal Health Coverage policy is key in the management decisions of the COVID-19 pandemic. More precisely, the research seeks to conduct a comparative study in countries where UHC is implemented: the UK and the Netherlands and in countries in which UHC is not currently implemented in which United States is as a representative.

1.2 Research aims and objectivesThe overall aim of the research is to assess the extent to which Universal Healthcare Policy is a key in the management decisions of COVID-19 by using three case studies (the UK, Netherlands and the United States). More specifically, the policy report aims at addressing the following four objectives.

To find out the extent to which UHC policy is a key in decisions of managing Covid-19 test and contact tracing in the three countries

To ascertain the extent to which UHC policy influences the effectiveness of containment measure of lock downs.

To establish the extent to which UHC policy is a key decider in managing Covid-19 vaccine roll out in the three countries.

To find out extent to which UHC policy is a key decider of the effectiveness of public education and awareness programmes aimed at guiding citizen behaviour.

1.3 Research rationaleTheoretically, the policy report is relevant in the sense that, while a host of researches have been conducted to investigate the role of UHC policies in managing pandemics, most of these researches have been on previous pandemics such as the H1N1. As such, there is relatively smaller number of studies on the relationship between UHC policy in a country and Covid-19 management (Tikkanen et al, 2020). In addition, the author recognises that most researches have been focused on explaining the differences in the success of Covid-19 responses by looking at factors such as differences in climate, pre-existing chronic conditions and economic factors such as level of income among others (Public Health England,2020). As such, UHC policy continues to receive little attention. The current research seeks to bridge this gap.

Practically, the policy report seeks to provide valuable insights on the extent to which UHC policy is a key decider in management of Covid-19. The findings will therefore inform policy makers including medical professionals and politicians among others on whether UHC is a key decider as well as possible ways of enhancing management of pandemics from the perspective of testing, contact tracing and vaccinations.

2. Literature Review2.1 What is Universal Health CoverageAccording to the Tauli-Corpaz (2020), universal health coverage encompasses all efforts aimed at making sure that all individuals and communities are able to receive the health services that they need, whenever they need them and where they need them, without having to suffer undue financial hardship. The above view is echoed by Sessions and Lee (2008) which points out that universal health coverage includes the full range of essential health services, from health promotion to prevention, rehabilitation, treatment and palliative care (Sessions and Lee,2008).

Further, United Nations (2020) explains that universal healthcare seeks to meet three main goals. These are: equity in access, no due financial risk and sufficient quality. More precisely, equity in access implies that everyone who needs the health services should be able to receive/access them as opposed to situations where only those who can afford them receive them. Secondly, as noted by WHO (2021), sufficient quality implies that the health services provided under the scheme should be good enough in order to ensure the improvement of the health of those receiving the services. Finally, no due financial risk implies that people who seek health services should not be put under risk of financial harm as a result of the costs of the using such health services (United Nations, 2020).

Precisely, Zieff et al. (2020) notes that there are three main versions of universal health coverage namely: purely private, market-based and governmental. For instance, as identified by Light (2003), the United Kingdom is considered to be implementing a fairly traditional version of the universal healthcare which is characterised by few options for and minimal use of privatised care and more use of the governmental care. On the other hand, a number of European countries including Germany, Netherlands and Switzerland are considered to be employing a relatively blended system characterised by substantial government and market-based components (Unger and De Paepe, 2019).

2.2 Review of literatures on UHC implementation in UK, the Netherlands and the United States2.2.1 Review of literatures on Universal healthcare coverage in the UKThe United Kingdom is associated with aversion of UHC which is largely governmental-based and as such, is characterised by few options for, and minimal use of, privatised care (Light, 2003). Precisely, healthcare coverage is free at the point of need and is paid for by general taxation. While the country has a growing private healthcare sector, healthcare provision in the country is still largely dominated by public health facilities. The universal healthcare coverage in the country is funded largely by citizen’s income tax which is about 4.5% of the average income of every citizen (Chang et al., 2011). The universal health coverage in the country is provided through the government-funded National Health Service (NHS).

The UHC system in the UK has been cited as one of the most successful the world in healthcare service provision over. As noted by Gorsky (2015), the NHS has been unique on the universalism it provides to the UK population owing to the fact that it provides comprehensive benefits to all residents, free at the point of access regardless of ability to pay, and with next to no patient charges. The success that the implementation of UHC in the UK, through the National Health Service has registered over the years has been acknowledged by a number of studies. The country’s healthcare system was ranked best in regards to Equity and Care Process (coordinated, patient-oriented, effective and safe) as illustrated in figure 1 below.

Figure 1: Healthcare System performance rankings

Source: The Commonwealth Fund (2017)

In the same vein, a research conducted by the Economist Intelligence Unit in the year 2015 ranked the UK’s healthcare system’s palliative care as the best in the world in terms equity and care process (Triggle, 2015). One of the major advantages of the UK’s UHC relative to other UHC programs employed by other countries is that it is characterised by enhanced access and equity whereby citizens have access to the same healthcare which, to a large extent, has no patient charges, regardless of socio-economic status.

However, Chang et al. (2011) note that the constraining healthcare costs is increasingly becoming a challenge to the implementation of UHC in the UK in the wake of increasing health demands especially from the UK’s ageing population. In connection to the view above, Gorsky (2015) notes that given the UK’s UHC needs to work for the benefit of all, cost effectiveness is must be achieved. Consequently, in instances where the cost of medication far outweighs the benefits, for instance, for special needs, patients are forced to resort to out-of-pocket spending (Light, 2003).

Therefore, against this background, the current research seeks to establish the extent to which the UK’s UHC policy which is largely government run is a key decider in managing of pandemics and more specifically the current COVID-19 virus. For instance, as echoed by Maizland and Felter (2020) and as already highlighted above, some analyses give the NHS high ratings for many health-care metrics including preventive care, equity and access. Providing preventive care reduces the risk of contracting diseases, disabilities or even death while equity and access ensure citizens are able to access quality healthcare services regardless of the socio-economic background. At the same time, Maizland and Felter (2020) point out that the UK’s UHC policy has also faced criticisms over lack of funding and decreasing quality, especially for primary care. Therefore, in chapter 4 of the research, the study seeks to establish whether these criticisms of the UK’s UHC policy have been evident during the pandemic and how these have in turn shaped the country’s overall response to the virus. Therefore, the current research seeks to establish the extent to which the UK’s healthcare’s response to COVID-19 can be said to be equitable besides providing universal access to all and how this has in turn mediated the economic and social impacts of the virus.

2.2.2 Review of literatures on Universal healthcare coverage in the NetherlandsUnlike the UK, in Netherlands, implementation of UHC involves a closer collaboration between the private and the public sector with the aim of enhancing the equity, access as well as quality of healthcare (Tikkanen et al., 2020). To this end, all residents of the country are required to purchase statutory health insurance from private insurers which are in turn required to accept all applicants. Precisely, Tikkanen et al. (2020) explains that financing of the country’s healthcare is largely public through a number of channels including tax revenues, premiums, and government grants. Further, setting of health care priorities is done by the national government besides being responsible for monitoring of key aspects such as costs, quality and access (Scott, 2020). In the Netherlands, all adult residents as well as non-residents who pay Dutch income tax are required to purchase statutory health insurance from private insurers with children below the age of 18 getting automatically covered (The Commonwealth Fund, 2020). Figure 3 below provides a summary of the organisation of the health system in the Netherlands.

Figure 3: Organisation of the health system in the Netherlands.

Source: Tikkanen et al. (2020).

The Netherlands’ UHC is considered to be one of the best globally with the Commonwealth Fund (2017) ranking the country’s healthcare system third overall as illustrated in figure 1 above. Commonwealth ranked the Health Care System performance in some of the high income countries. In this report, the organization assessed the performance of healthcare systems in eleven countries across five major domains access to care, care process, administrative efficiency, and equity and healthcare outcomes. The study established that the country’s healthcare system ranks first globally in regards to access and second globally in regards to equity (Commonwealth Fund, 2017).

However, despite the successes of the Netherlands’ UHC, critics argue that, by handing over much its healthcare to the private market, Dutch patients face higher financial barriers to care than their peers in more socialised systems such as the UK (Scott, 2020). For instance Netherlands spent $1615 which is more relatively lower than UK which spent $2989 on healthcare in 2020 (Wammes, 2020). Moreover, Scott (2020) reveals that spending on healthcare in the Netherlands by patients has accelerated in recent years, a trend that critics blame on the privatised market. In this regard, Wammess (2020) states that the annual deductible has more than doubled between the years 2008 and 2018 from $218 to $493. It is therefore increasingly becoming a concern that the rapidly increasing costs is making greater numbers of people to abstain from or postpone needed medical care.

Therefore, in light of the advantages as well as limitations of UHC policy in Netherlands which is mostly private, the current study seeks to establish how the unique features of the policy have been a key decider in the management of the virus thus far. For instance, the discussions above reveal that the all-private UHC policy in Netherlands is associated with rising costs of treatment in the Netherlands has made some Dutch people to either postpone or abstain from seeking medical attention in regards to COVID-19-related illnesses and how this has been decider in the management of the virus in the country. According to Statista (2020), there cost of healthcare increased from 87,334 million Euros in 2018 to 100,451 million euros in 2020.

2.2.3 Review of literatures on universal healthcare coverage in the United StatesThe United States is one of the developed economies that does not have a UHC program running. According to Zieff et al. (2020), the closest the United States have come to implementing UHC is the Obama-era passage of the Affordable Care Act (ACA). However, ACA was met with resistance especially during the Trump administration thereby leading to its failure. President Trump signed an executive order instructing administration officials to waive and grant exemptions to ACA popularly known as Obamacare. In 2017, the year of his election he described Obamacare as “horrible” and “very expensive”. He got rid of some of the requirements some of which included a penalty for failure to pay health insurance premiums (Simmons-Duffin, 2019). According to Zieff et al. (2020), the failure by the United States to implement UHC has resulted in debates on whether UHC is relevant especially for a country such as the United States. First, arguments against implementation of UHC in the country hold that although most developed economies have UHC programs running, few-if any-of these nations are as geographically large, racially diverse, and populous as the US (Office of Disease Prevention and Health Promotion, DPHP, 2020).

In the same vein, there is consensus among several scholars that implementation of UHC in the United States would necessitate significant upfront costs including the costs of technological and infrastructural changes as well as the costs of insuring/treating previously uninsured and largely unhealthy segment of the population (Blahous et al., 2018). Further, studies have established that the costs of implementing UHC would be significantly high to an extent that the federal tax proposals would not be able to cover fully (Sessions and Lee, 2008). For instance, a recently pushed proposal for universal healthcare included such options as a 7.5% payroll tax plus 4% income tax on all American citizens, with higher income-earners subjected to higher taxes (Zeiff et al, 2020).

However, supporters of UHC have argued that it can be an important way to address the growing chronic disease crisis, mitigate the economic costs associated with the said crisis, reduce the vast health disparities existing between people with different socio-economic statuses (SESs) besides increasing opportunities for preventive health initiatives (Crowley et al., 2020). According to Braveman et al (2010), low income earners who are also the least educated have the poorest quality health in the US. Zieff et al. (2020) notes that one of the most striking advantages of UHC in US is the potential to address the epidemic level of non-communicable chronic diseases, the economic strain from which is more evident among low SES who are both unhealthy and uninsured (Crowley et al., 2020).

Against this background, the current research seeks to establish whether the absence of UHC policy in United States has had any significant influence on the response by the country’s healthcare system to the virus thus far, be it positive or negative. In this regard, the current study is focused on finding out whether the country could do better or worse or just about the same if it had a UHC program in place like the other two countries. Put simply, chapter 4 of the research will provide analysis of data in order to establish how the absence of UHC program in US has been a key decider in the management of COVID-19 virus in the country.

2.3 Theoretical underpinning of the research Punctuated Equilibrium Theory (PET)PET, as a policy making theory, was first developed by Frank Baumgartner and Bryan True Jones who sought to provide a better explanation on how the same institutional set ups which act as barriers towards dramatic policy changes may also be responsible for occasional outbursts of attention thereby leading to disproportionately large policy shifts (True and Baumgartner, 2019). The development of the PET was informed by the limitations of previous policy theories which had only been successful in explaining either policy stability or large policy changes while providing little understanding on how governmental processes can cause both stability as well as large policy shifts (Joly and Richter, 2019). It is against this background that PET is considered a novel and original theory in the sense that, unlike previous theories, it explains how both large policy shifts as well as stability can be attributable to the same governmental processes.

As explained by GreenPedersen and Princen (2016), PET is based on the premise that, as a result of policymakers’ cognitive limitations, they are not able to attend to all the societal problems all at the same time. As a result, in most cases, policymaking is delegated to policy subsystems which includes groups of elites comprising of civil servants, interest groups and elected officials among others. In this regard, PET is based on the assumption that politics of subsystems generally serve as a barrier towards large policy changes thereby making small and incremental changes to be more common as opposed to large policy shifts which are proportionate to solving existing societal problems. On the other hand, PET is also based on the premise that large policy shifts can also take place especially when the manner in which an issue is understood changes (issue definition) and that people who were previously not interested in the given policy change are involved (agenda setting) (Baumgartner et al., 2009).

According to Baumgartner et al. (2009), issue definition and agenda setting that characterise large policy shifts are underpinned by sudden or steady attention of an influential political actor or may also be as a result of a major focusing event. Therefore, it is notable that the two concepts (agenda setting and issue definition) are at the heart of PET and as such, go a long way in providing a better understanding of the stability of some policies over longer periods of time as well as why some policies can sometimes be altered drastically and radically.

While PET was originally developed as an agenda-setting theory for examination of why some issues gain political attention, the theory has undergone evolution over the years and has become a more general theory on information processing in decision making (GreenPedersen and Princen 2016). In this regard, Cairney, Heikkila and Wood (2019) state that the theory examines the consequences of bounded rationality by holding that while policymakers at notional ‘center’ of government are able to pay attention to besides influencing most issues, they can only focus their attention on relatively small number. This implies that they will more likely ignore the rest of the issues. PET further holds that governments’ ability to address this limitation is limited by serial and parallel processing (Cairney, Heikkila and Wood, 2019).

Precisely, serial and parallel processing implies that, for most governments, there is ‘macropolitical’ attention to a smaller number of key issues, while most issues are processed in subsystems which are not only away from the attention of elected policymakers but also away from the public spotlight (Baumgartner et al. (2009). This therefore explains why, for most political systems, only a small number of policies are able to undergo significant changes if they receive sustained attention. Additionally, PET is based on the belief that significant policy shifts do not happen easily because policymakers also rely on institutions which are characterised by a set of rules or standard operating procedures in processing information. Therefore, the institutions contribute towards disproportionate processing of information or the tendency of ignoring much information routinely until there is sufficient pressure to pay attention to the given information (Baumgartner et al., 2009). Overall, Cairney, Heikkila and Wood (2019) put forward that PET is based on the overall proposition that the absence of central control given the center in itself, is not able to pay sufficient attention to all policy issues neither can the center control the information processing institutions especially those that manage pandemics.

The decision to employ PET in the current study is informed by the fact that the theory has been successfully applied to a wide range of public policies in numerous countries. To this end, the theory has been successful in generating both cross-sectional and cross-national analyses that are geared towards aiding comparison and providing better understanding of the causes of stability and change in different political systems (Joly and Richter, 2019). Therefore, the theory is best-suited for explaining why different countries have different UHC policies and why some countries such as the United States are yet to successfully develop and implement a UHC program. This is an indication that, through the PET, the current study will be able to gain a deeper understanding of how the differences in the political systems in the three countries (UK, Netherlands and the United States) have shaped the kind of UHC implemented or lack thereof and how this in turn shapes the countries’ responses to the Covid-19 pandemic. The research also identifies that while PET has been applied in various policy environments, its application in the healthcare sector and more specifically in explaining how political systems in different countries shape development and implementation of UHC programs is still limited.

3. Methods3.1 Data collection

Data is collected mainly from secondary sources. Secondary data refers to primary data which have been made available for reuse by the general research community. On the other hand, primary data is that which is original and has been collected using data collection methods that fit the problem under study best. The decision to use secondary sources of data is informed by the fact that it is time and cost saving. In addition, given the restrictions on movements as well as the need to mitigate the spread of COVID-19 virus, collection of primary data would involve physical movements which work against this goal. In this regard, secondary sources of data are suitable given they can easily be accessed electronically from the internet and at relatively lower costs (Saunders, Lewis and Thornhill, 2012).

In addition, with secondary data, a researcher is permitted to access the work of the best scholars relevant to the topic of study. However, a major limitation of this approach is that some sources may not be as credible. Secondly, it is also notable that the secondary data collected may not necessarily address all the research questions for the current study given the researches were conducted to meet goals different from what the current study seeks to achieve (Saunders, Lewis and Thornhill, 2012). In addressing the limitations above, the research only used credible sources besides using data that is closely related to the subjects under study. It is also important to note that the current study analyses the extent to which UHC policies in the three countries have been a key decider in the management of COVID-19 by looking at sources published from January 20th 2020 when the first case was reported in the United States to July 8th 2021.

The sources of data considered for the current research include publications by world bodies such as the World Health Organisation, national bodies such as the National Health Service, credible online newspapers such as the Guardian, the Washington Post and Vox among others. Some of the key words used