Human security and universal health insurance
Authors: Sudhir Anand
Journal: The Lancet (2011)

Human security is a multidimensional concept that has been a cornerstone of Japanese development co-operation for more than a decade. At the heart of security is the idea of protection or insurance against downside risk.1Anand S. Economic security. Paper presented at Common Security Forum Conference, Oslo, Norway, July, 1992.Google Scholar, 2Anand S Sen A Concepts of human development and poverty: a multidimensional perspective. United Nations Development Programme, New York1997Google Scholar Three distinct questions arise from the concept of human security. First, protection of what? Second, insurance against what? And, third, security for whom? The first question relates to the specification of what is to be protected. The definition of human security offered by the Commission on Human Security3Commission on Human SecurityHuman security now: protecting and empowering people.http://www.humansecurity-chs.org/finalreport/English/FinalReport.pdfDate: 2003Google Scholar is: "to protect the vital core of all human lives in ways that enhance human freedoms and human fulfilment". The core of a person's life is closely concerned with the person's wellbeing and agency, which is best viewed in terms of his or her "capability" to achieve alternative "beings and doings".4Sen A Commodities and capabilities. North-Holland, Amsterdam1985Google Scholar In this context, health assumes central importance for two reasons: it is directly constitutive of a person's wellbeing; and it enables a person to function as an agent—that is, to pursue the various goals and projects in life that he or she has reason to value. This view deploys the notion of well-functioning, but it is not grounded in notions of economic welfare that are based on utility or income. It is, rather, an agency-centred view of a person, for whom ill health restricts the scope of human agency. Since our ability to do things typically depends on our being alive, the capability to lead a long and healthy life must itself be regarded as a basic capability. The second question related to human security is insurance against what. Here the concern is to insure against falling below an adequate threshold of human capabilities—in the case of a person's health, a minimum acceptable level. The probability of falling below a minimum threshold depends on both how vulnerable a person is—the degree of downside risk the person faces—and how much above the threshold he or she is in the relevant dimension.1Anand S. Economic security. Paper presented at Common Security Forum Conference, Oslo, Norway, July, 1992.Google Scholar The extreme case of insecurity is certainty of being below a specified threshold, and the absence of any chance of avoiding that fate. Threats to human security can arise, for example, from natural disasters and environmental catastrophes—such as the 2011 earthquake and tsunami in Japan, and the consequent leakage of radioactive material from the Fukushima Daiichi nuclear plant. They can arise from disease outbreaks such as HIV/AIDS, severe acute respiratory syndrome and drug-resistant tuberculosis; from personal accidents and illness; from economic downturns as in the Asian financial crisis of 1997–98; and from various other hazards that people face.3Commission on Human SecurityHuman security now: protecting and empowering people.http://www.humansecurity-chs.org/finalreport/English/FinalReport.pdfDate: 2003Google Scholar, 5Sen A Why human security? International Symposium on Human Security; Tokyo.http://www.humansecurity-chs.org/activities/outreach/Sen2000.pdfDate: July 28, 2000Google Scholar, 6Chen LC. Health as a human security priority for the 21st century. Human Security Track III. The Helsinki Process, Helsinki, Finland, Dec 7, 2004.Google Scholar The vulnerability of a person to such risks will depend on his or her individual circumstances—including location, epidemiological environment, health status, and economic position. A person's health is affected by health care and various other determinants—eg, socioeconomic, behavioural, occupational, and dietary. But access to appropriate health care is also a vital factor in protecting a person from the risk of ill health, and especially of catastrophic ill health. Comprehensive health care is thus important both in promotion of health and in response to health crises. Without health insurance, a severe medical crisis that threatens survival, for example, can have disastrous financial implications—that can affect human security in many other dimensions. The third question concerns security for whom—the entire population or a subset of it? Universalism can be defended through a variety of different approaches, which all invoke equity, fairness, or impartiality in some form or other. For instance, we can appeal to impartiality through the device of Rawls's "veil of ignorance" in the "original position".7Rawls J A theory of justice. Harvard University Press, Cambridge, MA1971Crossref Google Scholar Behind the veil of ignorance, I do not know who I will turn out to be and what serious illness or health threat I might encounter, which could require extensive medical attention. Given this uncertainty, the institutional arrangement for health care I am likely to favour is one that ensures comprehensive coverage for all. The concept of human security has wide reach and includes multiple concerns. A major concern is protection of people's health, for which comprehensive health coverage for all is an essential requirement. Universal health insurance thus contributes directly to furthering human security. This implication is as valid for Japan as for other countries in the world. The tragic events of, and responses to, the earthquake of 2011 are a powerful reminder of Japan's concern for human security. In the past, several distinguished politicians, civil servants, and academics in Japan have drawn on and developed the concept of human security—including former Prime Minister Keizo Obuchi, Japan International Cooperation Agency President Sadako Ogata, global health expert Keizo Takemi, and Japan Center for International Exchange President Tadashi Yamamoto.3Commission on Human SecurityHuman security now: protecting and empowering people.http://www.humansecurity-chs.org/finalreport/English/FinalReport.pdfDate: 2003Google Scholar, 8Obuchi K Opening remarks.in: The Asian crisis and human security: an intellectual dialogue on building Asia's tomorrow. Japan Center for International Exchange, Tokyo1999: 17-19Google Scholar, 9Takemi K Japan's perspective on humanity and security.in: Matsumae T Chen LC Common security in Asia: new concepts of human security. Tokai University Press, Tokyo1995: 71-86Google Scholar, 10Matsumae T Chen LC Common security in Asia: new concepts of human security. Tokai University Press, Tokyo1995Google Scholar, 11Yamamoto T Yue CS Foreword.in: The Asian crisis and human security: an intellectual dialogue on building Asia's tomorrow. Japan Center for International Exchange, Tokyo1999: 7-9Google Scholar Indeed, universal health coverage in Japan, now in existence for 50 years, is indicative of the priority that Japan accords to human security. Over the decades, Japan has also undertaken policies to advance human security in other dimensions, such as basic education, social protection, and economic safety nets. Internationally, Japan has used the concept of human security to guide assistance to developing countries through bilateral aid and multilateral policies. The range and reach of the idea of human security are extensive, as Japanese actions have shown. A central manifestation of these actions is the country's commitment to universal health insurance. I declare that I have no conflicts of interest. Japan: universal health care at 50 yearsJapan marked the 50th anniversary of universal health care on April 1, 2011. During this relatively short period of time, Japan quickly became a world leader in several health metrics, including longevity. To celebrate and consider Japan's achievements in health, The Lancet today publishes a Series on universal health care at 50 years in Japan. Six theme papers and eight Comments by Japanese academics with international collaborators document the post-war evolution of health care in Japan—particularly the country's increased participation in global health. Full-Text PDF Why is Japanese life expectancy so high?For the past three decades, Japan has had the highest life expectancy in the world. This has been achieved while keeping health expenditures as a fraction of gross domestic product (GDP) under 8·5% in 2008, by contrast with 16·4% in the USA or 10·7% in Germany.1 Excellent health outcomes in Japan have been attributed to favourable risk factor profiles, health system performance,2 and universal coverage. Elucidating the underlying reasons for Japan's health success has important ramifications for other nations looking to achieve good outcomes at affordable cost. Full-Text PDF What has made the population of Japan healthy?People in Japan have the longest life expectancy at birth in the world. Here, we compile the best available evidence about population health in Japan to investigate what has made the Japanese people healthy in the past 50 years. The Japanese population achieved longevity in a fairly short time through a rapid reduction in mortality rates for communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates. Japan had moderate mortality rates for non-communicable diseases, with the exception of stroke, in the 1950s. Full-Text PDF Japanese universal health coverage: evolution, achievements, and challengesJapan shows the advantages and limitations of pursuing universal health coverage by establishment of employee-based and community-based social health insurance. On the positive side, almost everyone came to be insured in 1961; the enforcement of the same fee schedule for all plans and almost all providers has maintained equity and contained costs; and the co-payment rate has become the same for all, except for elderly people and children. This equity has been achieved by provision of subsidies from general revenues to plans that enrol people with low incomes, and enforcement of cross-subsidisation among the plans to finance the costs of health care for elderly people. Full-Text PDF Population ageing and wellbeing: lessons from Japan's long-term care insurance policyJapan's population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Full-Text PDF 50 years of pursuing a healthy society in JapanIn this Series in The Lancet, we review the past 50 years of Japan's universal health coverage, identify the major challenges of today, and propose paths for the future, within the context of long-term population ageing and the devastating crises triggered by the March 11 earthquake. Japan is recognised internationally for its outstanding achievements during the second half of the 20th century, in both improving the population's health status and developing a strong health system. At the end of World War 2, in Japan, life expectancy at birth was 50 years for men and 54 years for women; by the late 1970s, Japan overtook Sweden as the world's leader for longest life expectancy at birth. Full-Text PDF