key: cord-284711-l1za83w1 authors: Anand, Sudhir title: Human security and universal health insurance date: 2011-08-30 journal: Lancet DOI: 10.1016/s0140-6736(11)61148-3 sha: doc_id: 284711 cord_uid: l1za83w1 nan Human security is a multidimensional concept that has been a cornerstone of Japanese development cooperation for more than a decade. At the heart of security is the idea of protection or insurance against downside risk. 1,2 Three distinct questions arise from the concept of human security. First, protection of what? Second, insurance against what? And, third, security for whom? The fi rst question relates to the specifi cation of what is to be protected. The defi nition of human security off ered by the Commission on Human Security 3 is: "to protect the vital core of all human lives in ways that enhance human freedoms and human fulfi lment". 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". 4 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 facesand how much above the threshold he or she is in the relevant dimension. 1 The extreme case of insecurity is certainty of being below a specifi ed threshold, and the absence of any chance of avoiding that fate. Threats to human security can arise, for example, from natural disasters and environmental catastrophessuch 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 fi nancial crisis of 1997-98; and from various other hazards that people face. 3, 5, 6 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 aff ected by health care and various other determinants-eg, socioeconomic, behavioural, continuing commitment. Otherwise, we risk alienating patients and damaging the therapeutic alliance. As part of the eradication eff ort, WHO requested that countries and laboratories either destroy the remainder of their stocks of variola, the causative agent of 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 fi nancial implications-that can aff ect 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 diff erent 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". 7 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. 3, [8] [9] [10] [11] 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. Department of Economics, University of Oxford, Oxford OX1 3UQ, UK sudhir.anand@economics.ox.ac.uk I declare that I have no confl icts of interest. The "impossible patient": organizational response to a clinical problem Long-term opioid contract use for chronic pain management in primary care practice: a fi ve year experience Contracting for safety with patients: clinical practice and forensic implications Contracts between patients and healthcare practitioners for improving patients' adherence to treatment, prevention and health promotion activities Limiting exposure to medical malpractice claims and defamatory cyber postings via patient contracts Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain Are no-suicide contracts eff ective in preventing suicide in suicidal patients seen by primary care physicians? 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