Economic Viewpoint Universality: A Failed Ideal? In the international health policy arena, a lively debate exists between proponents of universal versus targeted approaches to health care. Those who advocate universality claim the poor are best served when they have equal access to a national health service financed through progressive general taxation. Proponents of this approach maintain – with strong conviction – that in the case of health care, need should be the principal criteria for equitable financing and access, not ability or willingness to pay. They point out that providing the whole population with access to a uniform health service is the only way to avoid a two tiered health care system in which the rich and poor have access to different levels of care. Furthermore, they say that such a system avoids the social stigma associated with having to means test the poor. In the OECD, 12 countries have achieved universal access through such a national health services approach to health care financing and service delivery, while many of the other countries offer the same benefits through a national social health insurance type of arrangement. Among the OECD countries, only Mexico, Turkey, and the US still fail to provide universal coverage for full range of health care services for their population. Many developing countries have tried to follow a similar path. Most have failed. Why? First, at low-income levels financial resources available through the public sector are extremely limited. It is hard to collect taxes from poor rural and informal sector workers. People with limited income are often reluctant to contribute to an insurance program where the benefits they will receive may not materialize until some distant point of time. Lack of quality and trust in government run programs compound this problem. Second, countries that have tried to cover health care for their whole population end up spreading scarce public resources so thinly across a large population that no one gets much of anything. Since many health needs require interventions beyond those that are affordable when offered to the whole population, most people – including the poor – end up seeking at least some care outside the supposed universally available public system. The fact that 80 percent of health care spending in many low-income countries is out-of-pocket indicates just how inadequate this approach really is. An alternative approach is to spend more public money on the poor who need subsidies the most and less on those who do not. Every dollar spent on care for people who could afford to contribute is a dollar not spent on the poor. With money freed up in this way, the poor can be offered more adequate services that extend beyond minimal basic care, decreasing their need to buy these themselves from private providers. Improved targeting can be achieved in several ways: (a) focusing scarce public resources on poor individuals or households; (b) allocating resources preferentially to poor regions within a country or on population groups that are particularly vulnerable to poverty; (c) emphasizing health, nutrition, and reproductive services used by the poor; and (d) giving greater attention to health care providers that serve the poor. Countries can still include the non poor in their public policies by supporting the establishment of contributory health insurance or some other forms of prepayment programs so that the health needs of those that can afford to pay are also dealt with in a responsible way but without diverting scarce public resources from the poor. The poor may be best served when such pragmatism prevails over lofty ideals about universality. |
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