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Submitted by Anonymous on
Very interesting piece. I particularly enjoyed your call to try hard to establish what is needed health care and compare it to what is actually being delivered, 'cause "if we don't try", "we could go badly wrong". And as you pointed out, establishing what's needed in health is hard. I am particularly concerned with one of the many difficulties for doing so: dealing with people’s expectations. What UHC movement has to say about that? I’ll try to explain myself. Ok, so UHC is an old wine in a new bottle, right? After reading the blog I wanted to taste the wine in one of those older bottles, so I went to the wine cellar and took one of my favorites (this one, not so old though, the World Health Report 2000). Of course, a lot of ideas in the report are common to the UHC movement, so I will focus on the objectives where I think there may be a key variation. The report proposes three goals that are intrinsically valuable: i) responsiveness to people’s non-medical expectations, ii) fair financial contribution and iii) health as the primary and defining goal of any health system. UHC on the other hand propose three dimensions that, despite being sometimes misleading, encapsulate a concept that means “that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result”, which implies other goals such as equity or quality of care. And all that is a means to end: better health for all (with equity) and improved living standards. Now I wonder: How does the responsiveness goal fit into the UHC concept? What is the interplay between health needs and people’s expectations? Are people’s expectations partly defining what is needed?, or the need should be ‘objectively’ determined?, is it possible? I really do not know which countries have achieved the goal of UHC, but let’s assume a country achieves UHC when its health system provides coverage to all the population for the costs of accessing health care within a reasonable set of services, with reasonable quality of care, given the resources the society have allocated to health, and also, the functioning of the system succeeds in guaranteeing that everyone receives the care, as stipulated in the paper. What if the average waiting time to visit a specialist in a country that has achieved UHC is, say, 5 days (assume 5 days is medically appropriate), but the people find such time unacceptable and they want same-day appointments for specialist care? What if the system provides effective coverage for most services, but excludes aesthetical care and the population or a group of people, think that such treatments should be covered as well? Or, what if a country achieves UHC, but people dislike the service because it’s perceived as rude and unfriendly? The above are probably extreme examples, but I think several countries may be in similar situations; many countries have taken huge steps towards UHC, both on paper and in practice, but the health system is still perceived by the population as administratively cumbersome, ineffective or inhumane. As they put it in the World Health Report 2000 (p. 24): "The three goals are separable, as is often shown by people’s unhappiness with a system even when the health outcomes are satisfactory". This is something in which the new bottle is somehow obscuring rather than illuminating. I agree that getting more people interested in the wine is a good thing, but if the concept is not clear enough and do not appropriately address real concerns for many countries, it may become useless if not harmful. You started the blog entry saying that the concept of UHC has become so elusive, and although you make a huge contribution in clarifying the concept, it is still a long way to go!