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Submitted by David Dror on
Adam, thanks for enlarging the debate. There are many points I concur with, which have been ably put so no need to repeat. There are a few that have been stated, which I think should be challenged, and have not yet been raised by others in this exchange. For one, you say that universal coverage exists already, to some measure, everywhere. Really? The reality that every person working at grassroots level at low income countries (and in some middle income ones as well) will confirm is that most people cannot get any service whatsoever under the existing schemes without some payment out-of-pocket. Payments may be for goods that are missing (e.g. drugs or perishables),or for services (e.g. tests and imaging) or for bribes that are de facto demanded for every access to any type of care, as well as indirect costs (e.g. interest on borrowed money to pay for the care, transportation, loss of income of care-giver etc). To describe this as a situation that universal coverage exists seems either an error or terribly cynical. I know you are not a cynic, and you rarely err. So, maybe a clarification on this very fundamental statement of facts is called for. The issue of funding precedes that of quality of care, or that of macroeconomic policy. Not that the other topics are unimportant - they are very important. However, the naked truth is that nobody wants to pay everything for everybody forever, and therefore everybody, even very poor, must pay something sometimes. At present, the very poor pay exorbitant prices for every kind of "protection" or "care". The case about "the unaffordability of free care" has already been made more than once. I would add that there is also the case that in most places in low-income settings, there is no market for health insurance, and a very dysfunctional market of health services. Governments most often bear the full responsibility for both, and expecting them to right the wrongs is perhaps naive, considering the huge flows of funds and the political interests involved. The main voices in this debate (WHO, WB) being governmental organizations sound to me too shy in pointing out those aspects. Painfully, the experience of more than 50 years suggests, indeed points, that governments are part of the problem rather than part of the solution, in all but very few exceptions. Would it not seem plausible that if governments cannot fix the basics (in part because the majority will not willingly transact with government-led schemes unless they must) and for/profit providers have not been keen to reach out to the large mass of poor in the informal sectors, maybe the time has come to look at other players that can provide at least some solution out of the box (both the UHC box and the conventional top-down thinking that prevails in this debate? I found no mention in your blog of the role of non/governmental and civil society players. Hopefully this comment might offer the opportunity to flag these basic points as well. Best and thanks