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Ethics, values and health systems

Patricio V. Marquez's picture

It’s widely accepted nowadays that the ultimate goals of a health system are to improve the health conditions of the population; minimize the risk of impoverishment due to catastrophic health events; and increase the level of satisfaction of the citizens of a country with the quality of services received.

What kind of health system needs to be developed to achieve these goals?

Professor Uwe E. Reinhardt, a distinguished Princeton University health economist, urges us to focus on broader social goals, including the distributive ethic or moral values in a country.   In essence, this means that the “structural parameters” of a health system—financing health care, risk pooling to protect individuals from the cost of illness, producing and delivering health services, purchasing or commissioning health care on behalf of patients, stewardship and governance, and production and distribution of health care resources--should be determined by the shared ethic or moral values in a society.

As Professor Reinhardt points out, alternative “distributive social ethics” or “moral values” may offer three broad health care organization models to choose from:  (i) a one-tier system, where health care is a social good available to all on equal terms; (ii) a two-tiered system, where health care is a social good for all with exception of the rich; and (iii) a multi-tiered system, where health care is a private consumption good like other services such as food and housing.

So which one of these models should governments adopt, adapt and develop? Which model should international organizations recommend as part of policy dialogue with governments? Is there an appropriate “government” versus “private market” combination that should prevail in a health system?

These questions perhaps are not very relevant for policy making or to ensure efficient allocation and use of scare resources since we may run the risk of confusing “means” with “goals”.  What is needed first is a better articulation and definition of a country’s social goals.

These debates have been taking place across the world:  For example, in the United States, around the  mandate that requires everyone to purchase health insurance to prevent healthy people from opting out; in Russia, around how to protect people from the impoverishing impact of out-of-pocket expenditures for medications; and in South Africa, on a proposed new health insurance scheme.

It is clear from these debates that how a health system is structured reflects decisions on what kind of society a country wants to have.

We have to be mindful that the definition of broad social goals ultimately guide policy and institutional decisions concerning the most appropriate and contextually relevant organizational forms, health care financing arrangements, and service delivery mechanisms that could be adopted to attain the intermediate goals of a health system (improved access, quality, efficiency, and fairness), which contribute to achievement of the ultimate goals of a health system (improved health status, financial protection, and patient satisfaction with health care received). 

Spiraling Drug Prices Empty Russian Pockets

Ideas and Ideals: Ethical Basis of Health Reform in Mexico

Better Outcomes Through Health Reforms in the Russian Federation (pdf)


Submitted by Adanna on
very interesting read.. i think the ideal scenario would obviously be the case where every citizen has the best possible health outcome, is satisfied with health care provided, protected from financial risk by a system that is sensitive to his needs. Some have come close e.g. the United Kingdom. However, there will be trade-offs that sometimes are not only a reflection of the underlying socialist versus individualistic themes, but gross limitations in resources available for health making it difficult for the public sector to play the preferred central and regulatory role. In the end therefore, I believe that in many cases, it comes down to the issue surrounding mobilization of resources, especially domestic, for health.

Submitted by Patricio Marquez on
Resource limitations, not only financial but infrastructure, technological, and human, certainly contribute to the shaping of the structural parameters of a health system. But as shown by different country experiences across the world, those countries that have adopted effective policies and allocated required resources to offer universal social health insurance or access to health services, have done so by establishing clear priorities around social inclusion considerations. The 1941 Beveridge Report that lead to the establishment of the UK's NHS that you mentioned in your comment, was structured around ways to address the "giants evils" in society: squalor, ignorance, want, idleness and disease. More recently, the Seguro Popular initiative in Mexico, that has expanded health insurance protection since 2003 to about 50 million beneficiaries, was designed around strong ethical considerations that paved the way for achieving political agreements and decisions at the highest level of government as well as to mobilize the required resources to operationalize it (see related article at the end of the blog by Frenk and Gomez-Dantes).

Submitted by Varadarajan Atur on
Very interesting and timely viewpoint. I thought I would find some clues or leads about how the three options play out in different country contexts (sans politics) but the article abruptly ended. How economics can relate to ehtics and values would be interesting in the context of health, social justice, gender equality, etc. Thank you.

Submitted by Patricio Marquez on
In my previous reply to the comment posted by Adanna (see above), I put forward the examples of the UK and more recently of the ethical framework that guided design of the Seguro Popular initiative in Mexico. More recently, this dilemma was vividly illustrated during the “back and forth” debate prior to the approval of the Affordable Care Act in the United States in 2009, concerning some of its key “social goals” provisions such as the requirement for health insurance companies to offer policies to everyone irrespective of his or her health status, the mandate that requires everyone to purchase insurance to prevent healthy people from opting out, and the provision of subsidies to keep health insurance affordable for the poor.

Submitted by Maria on
Thanks a lot for this post. We have already (empirically) demonstrated that there are social inequalities in health. Now, the question is: do we consider these differences unjust or unfair? In order to make that judgment, we do need an ethical framework, a set of broader goals, regardless available resources.

Submitted by Patricio Marquez on
Your point is right on the mark. And it could be added that a clear definion of social goals would also help us determine if a health system is efficient or not as well. As argued by Prof. Reinhart, if “efficiency” means reaching a goal with the minimum expenditure of real resources,then we will be able to determine whether a health system is “efficient” by knowing the ethical goals the system is to reach.

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