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).
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