From a Utilitarian Universal Health Coverage to an Inclusive Health Coverage
Healthcare systems vary across countries, but the access to health is considered fundamental both individually and collectively. Individually, good health is one of the main contributors to well-being, and collectively it has an important effect on countries’ productivity. From a utilitarian perspective, governmental intervention in health coverage has the purpose to maximize the total “utility,” in this case the total welfare, of all the members of society. Health services must therefore be produced and allocated efficiently and distributed in accordance to equity. This approach gave origin to the so-called “universal” healthcare systems, in trying to provide healthcare for as many members of a community as possible. Such systems can be considered inclusive insofar they try not to leave anyone out of coverage, but their implementation is not free of criticism. One of the limitations is that they tend to provide the same level of coverage for everyone, regardless of their differing characteristics, circumstances, and needs. This also means that some health issues will not be covered by the public health system, and if patients need specialized attention, they will need to use private health provision, with the subsequent exclusion of those without enough resources. It is for this reason that healthcare systems are evolving to become “inclusive” in a different manner, away from the “one size fits all” approach covering only basic minimum health services, and aiming to provide different services to people with different needs, including giving access to health to the poorest of society.
Healthcare Systems: From Universal to Inclusive
The expenditure in healthcare by different countries is source of agitated political debates. In the United States (US), the expenditure is increasing to worrying proportions overtime, reaching 17% of the economy in 2013 (Dieleman et al. 2016), while at the same time, less proportion of the population has health insurance. The country has the highest proportion of population having to recur to private health insurance (55.3%), compared to other high-income countries (Papanicolas et al. 2018). The press has recently echoed the controversy created by the election of Donald Trump and his attempts to repeal Barak Obama’s Affordable Care Act (Walters 2017) fearing a decrease in the access to healthcare by the poorest population groups. In the United Kingdom (UK) meanwhile, the funding of the NHS (National Health System) is recurrently in the news. Expenditure has been increasing overtime (Cooper 2017) but in very small proportion compared to previous decades and below the levels of other developed countries (Stoye 2017). Criticism of the system is growing, with a perception of a “postcode lottery” with regard to access to care in particular areas such as dementia or diabetes, depending on which local authority patients belong to (The Guardian 2016). There is a general recognition that the system is under strain, particularly due to aging population and the cost of new technologies, though depending on which measurement definition is being used, the UK is not performing so badly compared to peer countries as traditional reports suggest (Neville 2017).
In developing countries, the issue of lack of access to healthcare becomes even more striking, as it is in these countries where the highest proportion of maternal mortality rates, deaths of newborns and children under the age of 5, or lack of access to vaccination and medicines concentrate (UN 2017). It is also in these less developed countries where the access to healthcare becomes more unequal, with the poorest of society less likely to receive effective healthcare than the better off (O’Donnell 2007). Progress has been made in many countries, but lack of resources seems to be a constant barrier, with governance and regulatory issues at play in order to ensure an inclusive access to health services (Perlingeiro 2014; Kelsall and Heng 2016).
In the following sections, it will be explored to which extent the issues, public debate, and changes around health coverage are related to the understanding of a health system as utilitarian and universal or inclusive.
Utilitarian View of Healthcare
Utilitarianism is an ethical theory according to which “the morally right action is the action that produces the most good” (Driver 2014), so an action is measured in terms of the consequences it produces. The classical understanding of utilitarianism also includes the characteristics of impartiality and agent-neutrality and the purpose of maximizing the overall good – the good of others and one’s good (Driver 2014). Under these premises, it has been traditionally argued that intervention and public health systems are rooted in utilitarian principles, but there are also arguments against this view (Bellefleur and Keeling 2016). The utilitarian framework is used in this paper due to its historically wide use and acceptance as philosophical ground for healthcare. Alternative approaches have also been discussed by the literature (Stein 2012) but reaching the conclusion that, for instance, the use of egalitarianism instead of utilitarianism for the allocation of healthcare yields results that are not plausible. More recently, some authors (Crisp 2017; Donaldson 2017) have discussed a Kantian approach, arguing that healthcare should not be taken as a right but as a duty, providing arguments for a universal healthcare system (Crisp 2017). It is left to the reader to decide if the universal view of healthcare portrayed in this paper is consistent with the Kantian view or not.
In order to understand what does this have to do with healthcare, we need to look at the characteristics of healthcare as a good or service and decide if it can be provided by the market like other goods such as clothes or food. One of those characteristics is the uncertainty about its demand (Le Grand et al. 2008), since a priori, no country can know how many people are going to be sick, nor when, for how long, or the severity of that sickness. Another characteristic, linked to the first one, is the imperfect information about the consumer of healthcare (Le Grand et al. 2008). Until a patient seeks medical attention and receives treatment, they usually do not have information about what may be wrong with them, and since some sicknesses or accidents may only occur once, there is no opportunity for patients to “learn” what to do in the future. Another very important characteristic of healthcare is that it provides external benefits, externalities (Le Grand et al. 2008). The most common example is vaccination, since it provides protection for the person that receives the vaccine, and it reduces the probability of those around that person to get the same disease (Perman et al. 2011).
These characteristics would make the provision of healthcare by the market to fail and justify governments’ intervention in the design of health policies and the provision of public health systems. Furthermore, private markets are mainly driven by efficiency in the allocation of resources (i.e., maximize production with the limited resources available, produce the optimal combination of goods given the available technology and consumer tastes, and maximize people’s utility when consuming those goods – which is linked to the utilitarianism point of view) (Barr 2012). But with healthcare, the idea is to combine efficiency with criteria of equity or fairness (Barr 2012; Le Grand et al. 2008). And here the next area of controversy is found: What is considered fair and equitable with regard to the provision and coverage of healthcare?
There are several ways in which equitable provision of healthcare can be defined. One possibility is in terms of a minimum standard, which would involve that “all citizens should be entitled to some minimum level of treatment if in need” (Le Grand et al. 2008). But this creates a further problem: What is it going to be included in that “minimum”? What is the reach of the “coverage”?
A second possibility is linked to the broader objective of “full equality,” under which, and as it has been previously mentioned, equal treatment should be provided for equal need (Le Grand et al. 2008). In plain terms this second approach would involve that there should not be distinction or discrimination in the provision of care based on the geographical location of the patient. The “postcode lottery” issue mentioned for the UK is an example of this not being achieved, but it is not a unique case. In Spain, children vaccination is not compulsory but recommended, and the provision of free vaccines depends on the criteria of each autonomous region, based almost entirely on the priority given to the funds they have available (Sevillano 2015). The opportunity for equal treatment is also hindered by limited access to health in rural or remote areas (Chan et al. 2006; Wang and Luo 2005), which is true for developed and less developed countries. In the case of less developed countries, the issues associated with the difficulty to retain health personnel in remote or rural areas become more acute (Lehmann et al. 2008).
A third approach defines equity in terms of “equality of access,” which is also open to interpretation. One suggestion is to look at it in terms of the “costs or sacrifices” that people make to get medical care, which may include fees or charges, money lost through time off work, cost of travelling, etc. It becomes apparent that these costs will be different for everybody (as the example of the rural areas aforementioned shows), so this will be indicative of inequality of access, as it does not cost the same to everybody to access healthcare (Le Grand et al. 2008).
It can be argued that the three interpretations of equity are necessary in order to reach a universal healthcare system. ‘Universal health coverage means that all people are able to receive needed health services of sufficient quality to be effective, without fear that the use of those services would expose the user to financial hardship’ (Kutzin and Sparkes 2016, p. 2, italics by the author). It is debatable that the utilitarian approach is sufficient to cover all the complex aspects of healthcare underlined by this definition.
The universality of health coverage is one of the targets of SDG 3 (ensure healthy lives and promote well-being for all at all ages). Specifically, target 3.8 includes, as part of universal health coverage: “financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all” (UN 2015). This recognition of health as a key instrument to achieve sustainable development goals appeared as necessary in order to prevent the loss of the progress made with the Millennium Development Goals, but it also emerged as a criticism to the short-term reach of those goals, as well as their narrow focus on disease-specific approaches (Ticheron and Sridhar 2017).
The issues identified in this section make it necessary to explore to which extent the limitations of the utilitarian approach have contributed to the deficiencies and challenges affecting healthcare systems nowadays, so that a path toward a truly universal and inclusive health system can be achieved in the coming future.
Criticisms of Utilitarian Views of Healthcare
Utilitarianism as an ethical theory would be against the concentration of power and resources in the hands of a minority, so in this regard, it would have distributive implications from the richer to the poorer (Bellefleur and Keeling 2016), which would be generally perceived as something positive. More controversial is the justification, under utilitarian views, that in order to protect the collective good, it would be morally right to infringe on individual preferences. This is considered as both a strength and weakness of the theory. The criticism comes from the fact that under that rule, it would be justified, for instance, that a minority could be oppressed if this increases the utility of the majority (Bellefleur and Keeling 2016). This raises questions over rights, fairness, and social justice.
Utilitarian approaches also make it necessary to define and measure harm and benefit, which for healthcare becomes extremely complex. Even if only one individual is considered, the weight of the distribution of harm and benefit over a lifetime would be difficult to calculate. Is it preferable to have a period of pain followed by a period of happiness or vice versa? If the public health policy for a community is to be considered, how are benefits quantified and how can it be ensured that they outweigh the harm? (Hann and Peckham 2010).
Additional criticism emerges when looking at the principles of justice to make decisions over healthcare priority-setting or “rationing,” acknowledging that there are limited resources that can be dedicated to health services. The three main principles are need principles, maximizing principles, and egalitarian principles (Cookson and Dolan 2000). Different authors recommend the application of different principles, with the maximizing ones being rooted in the utilitarian theory. However, it becomes apparent that the preference of the public is a combination of the three types of principles, as each of them separately would have limitations to provide the right level of care (Cookson and Dolan 2000). This conclusion is consistent, for instance, with the need to apply the different approaches to equity in a joint manner, in order to capture in full all the complexities of the concept.
The maximization principle has been taken to the extreme of developing economic valuation tools in order to measure the efficacy of the healthcare, so that the cost of a health intervention can be weighed against the utility it creates (Bellefleur and Keeling 2016). One of such tools is the quality-adjusted life years (QALY) index. On a positive note, a common measure of health outcomes allows for comparisons between different areas of healthcare. QALY includes a measure of the health intervention on the patients’ length of life but also on their health-related quality of life. QALY informs both clinicians and health economists in the evaluation of treatment options. The QALY index would be the “health outcome,” obtained through the arithmetic product of quantity and quality of life (Kind et al. 2009). The criticisms of this tool come from the fact that it is limited in terms of the health benefits that it can capture and it does not account for equity considerations (Whitehead and Ali 2010). However, this kind of tool is widely used to decide which type of drugs would be supplied by the public health system of a country or which interventions (for which diseases) would be offered as a minimum care coverage.
This utilitarian and maximizing approach has other limitations. The focus on the economic value of which interventions to decide if benefits outweigh the costs is mostly based on how much a patient who receives a particular health service would see his/her life improved (in years and quality) in such a way that can be economically productive for the society. Such approach is implicitly biased toward those citizens of younger and working age, generally fit, and seems to give less weight to the needs of the elderly, disabled, or chronically ill (Cohen-Almagor 2002). One could question if it is ethically or morally right to prioritize citizens’ healthcare needs ranking citizens based on their possibility to contribute economically. However, even from a more objective point of view, it can also be argued that medically speaking, there are other factors, and not only age, determining someone’s health. Morally, the argument would say that a “liberal society should not desert its citizens at the time they need its help most” (Cohen-Almagor 2002).
Bearing in mind all the abovementioned limitations and criticisms, it can be argued that a utilitarian approach to healthcare is narrow-minded and undermines its originally stated purpose of getting universal healthcare coverage. Healthcare is not a typical good or service that can be studied from a purely market perspective.
Health as a Public or Common Good
The Constitution of the World Health Organization (WHO) in 1946 established health as “one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition,” and many other international forums have qualified health as a right ever since (WHO 2008). However, while there is a generalized recognition of health as a moral right, there is still some who question if it should be considered a legal right (Maruthappu et al. 2013), among other reasons, because it is dependent on the availability of resources of a society, as it has been highlighted in previous sections.
The dependence of health provision on the availability of financial resources takes us back to the characteristics of health as a good. A generic classification of goods distinguishes between private and public goods. Goods are considered private if they have the characteristics of excludability (my consumption would prevent someone else from consumption) and rivalry (my use of a good diminishes someone else’s ability to use it). If the opposite is true, i.e., they are non-excludable and non-rival, goods will be classified as public goods. However, goods are complex and can be classified according to different sets of characteristics or have characteristics of different types of goods. Based on excludability and rivalry, an additional classification distinguishes between common resources or common goods, when goods are rival but non-excludable, and club goods, if they are excludable but non-rival (Mankiw and Taylor 2017). Common and club goods are considered, through this lense, as “quasi-public goods.” Where does health fit? The short answer is: it depends. It depends on what aspect of health we are talking about.
Some experts consider “health,” “the science of health,” or “healthcare” as a public good (Karsten 1995; Fried 2017). Some others refine the expression to consider “public health” or “universal health insurance.” There is not much precision in the use of terms, but this is due to health being multifaceted. Universal health insurance is seen as a common good by many (The Economist 2009; Stein and Sridhar 2017). If we add that health-related issues can have an international dimension (for instance, diseases spreading across countries), a new term appears. Health would become a Global Public Good (Woodward and Smith n.d.). Preparedness for a pandemic, in this sense, would be a public good where international cooperation is required (Stein and Sridhar 2017). So global public goods would be a particular case of public good with quasi-universal benefits in terms of countries (more than one), people (over several population groups), and generations (extending to both current and future generations) (UNDP 1999).
There is confusion around how to classify health or healthcare because there are arguments against it being considered a public good in the first place. “One person’s or country’s health status is a private good insofar he/she/it is the primary beneficiary of it;[…] health is also often rival and excludable between individuals and nations” (Woodward and Smith n.d.). But health also has important externality effects that would allow it to be conceptualized as a global common good: The first aspect is the prevention or containment of certain communicable diseases such as HIV/AIDS or tuberculosis. The second aspect is the wider positive economic externality effects (Woodward and Smith n.d.), in the sense that even if the effects of ill-health may appear private, the cumulative effect in the economy of a particular area would result in loss of both production and income. Health improvements would provide potential gain for the economy as a whole.
The classification of something as global has further implications. Policy areas that used to belong to the exclusive domain of national governments are now discussed internationally (UNDP 1999). Health is one of them, but it is also the case for employment, poverty, equity, or social cohesion, being understood that policy-making is still not appropriately equipped to handle global public goods issues (Kaul et al. 1999).
In any case, despite the progress on international cooperation about health in recent times, policy issues are still decided in the domestic sphere. This means that even with the widely accepted idea that people should not be deprived from the access to health services if they cannot pay, as it would be morally wrong (Karsten 1995), there is controversy as to who should provide health services and how should healthcare be paid for. How, under the limited availability of resources, can societies achieve universal and inclusive healthcare systems?
Inclusive Healthcare Systems
Safe drinking water and adequate sanitation
Adequate nutrition and housing
Healthy working and environmental conditions
Health-related education and information
Looking at this list, it could be argued that for a healthcare system to be inclusive, it cannot be limited to the treatment of diseases when they appear. It requires preventive action, but not only from governments, through regulations, standards, monitoring, or direct intervention. Every sector of society needs to be involved: Specific business sectors such as food and drink, or construction, appear as obvious examples from the list above. But everyone would be responsible for healthy working conditions (a private employer, the government as employers, and individuals who work self-employed, but also the employees). So an inclusive healthcare system will have an influence on many aspects of people’s lifestyle because it will be implemented not by one but by multiple actors.
However, the access to healthcare keep focusing the interest of governments and academics, particularly in developed countries, as many of the points of the list are in some cases taken for granted (such as safe drinking water and adequate sanitation), or taken care of through other areas of well-established welfare systems (such as education or working conditions). It becomes apparent that something is failing in those “taken for granted” areas, when most developed countries have worrying levels of obesity (Bleich et al. 2008).
With regard to the access to healthcare, the controversy keeps centered on who should provide healthcare: Should health provision be private or public?
There are several models that countries have been applying overtime, which can be used to classify healthcare provision and health policies: In the Beveridge model, there is public control of healthcare provision, and healthcare is available to patients for free, with the government paying for the service through tax revenues. This is the system of countries like the UK (Bhattacharya et al. 2014). Canada has also been included as example of the Beveridge model (Bhattacharya et al. 2014), but other authors (Barr 2012) include this country as part of another system, of public financing with private production. In the opposite side of the spectrum, we find the so-called American model, unique to the USA, where there is private financing and private production of healthcare. Here private markets have a central role, and both health insurance and hospitals are dominated by private companies (Bhattacharya et al. 2014; Barr 2012).
The Bismark model can be considered an intermediate system, where there is universal health insurance with private providers but heavy public regulation through price controls. France and Germany are examples of this approach (Bhattacharya et al. 2014).
Health service provision-oriented type (high number of service providers and free access to doctors)
Universal coverage-controlled access type (healthcare provision as social citizenship right, with equal access to healthcare given more importance than free access or freedom of choice)
Low budget-restricted access type (access to healthcare restricted by high out-of-pocket payments)
It becomes apparent that the first two types would be more inclusive than the third one, in a similar way that the Beveridge or Bismark models would be more inclusive than the American one, as the criteria of equity seems to be left out, and those with less economic resources would struggle to get the access to the health services they may need.
But the role of the private sector in the provision of healthcare can also be looked through other lenses. Some researchers have started looking at private provision as a complement to public provision in order to reach an element of competitiveness and prevent problems with the so-called health tourism (Medhekar 2014). In the USA, however, the relationship between public and private sectors in healthcare seems to be perceived as collaborative and contributing to expand health coverage, though there is controversy around the fact that public funding can be supporting private business which can be more focused on their own financial interests over those of the patients (Field 2015). The reforms in the health system of the USA are considered positive insofar they are thought to expand inclusion and coverage, even if implementation may result complex due to multilevel institutional interactions (Beland et al. 2014).
In addition to all the domestic aspects of healthcare systems, several areas of this text have made reference to their international dimension. And this is not only true for aspects such us health tourism or the transmission of diseases across countries. The access to health services is not limited to the citizens born within the borders of a country, and migrants of different conditions may require access to health services at some point in time. Inclusive health systems would require no discrimination over these patients, and depending on the mode of entitlement, this may not always be guaranteed. Some researchers (de Freitas and Martin 2015) advocate public participation in the healthcare decision-making process which includes also migrants and ethnic minorities, as a means to achieve more responsive policies, better services, and, ultimately, healthier populations. Notwithstanding the different stages of development in which healthcare services of different countries are, this suggestion seems to go in the right direction toward better and more inclusive health services in the future.
The access to healthcare and the provision of healthcare services seem to be at a turning point. The importance of good health at individual and collective level has elevated the debate to international forums, and health is recognized as a global good that requires international cooperation. Healthcare coverage can no longer be considered from a utilitarian point of view, in terms of the economic benefits that good health may bring. Where less accessible systems are the rule, attempts of reform have encountered resistance from those used to the status quo, but there is no denial that changes are required. Inclusive healthcare systems for the future, which contribute to sustainable development, need to be integrated and target not only the access to healthcare but the rest of factors that contribute to a healthy life. They need to be inclusive in an ample sense of the word, not only caring for those in the lower-income spectrum of their borders but also for those that may need help when coming from other countries. Our globalized world will require new approaches to healthcare: While equity and justice aspects are widely recognized, the lack of sufficient funds to care for everyone keeps being the biggest issue policymakers have to deal with.
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