Health care policy should not focus on finance, says research

Policy makers need to consider social and political sustainability

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Sustaining Universal Health Coverage: The Interaction of Social, Political, and Economic Sustainability
Elio Borgonovi, Amelia Compagni,
Value in Health, Volume 16, Issue 1, Supplement, January–February 2013, Pages S34-S38

In the midst of global economic challenges, policy makers often look to health care systems to find economic savings by cutting budgets. But if we want sustainable universal health care systems, focusing on financial budgets is not the way forward, say researchers: social and political sustainability are just as important.

A study published in Value in Health urges policy makers to take social and political factors into account when developing universal health care systems. Universal health care gives all people equal access to health care, regardless of how much money they have. The researchers say this is a human right, and governments need to shift their focus away from finance to provide it.

“Until now, discussions about universal health care have focused on economic sustainability; policy makers are concerned about how they’re going to pay for care,” said Professor Elio Borgonovi, lead author of the study from Bocconi University, Milan, Italy.

“We think there’s a problem with looking at it this way: what about the issue of getting political consensus, or making sure that all people – rich and poor – have equal access?”

For the study, the researchers looked at the current discussions around universal health care. They summarized and analyzed arguments about the economic, political and social factors affecting the development of universal health care, and looked at case studies around the world.

They concluded that considering financial sustainability alone is not enough to provide universal health care; social and political sustainability are just as important.

“There has been a real focus on economics in recent decades,” said Prof. Borgonovi. “Policy makers assume that getting the finances right means they will automatically reach political consensus and social equality, but we don’t agree. The three factors – economic, political and social – are connected, but they’re also independent, and they all need to be considered.”

Traditionally, health care systems have been managed using financial budgets as a basis for decisions about new hospitals, free services and treatments to offer. One of the challenges universal health care faces is an aging population: as more people have access to health care, they will live longer, requiring more treatment and therefore costing more.

However, the researchers say it’s not so simple: countries with universal health care, like the UK, often spend less on the system than countries without universal health care. Rather than focusing on the money, policy makers should think about the social aspect by involving patients in planning, and build political consensus without finance being a factor.

“I’m afraid that in this period of economic pressure, policy makers will miss out on the opportunity to create universal health care systems that survive in the long term,” said Prof. Borgonovi.

Health care is an industry based on knowledge, which has the potential to provide thousands of new jobs, and a much-needed boost to the economy. But that will only happen if policy takes a longer view, added Prof. Borgonovi.

“A strong health care system can provide new jobs and boost so many industries – pharma, biotechnology and informatics, for example – but we’ll miss out on this if policy makers continue to focus on the money.”


A conversation with Professor Elio Borgonovi

Universal health care is a hot topic of discussion around the world. But why is it important and what makes it so controversial? We talked to author Professor Elio Borgonovi to find out what he thinks policy makers should be doing differently.

In this podcast, Professor Elio Borgonovi from Bocconi University in Milan, Italy,talks about his research into the long-term sustainability of universal health care, and explains why focusing on finance alone could ultimately be bad for the economy.

Universal health care is part of the Millennium Development Goals; why is it economically important?
The aim is to guarantee health care as a human right. There is evidence that universal health care can be economically beneficial: in the US, where universal health care is not guaranteed, the total expenditure is about 17% of the GDP, while in continental Europe and in the UK, which do provide universal healthcare, the total private and public expenditure is between 9.2% and 12% of GDP.

Why is the sustainability of health care systems a matter of current discussion among policy makers and scholars?
Universal health care systems are controversial because scientific progress, and in particular the aging population, raise the problem of economic sustainability. There is a paradox that is not a paradox. Scientific progress enables us live longer: we can now deal with severe diseases that were not affordable in the past, which meant people passed away.
We started looking at this issue and we broadened our analysis. Until now the problem has been discussed only in terms of economic sustainability, while we are convinced that political sustainability is also important, because you need to have consensus in democracies. And you have also the problem of social sustainability; you cannot have people who can afford a high standard of health care and others who can only afford a very low level of health care.

Why has finance has been the main consideration when creating universal health care systems?
In the last few decades, economic issues have prevailed over other issues, on the assumption that if you guarantee economic sustainability, you can reach political consensus and manage social issues. We do not agree that this is true, because economic, social and political sustainability are three aspects that are in some way independent one from the other. Our aim with this paper was to clarify that you have to discuss and keep in mind the three dimensions of sustainability; there is not one dominant aspect.

Do you think there is an ideal approach to universal health care?
There is not only one approach. We are convinced that each country should have a different approach to the three dimensions. There is not one dominant or optimal model, as it is claimed in the economic literature, in which optimizing and maximizing efficiency and economic viability are the dominant aspects. We are convinced that as political and social issues are involved, you cannot have a standardized approach. We just need to be aware of these three dimensions.

Do you expect to see successful universal health care systems appear globally?
I’m not sure, because in this period of worldwide difficulties and systemic crises, I’m afraid that the solution will be just to give priority only to economic sustainability. The aim of our paper is to make policy makers aware that they also have to consider social and political sustainability, otherwise in the future they will have trouble managing society.

You published your paper in 2013, has anything changed since then?
I don’t think that things changed very strongly, I think that the issue is still on the table. There has been a little switch, to considering that maybe austerity is not the right solution, and so some investment in health care could be used as a driver for development.
Health care is a labor-intensive and knowledge-intensive sector. Because of that, it could be an industry that supports economic recovery and growth with jobs. So healthcare and universal coverage could be – and in our mind should be – used as a driver for a new type of economic recovery with jobs.

What’s next for your research?
Much more research is needed and at Bocconi University, we are involved in doing some research in the field of health technology assessment – an approach to economic evaluation that considers not only the economic impact but also the social impact of new approaches to cure and to care. We’re involved in highlighting the issue of using healthcare systems – and in particular universal healthcare systems – as a potential driver of a new economy.


About Value in Health


Published on behalf of the International Society for Pharmacoeconomics and Outcomes Research, Value in Health publishes research on the economics of health and health policy. It aims to provide valuable information for health care decision makers as well as the research community, helping them translate research into real health care decisions.


Further Reading

Evaluating the political and economic aspects of universal health care – part of a series from The Lancet

Universal health coverage challenges: exploring the case of India

The limitations of universal health care in improving reproductive health

Could privatization be the answer? In the US, privatizing care in three states had benefits, but not for the community

A call to action for universal health care in Latin America – the fourth article in a series from The Lancet

A paper commissioned by the World Health Organization to explore critical issues in health care systems research

Report from the US Congressional Budget Office on the long-term outlook for health care spending

Does investing in health care make people healthier? This paper challenges the view that health care only has a small impact on health

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