The goal of universal health coverage is not only to provide services to all in need but also to deliver services of the same quality level to all irrespective of the patient’s ability to pay. To achieve this goal, patients with means must be prohibited from accessing and purchasing services of higher quality. However, to my knowledge, no country has pursued, let alone achieved, equity to this level. For example, in England, the elite are able to access services of high quality and are not placed on a waiting list.
It should also be noted that doctors are not all equally competent. This fact is well known among doctors. The best doctors tend to practice in premier medical centres which are generally better equipped and are able to employ more support staff. These advantages make it possible for their doctors to further enhance their skills. Thus, the disparity among doctors is likely to increase, not decrease as their career advances.
Patients may not be aware of the above dynamics. However, they do infirm that some doctors are more competent than others. Moreover, from their perspective, there is also a less tangible, but equally important, benefit in being treated by a renowned doctor in a premier medical center. This is the “positional good” aspect of health services. The value and demand of some goods, such as a painting by Picasso, lies not only in its intrinsic value, but also in it being scarce. In health care, patients place value on being treated by a renowned doctor irrespective of the outcome.
The above aspect should be given due consideration in designing health care systems. Thus, the goal in health care reform should not be placed on delivering the same level of quality to all patients, but to minimize the disparity that exists. This goal will become even more important in the future because both the income disparity among patients and the concentration of medical resources to the premier medical centres are likely to increase. I believe this would lead to lengthening waiting lists in high-income countries, and even more crowded hospitals in low-income countries. Recognizing this fact should be the starting point of any health care reform.
Reference
Ikegami, Naoki, ed. Universal Coverage for Inclusive and Sustainable Development: Lessons from Japan. World Bank Study. Washington, DC: International Bank for Reconstruction and Development / The World Bank, 2014.
Ikegami, Naoki. “Fee-for-Service Payment – An Evil Practice That Must Be Stamped Out?” International Journal of Health Policy and Management 4, no. 2 (2015): 57-59.
About the author
Naoki Ikegami is Professor Emeritus at Keio University, Tokyo. He was Chair of the Department of Health Policy and Management at the Keio School of Medicine, from which he received his MD and PhD. He also received a Master of Arts with Distinction in health services studies from Leeds University (United Kingdom). He has been a visiting professor at the University of Pennsylvania’s Wharton School and Medical School, and President of the Japan Society of Healthcare Administration and the Japan Health Economics Association.
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