Life and death in Asia and Africa

How universal health care can be implemented everywhere

Over the past years I have attended a large number of conferences and public lectures. It occurred to me that much of what one learns in this way is lost again, because we fail to learn meaningfully (in the sense used by Joe Novak of IHMC) and organizers tend to ignore the need for providing concise and meaningful overviews of what was presented and discussed once the event has taken place. ‘Meaningful’ here means that conceptual linkages are made between different bits of information to turn the presented material into a higher form of knowledge. This ‘concept mapping’ is hardly ever perfect, but it generally allows for a structured comprehensiveness that is hard to achieve otherwise. Below is my attempt to restructure a lecture by Amartya Sen on the prospects and potential of universal health care in the global South, a very important subject.

Amartya Sen       A few days ago (10 March) Nobel laureate Amartya Sen delivered the Annual Lecture 2015 (video) of the International Institute for Asian Studies (IIAS, Leiden University) on the issue of universal health care. I only knew Sen as the author of ‘Development as freedom’, which is about the need for agency by the world’s poor as a precondition for development, a very good point. As a reader I also knew Rabindranath Tagore, the first Asian Nobel laureate and the one who gave Sen his unique first name Amartya. Both hail from Bengal, the largest province in the British Raj. A month ago, Sen received the Charleston-EFG John Maynard Keynes Prize for his work in welfare economics. I think that’s funny, because I just thought that Sen’s book on freedom  or his lecture on universal health care could well have benefited of the same subtitle as Schumacher’s ‘Small is beautiful’, viz. ‘Economics [or development] as if [poor] people [‘s health] mattered.’ And Schumacher, after his escape from Nazi Germany in the ’30s, was released from jail by Keynes. Keynes, Sen, Schumacher show how to combine values and economics, which is good in this age of unadulterated neo-liberalism.

Amartya Sen speech IIAS

Welfare economics       … underpins public economics. It looks in particuar at the equity and efficiency of government policies. Welfare economics has shown that health care has some characteristics of a collective good, which means that the private sector may have difficulties providing it efficiently. This ‘problem’ is a key notion in welfare economics, because it justifies alternative approaches that involve public government. The mechanism involved is a simple one. Because private health care suffers from information asymmetry (i.e. doctors knowing vastly more than their ‘clients’), market competition is imperfect and the usual efficiency cannot be achieved. The same applies to health insurance providers. Sen explains this in both his lecture and a recent article of the ‘long read’ variety in The Guardian (link).

Universal health care     … treats health care as a collective good and is therefore a much better option than private health care from a welfare economics point of view. It works in the West and a few other places (Japan, South-Korea, Taiwan, Singapore). The question is: can it work in the global South? Sen provides examples from the South to indicate that it can. He also explains how such as thing is possible. In the Netherlands the rising cost of health care over the past years has become a political problem of great concern, both to the government and the citizens it asks to pay for it. But that’s a slightly different story. Sen points out that health care is a labour-intensive industry. Since wages in the South are much lower than in the North, universal health care may be much more feasible than one might think off-hand.

Basic universal health care     … remedies only the most easily curable diseases (1), mostly as ‘cheap’ out-patient care. It also prevents a large number of avoidable ailments. It does do by immunization (2), preferably at 100% coverage, and effective epidemic control (3). Investments in unversal health also enhance social and economic opportunities, which reduce inquality, which in turn may (4) improve the social determinants of health. These four intervention types strongly reduce the need for much more expensive in-patient care. They also increase labour productivity, which may accelerate economic growth. It is important to make sure that basic universal health care is provided efficiently, against the lowest possible cost, and by means of a well-organized health sector. Only then can it be implemented throughout Africa and Asia, two continents that represent 79% of the world population and the quasi-totality of the world’s poor.

Universal literacy as a complement    … cannot be underestimated as to its importance. It works in several ways: (1) it helps people live healthier lives; (2) it enhances the effectiveness of health care; (3) it increases labour productivity even more (skills!); and (4) it reduces the information asymmetry. Within the home, women are the main care providers. This means that if literacy is indeed universal enough to cover all women, the chances are that these women will help all the people in their care to live healthier lives, too. A double whopper, so to speak. Experiences from the West point to the importance of literacy, too.

Experiences from the South   …. include Thailand, Rwanda, Bangladesh, China, and India. Thailand introduced a low-cost universal coverage system in 2001. It minimized infant and child mortality levels, while boosting life expectancy. In that period Rwanda conducted an inclusive health system pilot, which it upscaled to cover the entire nation in 2004/2005. This doubled life expectancy (see also Paul E. Farmer, who teaches comparative health systems). In Bangladesh, with NGO support, women were systematically involved in health and education provision. Health indicators improved significantly and, very important in such a densely populated country, fertility rates went down to 2.2, very close to the replacement rate of 2.1.

Experiences from China and India   …. are very interesting, too: China seesawed, whereas India shows only patchy progress until now. China had 100% coverage in 1978, the year when the responsibility system was introduced. This new system worked well for agriculture, but played havoc on health coverage, which dropped to 12% in 1981. Only by 2004 it was recognized that this was a big mistake and in 2014 coverage was back up at 97% of the population. India shows progress in some states (Kerala, Tamil Nadu, Himachal Pradesh), but stagnation almost everywhere else. The federal government seems to lack the will to address the issue, with a public expenditure on health of only 1.2%, while 3% is the minimum. Kerala was the first state to start universal coverage, jointly with universal literacy. At the time (around 1960), Kerala was one of the poorest states. Today it is one the wealthiest.

That was Amarthy Sen´s compelling story, in a bit over 1000 words (estimated reading time: 6 minutes, the core of it less than 4 minutes). It changed my ideas about universal coverage. I forgot to mention that addressing inequality is also a key value. Nor did I mention the need to invest in human capital (as did Milton Friedman in the ealy 1960s in India). Perhaps I should also have mentioned this other public good economist, Paul Samuelson. It seems to me that the introduction of universal coverage is not without its complexities. It made me wonder if learning between countries could not be enormously enhanced by taking that complexity into account using a systems approach. 


About Sjon van ’t Hof

Development professional who worked in rural development, tropical agriculture, and irrigation development in Chad, Zambia, Mali, Ghana, Mauritania, Israel, Burkina Faso, Niger, and the Netherlands in capacities ranging from project design and management to information management. Conducted missions to India, China, Kenya, and Bangladesh. Experience in the development and delivery of trainings in irrigation equipment selection, information literacy, Internet searching and database searching. Explores systems thinking in relation to international development, education, and management, with an ever stronger focus on the systems approach of C. West Churchman. Knowledgeable in tropical agriculture, project design and development economics, agricultural mechanization, irrigation, plant pathology, environmental degradation and protection, rural development. Co-authored "Wicked Solutions: a systems approach to complex problems", a book written by Bob Williams and Sjon van 't Hof. It was published in June 2014 and provides a practical way of dealing with wicked problems. Wicked problems are complex, ill-structured, human problem situations. This book will help you design an inquiry and intervention in such messy, wicked situations. It does so by guiding you through the steps and stages of a systemic process that addresses your own wicked problem. For more information, see or
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