By Meghan Bruce Kumar

I spent several days last week attending the International Health Economics Association’s biennial congress in Boston, USA.  Aside from being a great place to enjoy the company of my delightful brother and his family, who live there, it was also a chance for me to reflect on other perspectives that sometimes get lost in the disciplinary bubble in which I find myself.

Much of the time during this meeting, I was reminded of my MSc course on Health Policy, Planning and Financing. By design, the course is spread between two institutions, the London School of Hygiene and Tropical Medicine and the London School of Economics. Ostensibly, this gives the student the benefit of these two institutions: diverse areas of expertise, networks of alumni, and of course perspectives on global health issues.  In reality, it often felt like being in the middle of a great debate about whether equity and epidemiology or financing and utilization were more important considerations in shaping health systems.  More broadly, this reflects fundamental beliefs about whether individuals combine to shape the system (bottom-up) or whether the system will determine the outcomes (top-down).

That feeling aside, a few things that stood out for me from the conference:

1. Defining Universal Health Coverage (UHC) is a question that is dealt with on a national level:

In my day-to-day work, we emphasize increased equity of access to care as the key aspect that would be a change from current systems under UHC.  In the conference, there was a lot of focus on the WHO Cube, which talks about three dimensions: for whom (equity), what (services), and how (financing) UHC would work.  This was a good reminder to me that each of these elements need to be defined.  Sometimes we take a naïve view that UHC means free healthcare for all.  But really, it’s some services for some people paid in some part. Defining that package is still in progress in most countries and greatly shapes whether UHC is claimed as an achievement.

2. Quality continues to be a neglected piece of UHC debates:

All this talk about UHC is great, but it’s amazing that in a group of people (read: economists) who talk so much about benefits and value, we are still struggling with defining quality of care.  Dr. Kruk, Chair of the Lancet Commission on High Quality Health Systems, was the only person I heard describe this problem in detail.  However, repeatedly I heard people saying something to the effect of, “We keep confusing the fact of whether we want more healthcare or more health – they aren’t synonymous”.  So there is clearly a need for more work on improving quality measurement and the reliability of data as well as quality improvement work at all levels of the health system.

3. But really, who decides?:

The top-down, system and finance heavy approach to UHC leaves the mixed methods researcher in me a little queasy.  An increased focused on complexity and low- and middle-income countries was welcomed in the conference agenda. However, these conversations were often absent in the session debates. I’d like to see more space in the UHC world for innovation and policy experimentation rather than blanket policy norms. This would require active elicitation of narrative and qualitative reporting exploring what different approaches mean for the people involved, whether positive or negative (e.g. increased workload, more satisfied customers, improved skills), as well as questions about money.

At the end of this meeting, I was left with a strong feeling that I’m working in the right place.  The issues that we deal with in REACHOUT at the community level are very relevant within the national and global debate on UHC. Individuals shape systems and systems shape individuals and we need to bear this in mind as we move toward evidence-based decision-making alongside donor-driven priorities and domestic politics.

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