Werner Soors (ITM)
When some day in the future people will be asked what happened in Boston in April 2013, I reckon few will come up with Harvard’s conference on universal health coverage. Yet, while the city’s public life froze between the marathon bombing on Boylston street and the capture of ‘suspect 2’ a few days later, part of the global public health community gathered in central Boston to discuss ethical dilemmas on the path to UHC in developing country health systems. As media coverage was possibly not fairly distributed between the two events – and as the International Health Policies newsletter is what you’re subscribed to – let me tell you about the conference, in this very particular Bostonian context.
Day 1 started as you would expect at any high-end conference dedicated to ‘developing countries’ yet with participants from the Global South – as usual – underrepresented: opening with Julio Frenk’s refurbished rendering of Mexico’s Seguro Popular (unifying the selective technocrat approach and the social rights-based approach), meandering through Adam Wagstaff’s metaphor of UHC as ‘old wine in a new bottle’ (but we like the wine) and spiced up with a dose of gratuitous criticism (the WHO box is not convincing enough – Gita Sen).
How could I have been so naïve as to having expected something more thrilling? (Should I stay or should I go? – The Clash, 1982)
But then there was William Hsiao (known for his work on health systems in many developing countries, including Vermont – introduction by Norman Daniels), and things suddenly changed. Good old Bill gently woke up the audience (I think the US can teach the world how not to go for universal coverage), convincingly showed how the overly simplistic cube can be layered to reveal inequities within a society (see slide 8 of one of Hsiao’s earlier presentations) and argued that political paths to universal coverage in the end are defined by setting ethical priorities. In the afternoon, Peter Berman expanded on similar thoughts, explained how different pathways lead to different outcomes, and claimed that ends should drive the means: let us discuss the ethical basis of these choices. This led in the evening of day 1 to some animated discussions.
So far so good: 300+ conference attendees went for a rest, expecting more in-depth food for thought on ethics and UHC on day 2. Who could foresee that a couple of hours later a shootout at the MIT campus would lead to a 24-hour manhunt that paralysed the city? (You know something is happening, but you don’t know what it is – Bob Dylan, Ballad of a thin man, 1965) The conference resumed with four hours of delay the next day, with less than 50 participants.
On day 2, the conference started as unsettling as the empty Boston streets: Nir Eyal – associated Harvard professor of medical ethics – made a plea not to use coverage as WHO does, to stay away from universal population coverage and instead go for what he called selective facilitation. The latter basically means giving the rich no coverage (you might also call it ‘selective universal coverage’; history sometimes repeats itself). In Eyal’s view, this is a matter of fairness and would leave more money for the poor. Your man in Boston was flabbergasted, but not speechless. Mr. Eyal, isn’t that reasoning a bit at odds with long-standing evidence for broad collection and pooling? Would you really expect the rich to keep on paying if they get no benefits? – Indeed, Mr. Soors, I can see a political will for that in my country. Which did leave me speechless: I never before had regarded the US of A as the exemplary ‘developing country’.
(You can fool some people sometimes, but you can’t fool all the people all the time – Bob Marley, Get up, stand up, 1973)
The following session however not only lifted my spirits, it – more importantly – provided a landmark in ethical reasoning, thanks to the quartet of Marc Fleurbaey (Princeton), Matt Adler (Duke), Larry Temkin (Rutgers) and Alex Voorhoeve (LSE & Princeton). They engaged in an in-depth discussion on the social welfare function, Pigou-Dalton transfers as the equitable cousin of the efficiency-oriented Pareto principle, and solidarity, all within the framework of universal coverage. If you ever have the chance to hear any of these four gentlemen in your neighbourhood, do not hesitate. For a teaser, please have a look at one of Fleurbaey’s key publications: Health, equity and social welfare.
After having concluded the conference, the organisers announced that ‘suspect 2’ had been captured. They didn’t say that Dzhokhar Tsarnaev had arrived more dead than alive at the Beth Israel Deaconess hospital, just in front of the conference building. Most of the conference attendees applauded, and left satisfied. Thousands of Bostonians started dancing in the streets till the early hours.
Following up on this conference, WHO hopes to produce a guideline later this year. Working title: A fair path to universal coverage. We’ll keep you informed.