Can Double Standards be Fair? Health Systems Metrics for Developing and Developed Countries

With discussions underway about the post-2015 agenda, the global health community appears to be zeroing in on universal health coverage (UHC) as a prime target for inclusion in the new set of targets to be developed. The Rockefeller Foundation recently released a report, co-produced with Save the Children, UNICEF and WHO, explaining the benefits of UHC (ensuring access to essential care regardless of ability to pay, and that financial hardships are not the result of obtaining needed health services), particularly for low and middle-income countries (LMIC).


The concept that UHC should be included in a vision for health systems and into metrics against which countries’ health system performance are judged is not new. Julio Frenk and Christopher Murray included “fairness of financial contribution” in their outline of fundamental health system goals in their 2000 article in the Bulletin of the World Health Organization, “A framework for assessing the performance of health systems.” However, with many developing countries still struggling to offer basic care, and with underdeveloped taxation, public finance and accountability systems, this big jump in expectation from the MDG metrics applied to LMIC countries now may set countries up to fail. One option to consider may be tiered standards. Drawing from the same piece by Frenk and Murray offers an option for such a tiered measurement system, already de facto in use.


The first of the fundamental goals described by Murray and Frenk is “improving health.” Developing countries are being ranked against this standard now, with the MDG metrics, including halting the spread of HIV and reducing the incidence of malaria.  


The global health community expects more from developed countries. This is where the second fundamental goal comes in: “enhancing responsiveness to the expectations of populations.” This metric is being used to judge developed health systems already. For example, a 2010 report from the Commonwealth Fund (“Mirror, Mirror on the Wall: How the Performance of the U.S. health Care System Compares Internationally”) ranked developed country health systems using the quality, access, efficiency, equity and the outcomes metric of “Long, Health, Productive Lives.” Such standards are sometimes used for developing countries, but appear more common for developed ones.


While a highly equitable, effective and efficient health system with pooled financing and UHC is an excellent target for all health systems, a tiered system of measurement and comparison may be fairer and potentially more useful. Given the diversity of current health system performance, incorporating the third fundamental goal of “fairness of financial contribution” may be appropriate only for those countries whose health systems are already performing reasonably well on the first two standards. These standards could be configured as a roadmap towards that goal, offering useful comparisons at each stage of development, while offering a tool for resource prioritization at each point. While double standards are generally considered the definition of unfairness, this may be a case where they are actually the fair choice.


– Sarah Sullivan


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