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EDITORIAL

Universal Health Coverage—Big Thinking versus Big Data

These days we hear a lot about ‘‘big data’’ and how comparativeeffectiveness research (CER) is going to help us make betterdecisions (big data refers in the health care context to long-itudinal medical claims data for millions of patients linked totheir electronic health records [1]). Most of us working inpharmacoeconomics and outcomes research rely on data—bothrandomized and observational—to generate and assess evidencewith the aim of supporting better decision making about resourceallocation. Most articles in Value in Health are research or methodol-ogy articles: the number of policy articles is very limited. My quicksearch for ‘‘universal health coverage’’ (UHC) found only 11 citationsin the journal, but none focusing on UHC. The articles in this specialsupplement, based on a conference held at Bocconi University inMilan, Italy, earlier this year, remind us that there are large andimportant policy issues that rely on ‘‘big thinking’’—with less hardevidence—to understand and try to reform what is going on inhealth systems and health policy. Nonetheless, as we often empha-size to others, decisions will have to be made—with or without goodinformation—and making no decision is itself a choice.

The eight articles in this special issue illustrate the diversityof the approaches and methods that social scientists use tounderstand and meet the evolving challenges of an increasinglycomplex and global health care environment. Economics andother social sciences can help us to think big about incentivesand likely behavioral responses in an important qualitativefashion even if quantitative rigor is infeasible. This conferenceand these articles were mostly about big thinking based on alimited number of—what economists like to call—‘‘stylizedfacts,’’ that is, generally held propositions about behavior, oftenbased on a broad review of the state of our knowledge.

To be clear, big data in the form of CER may be well worthsubsidizing and even requiring through regulation because infor-mation generally has public good properties, and we expect it tobe undersupplied in a competitive marketplace—a big thinkingresult itself. However, big thinking alone will not tell us theoptimal amount of CER: we need empirical evidence on theimpact of having more information. But we also know that moreinformation is neither necessary nor sufficient for better decisionmaking: arguably, the major developed countries have to workwith the same limited evidence on what works well in medicine,yet some achieve much better population-level health outcomes.But big thinking or theory may not be sufficient either: forexample, economics cannot, of course, tell us a priori whetherone medicine is clinically better than another, but it can suggesthow we could encourage the use of a better medicine by usingincentives.

Our field seems polarized at times between those who want torely primarily on randomized, controlled clinical trials and those

rest: The author has indicated that there is no c

who want to use primarily real-world, observational data (thoughthey are most happy to have natural experiments). And thenthere are the modelers in between the groups who are busytrying to synthesize the data from both sources. The decision inthe United States about whether to subsidize CER and fund thePatient-Centered Outcomes Research Institute was more of a bigthinking result. There is, however, a certain irony in the fact thatthe Congressional Budget Office produced estimates of thepotential aggregate, longer-term impact of CER based on a model(with obviously very limited, directly relevant data) [2].

This special issue is about the many facets and issues thatsurround the widely sought goal of UHC. The World HealthOrganization (WHO) defines it this way:

Universal coverage is defined as access to key promotive,preventive, curative and rehabilitative health interventions forall at an affordable cost, thereby achieving equity in access.The principle of financial-risk protection ensures that the costof care does not put people at risk of financial catastrophe. Arelated objective of health-financing policy is equity in finan-cing: households contribute to the health system on the basisof ability to pay. Universal coverage is consistent with WHO’sconcepts of Health for All and Primary Health Care.

This topic is very timely and was also the subject of a series ofrecent articles in The Lancet; see, for example, the accompanyingjournal editorial [3].

I imagine that the large majority of ISPOR members wouldsubscribe to this as a worthy goal for a national health caresystem. But most of the research that we do takes the overallhealth care system as given and aims to improve resourceallocation given a limited budget or resources. Our widely usedmethod of cost-utility analysis based on the quality-adjusted life-year (QALY) does not include a factor for ‘‘financial risk protec-tion.’’ Nonetheless, the peace of mind that comes from havingprotection against catastrophic financial loss from poor health isof great value and importance to most of us, and most developedcountries have adopted UHC. For example, this is part of thewelfare loss that the millions of uninsured in the United Statessuffer from not having health insurance. To my knowledge, noone has tried to calculate this part of the welfare loss in theaggregate, and in comparison to the direct health and well-beingloss due to reduced utilization because of poor access, which isalso very important and large.

Without attempting a thorough synopsis of each article in thisissue, in the next few paragraphs, I will highlight what were—forme—some of the most interesting findings and observations inthe eight articles, with the aim of providing a quick sense of the

onflicts of interest to disclose with regard to the content of this

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breadth and depth of topics addressed. I also try to tie each backto the crosscutting theme of UHC.

The conference and this issue were motivated by Tarricone ina big thinking article that asserts that UHC is the major issue ininternational health and challenges us to think about three majortrends that will affect the ability of societies to achieve it:accelerating technological change, the aging of populations, andthe epidemiological transition to chronic disease—even in lessdeveloped countries. She sees the current era of acceleratingchange as one in which revolutionary ideas are needed and arebest generated through advancing education. Her major point isthat given these challenges, ‘‘y education needs to fosterimagination and creativity.’’ In its 13 years of existence, theMasters in International Healthcare Management, Economicsand Policy at Bocconi has graduated more than 400 studentsfrom more than 70 countries. She believes that this kind ofdiversity in education worldwide will be the driver of the changesthat are needed. She concludes with a call to arms for all of us tohelp to drive this change.

The team of McKee, Balabnova, Balabanova, Basu, Ricciardi,and Stuckler combines previous data analysis with big thinkingabout historical factors to review the potential fragility of UHC.The optimists among us tend to assume that change is generallyevolutionary and is a good thing (i.e., changes are tested in thereal world and good ones survive). In the US context, the repeal ofSecretary Bowen’s Catastrophic Insurance Act in the late 1980s [4]and efforts to repeal the current Affordable Care Act would beenough to convince most that greater insurance protection is notirreversible. A prior study [5] defined UHC operationally as being‘‘y in place where there was legislation explicitly stating that theentire population is covered by a defined health plan and wherethat population has access to at least skilled attendance at birthand 90% of them have insurance coverage.’’ By this criterion, theyfound that 58 of 194 countries had UHC, and surprisingly severalof them were relatively poor. For example, the United Kingdomachieved this in 1948 and both Thailand and Rwanda veryrecently. They point out that there are numerous theoreticalframeworks (e.g., class or development theories) that can be usedto understand these developments, but none alone provides asatisfactory explanation. They sift through the data to identifyfive key factors that enable UHC: ‘‘the strength of organized laborand those left-leaning parties that represent them, the availabil-ity of resources (including economic growth), potential for build-ing shared identities and public goals (as seen in morehomogenous societies), path dependency (so that the conditionstoday impact the possibilities for tomorrow), and windows ofopportunity (often created by exogenous events such as financialcrises, natural disasters or wars, or political transitions).’’ Clearly,this is big thinking and is quite plausible and understandable, butit will be difficult to undertake any definitive measurement ofthese factors and their quantitative relationship. The authorsconclude with the caution that history has shown that reformsare reversible and that windows of opportunity, such as the GreatRecession of 2008, might also provide an opening for the oppo-nents of UHC to undo it.

The article by Missoni is another good example of bigthinking—an analytical policy piece (‘‘a systems thinkingapproach’’) that explores the potential impact of global tradeliberalization on UHC. The article systematically assesses thepossible adverse impacts of global trade on each of WHO’s sixhealth system building blocks: service delivery; health workforce;information; medical products, vaccine, and technologies; finan-cing; and leadership and governance. While trade and knowledgespillovers—for example, the availability of low-cost, first-lineantiretroviral treatment for HIV disease—can benefit those indeveloping countries, the article identifies numerous possibleadverse effects. These range from the ‘‘commercialization’’ of

health care under trade agreements, to the disconnect betweendrug development and the global burden of disease, to theexportation of unhealthy Western lifestyles and habits, to numer-ous other examples. This is a big thought experiment in need ofsome systematic quantification and evidence development.Nonetheless, this long list challenges us to entertain the possi-bility that further global regulation and coordination is needed ifUHC is going to succeed in more nations. This may be anothercase where uncertainty produces a type of market failure thatjustifies a regulatory intervention. Missoni argues for strengthen-ing the role of the WHO in promoting ‘‘global governance forhealth’’ in our increasingly connected world.

The article by Fattore and Tadiosi on cultural values and theirrole in governance in relation to UHC is another good example ofa big conceptual thought piece. They lay out a plausible story ofhow different underlying cultural values can lead societies toselect different management and governance structures that aremore or less friendly to UHC. They distinguish between ‘‘manage-ment’’ and ‘‘governance,’’ the former being more about opera-tional activities and the latter about how policies and regulationsare developed and monitored. They emphasize, however, that notonly are both management and governance critical to supportingUHC policies, but these solutions and how they are developed arerelated to underlying cultural values. Interestingly, on the basis ofcultural theory, they characterize four cultural archetypes: hier-archist, individualist, fatalist, and egalitarian. These archetypesvary—oversimplifying a good bit—depending on two dimensionsin a society: the importance of rules and authority structures,and the group versus individual orientation. Interestingly, theyweave a complex story, arguing that it is not clear that any onearchetype is most conducive to UHC. The hierarchist and egali-tarian perspectives both share a ‘‘groupness’’ orientation thatshould be enabling to some degree. On the other hand, they donot rule out an individualist solution to providing UHC. This isanother example of big, complex thinking that may yield sometestable implications if we can begin to measure the archetypes.Their major conclusion, however, is more subtle: implementationcan matter as much as the goals implied by cultural values. Inother words, both management and governance are importantfor the implementation and sustainability of UHC, and how theyare best used to support a UHC goal will depend on societalcultural values.

The article by Lega, Prenestini, and Spurgeon is more empiri-cally grounded than some of the preceding thought pieces butcomplements them by summarizing the evidence on the impor-tance of management practices. They point out that both publicand private health systems are struggling with costcontainment—and therefore with the broader issue of sustain-ability: thus, the management of these health plans comes intoquestion. They attempt to summarize a large and complexliterature, consisting of both qualitative and quantitative studies,on this topic. They conclude that yes, management matters. Andthey note the intriguing finding that health care managers withsome clinical background seem to do a better job. This is notnecessarily surprising, but it does imply that training managersto have both clinical and business skills means a larger societalinvestment. Others in this special issue emphasize the impor-tance of management and particularly in relation to the need forproper health system governance at both a health plan level anda supranational level if UHC is to be promoted and succeed in ourrapidly changing world.

The article by Villa and Kane is the only one in this issue thatproffers a new empirical analysis. They identify all hospitalconversions (from public to private, for-profit) in three Americanstates (California, Florida, and Massachusetts) between 1994 and2003. They find 58 conversions to analyze and compare them pre-versus postconversion and in relation to a larger universe of

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hospitals. The findings are as expected: privatization is asso-ciated with reduced length of stay, costs, and the use of low-margin services; also, prices and operating margins increased,but access to community-based services in these hospitalsdeclined. They are understandably cautious in generalizing toall conversions or to other countries. But it is clear that hospitalbehavior and performance changes with changed incentives andthat there are trade-offs between access and cost. Pluralistichealth care systems attempting to achieve UHC by altering themixture of public and private hospitals will need to pay carefulattention to this trade-off. In the United States, the use of theemergency room as the safety-net provider of last resort has beena costly and imperfect way of providing UHC because it mostlikely fails to provide the important peace of mind that is a keyaim of UHC.

The article by Drummond, Tarricone, and Torbica addressesthe challenges that UHC systems face in trying to provide accessto costly innovative technologies. Of all the articles in this issue,it probably falls more into the comfort zone of Value in Healthreaders in terms of terminology and concepts, while still provid-ing some new insights into the relationship between healthtechnology assessment (HTA) and UHC. They note the naturaltension that exists among the key stakeholders—patients,payers, and manufacturers of innovative technologies. Patientswant (via their physician agents) access to new technologies thatprovide positive net clinical benefit; payers need to manage theirbudget and want value for the money spent on behalf of theirclients—the taxpayers or plan members; and manufacturers seekrewards that would provide the best return on their substantialinvestments. They ask: how can we reconcile the conflictinginterests among these stakeholders? They note that somesystems—most notably the National Institute for Health andClinical Excellence (NICE) in the United Kingdom—have used anHTA evaluation system based on the QALY to make judgmentsabout value and access recommendations regarding specific tech-nologies. They cite the well-known limitations of the QALY andNICE’s pragmatic adjustments to deal with them. I would onlyrepeat that the QALY as usually implemented does not reflect thepeace-of-mind premium that is one key aim of UHC. They arguethat the QALY may not adequately reflect ‘‘social value’’—a broaderconcept that would consider more products attributes than just theincremental cost-effectiveness ratio. They also identify other ana-lytic options—such as discrete choice experiments—that couldweigh other criteria as well. The authors also note the limitationsof the current drug development paradigm (e.g., placebo-controlledrandomized clinical trials and noninferiority randomized clinicaltrials in highly selected populations). Earlier dialogue with payers issuggested as a useful approach to address this. The greateremphasis on CER is noted. Finally, they cover at length thechallenges of promoting greater patient involvement in HTA deci-sion making, which HTA practitioners have recognized and beenpromoting since the 1990s. They would clearly support the idea ofproducing big data to enable CER and better HTA decision making,and they make specific recommendations for specific studies andmethods experiments to support policy choices. This article isanother good example of the need for and power of big (analytical)thinking to sort out critical issues and to define a research andpolicy agenda.

In the final article in this issue, Borgonovi and Compagnireturn us to the question of the sustainability of UHC that wasalso raised in the McKee et al. article. UHC is currently anaspiration not only in emerging markets such as Brazil, China,and India but also in the United States. They emphasize thatwhen most analysts think about sustainability, they are mostlythinking about economic sustainability. It is important toacknowledge, however, that sustainability has political and socialdimensions as well. Like the McKee et al. article, the policyanalysis and commentary in this article suggests that theeconomic unsustainability might be used as an argument toundermine social and political sustainability. In the realm ofassessing economic sustainability, they argue persuasively thatthere is a greater role for the analysis of management practices.There is not space here for me to fully explore subtle and usefuldistinctions that they make in defining social and politicalsustainability. I was intrigued, however, by their observation thatUHC could ‘‘y generate positive social spillovers (or social value)well beyond health’’ that would contribute to social and politicalsustainability. Again, the article argues both conceptually andusing country case examples: another example of big thinkingusing the limited data available.

The preceding overviews will, hopefully, help readers of thisissue identify where they would like to dig more deeply. To end byreiterating two major contentions: 1) big data can clearly supportbetter decision making, but understanding and altering incen-tives is probably more important for producing population healthimprovements, and 2) in the end, many major policy decisionsare based on limited data and are driven more by big thinkingabout incentives and likely responses—and by politics. The bigthinking in this special issue stimulates us to broaden our view ofhow we can grapple with the challenge of pursuing UHC.

Louis P. Garrison, Jr., PhD

Department of Pharmacy, University of Washington,

Seattle, WA, USA

1098-3015/$36.00 – see front matter

Copyright & 2013, International Society for

Pharmacoeconomics and Outcomes Research (ISPOR).

Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.jval.2012.10.016

R E F E R E N C E S

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of Medical Treatments: Issues and Options for an Expanded FederalRole. A CBO Paper, December 2007.

[3] Editorial. The struggle for universal coverage. Lancet 2012;380:859.[4] Rice T, Desmond K, Gabel J. The Medicare Catastrophic Coverage Act: a

post-mortem. Health Aff (Millwood) 1990;9:75–87.[5] Stuckler D, Feigl AB, Basu S, McKee M. The Political Economy of

Universal Health Coverage. Geneva: World Health Organization, 2010.