Source: French to English Tester Published on: 2026-04-23
Source: The Conversation – in French– By Marwân-al-Qays Bousmah, Research Officer, Ined (National Institute for Demographic Studies)
To have efficient health systems, for example in terms of gains in life expectancy, should one prioritize controlling health expenditures or fighting health inequalities? A study based on the observation of the health systems of 36 OECD countries, including France, over the past two decades provides some answers… contrary to the political choices usually favored.
The question of possible conflicts between efficiency and equity is a very old issue, but the recent evolution of health systems provides a renewed illustration of it.
In terms of health, the search for efficiency could notably lead to neglecting important segments of the population, the most disadvantaged, in terms of access to care and equitable treatment of their health problems.
An unbiased observation of the health systems of the richest countries, over twenty years
Should health systems prioritize efficiency or equity? Although the tension between these two objectives seems obvious and continually fuels debates, it has been relatively little studied empirically, particularly in the field of health policies. Ourrecent studyaims to fill this gap.
From time series covering the period 2004-2021 and concerning 36 countries of the Organisation for Economic Co-operation and Development (OECD), we have examined, withouta priori, all possible statistical interrelations between efficiency and equity in health systems.
Efficiency is measured by the improvement of an expenditure/results ratio in terms of gains in life expectancy. To evaluate equity, we use a simple and very common measure based on the assessment of health status by the individuals themselves. By establishing a ratio between the proportion of respondents in good health in the wealthiest and poorest categories, we obtain an indicator of social health inequalities.
What does observation without teaching usa priorihealth systems of the richest countries in the world over a period of twenty years? Have the countries that have made the greatest efficiency efforts – that is, those that have most strongly reduced their spending for a given result – been the ones that saw health inequalities increase the most or the least? And, conversely, has the evolution of health inequalities been statistically associated with variations in efficiency, and in which direction?
“To grow the cake before sharing it”?
Political leaders as well as media commentators often resort to the metaphor of the cake: before sharing it, one should first make it grow. This image conveys an idea now widely spread: priority should be given to efficiency. Equity – understood here as health for all, regardless of income – would come in a second phase, once a level of economic efficiency deemed sufficient has been reached.
It is also the famoustheory of “trickle-down”(trickle down, in English) which underpins the given primacy to efficiency, according to which, if the rich become richer, then the poor will become less poor.
However, this perspective has not always been dominant. As the reading ofThinking like an Economist(Thinking Like an Economist, in French) by Elizabeth Popp Berman (2022), the search for more efficient policies emerged in the United States in the 1960s; Presidents Kennedy and Johnson launched the movement, making efficiency the driving force of the “reorientation of social services towards the provision of services to the poor, rather than towards their empowerment.”
Before Kennedy and Johnson, efficiency was only one objective among others, such as economic stability or equity among citizens. According to Berman, the choice to prioritize efficiency, based on the mandates of these American presidents, was a profoundly political choice, even if this choice was often concealed by the use of sophisticated, excessively technical tools.
Equity as a prerequisite for better overall performance of health systems
Inour study, descriptive data analysis first allows to detect trends. In most countries, the efficiency indicator has almost everywhere improved over the past twenty years. It can be said that the efficiency effort has been significant, although unevenly distributed among the 36 countries. In France, for example, one can refer to the considerable reductions in hospital stays over the last two decades. Health inequalities, on their side, have slightly decreased over the period.
But the most enlightening lesson comes from the combined analysis of these two developments at the national level. The statistical results highlight a bidirectional relationship between efficiency and equity in health systems. In other words, each influences the other. And the nature of these relationships proves particularly instructive.
Firstly, efficiency gains – in other words, better cost control to achieve a certain level of life expectancy – are accompanied by an increase in health inequalities. However, this effect is only observed in countries where the provision of care is predominantly operated by the private sector. Secondly, the reduction of health inequalities produces the opposite effect. When it occurs, it systematically improves the efficiency of the system, whether care is provided by public or private actors.
These results therefore suggest that, contrary to what is regularly claimed, it is equity that is a prerequisite for better overall performance of systems, and not the other way around.
The track of ignorance?
Focusing on efficiency in OECD health systems would therefore have a significant social cost: the increase in health inequalities.
In the United States,Some health economists question the choices made under the Trump administration. Is she really trying to improve efficiency, within the framework of a deliberate trade-off with equity? Or elseignore-does she have theeffects of mass layoffs on the healthcare systemand on the inequalities that result from it?
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Public health: uncertainties about funding are harmful, as shown by the example of the United States
The answer is clear: it is ignorance, and it is probably even a “deliberate ignorance”! Knowing the very role that social protection plays, when decision-makers implement drastic reforms aimed at improving the efficiency of a system, except for specific protection measures for vulnerable populations, it can be said that they deliberately choose to neglect the consequences of their actions on the most disadvantaged people, who are the primary beneficiaries of the protection offered by the healthcare system.
In France, territorial inequalities in access to healthcare
Several mechanisms could be at play. In France (ranked 13th out of 36 in terms of efficiency in 2021, according to our results), persistent inequalities in health could partly stem from territorial inequalities in access to care, exacerbated by a deliberate scarcity of qualified doctors (due tonumerus claususimplemented in the 1990s to enter the second year of medical studies), in order to control health expenses. This problem of sociospatial inequality in the primary care network suggests a concrete mechanism by which the attempt to control costs – in a rather clumsy way, by reducing the number of trained doctors – can worsen health inequalities.
Other countries exhibit comparable dynamics. In Chile, for example, while universal health coverage has improved access to care for everyone, the persistent fragmentation of the health system maintains significant differences depending on income level. Specifically, not all patients have access to the same resources. A diabetic patient followed in the private sector can, for instance, obtain more test strips — essential for daily monitoring of blood sugar — than a patient covered by the public system.
Also at issue: the “client-payer” model applied to health
Another mechanism by which spending control affects inequality in access to healthcare is the implementation of user financial contributions. Initially perceived as a means to combat unnecessary expenses (the “client-payer” model being intended to rationalize choices for healthcare use), this measure has exacerbated inequalities in health and access to care.
Such a policy of financial participation by users necessarily increases the risk of unequal treatment, as the ability to pay these financial contributions is unevenly distributed according to socioeconomic level. Although ourstudydoes not specifically focus on the financial participation of users, it adds to the growing evidence opposing this practice in the health system.
Refocus priorities
Our empirical results invite a reconsideration of priorities in health policy. In most OECD countries, where efficiency levels are already high, the greatest scope for progress is now on the side of equity.
Specifically, this implies:
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to strengthen universal health coverage, based on the model of public health insurance simply accessible on the criterion of residence, as is the case in France;
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to reduce the burden of direct private financing (notably the amounts that remain the responsibility of healthcare users) in countries where it remains high;
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to implement active policies to fight social health inequalities.
These orientations are not only an ethical imperative. They also constitute a pragmatic strategy to improve the overall performance of health systems. From this point of view, our results convey a clear message: reducing health inequalities acts as a lever for efficiency, whether health systems are predominantly public or private.
Thus, far from being antagonistic, equity and efficiency can mutually reinforce each other, provided that equity is placed at the heart of health policies.
Mohammad Abu-Zaineh is a member of the AHEAD Network (Allied Health, Environment and Development Research Network).
Bruno Ventelou, Marwân-al-Qays Bousmah and Simon Combes do not work for, advise, own shares in, or receive funds from any organization that could benefit from this article, and have declared no affiliations other than their academic positions.
–ref. In health, controlling expenses is done at the expense of the most disadvantaged –https://theconversation.com/en-health-cost-control-is-done-to-the-detriment-of-the-most-deprived-280662