Count the people who needed care but could not get it, and make that number the first measure for reviewing health care systems
Steps to make it happen
- A survey team that is independent of government offices visits homes every few years and asks people questions.
- The team asks each person, "Have you ever been sick but could not go to a doctor or hospital?".
- The team asks why people could not go, sorting the reasons into money, distance, waiting time, language, and too few health workers.
- The team also asks whether anyone went into debt or sold belongings to pay for treatment.
- The results are sorted by area, income, and age, and then published so that anyone can see them.
- The government explains, within a set time, why so many people could not get care and how it will fix the problem.
- People come to judge a health system by whether fewer people are left without care, not by how many hospitals it has.
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The proposal in detail
This proposal replaces the main measure used to check a health care system. Instead of counting what the providers supply, such as the number of hospitals, the number of doctors, and total health spending, it would measure the share of people who needed care but did not get it, and the share of people whose lives were badly damaged by the cost of care. Hospital records do not include people who never came, so the survey is done by interviewing residents, not by collecting data from medical facilities. It covers everyone who lives in the area, not only people with insurance: people without insurance, people who have moved in from elsewhere, people without stable housing, people with disabilities, and others. The questions sort the reasons for not getting care into cost, distance and transportation, waiting time, being unable to take time off work, barriers of language and information, discrimination and distrust, and a shortage of health workers. The survey is carried out by a statistics agency or another third party that is independent of the government office in charge of health, and the results are published broken down by region, income, sex, age, whether the person has a disability, and so on. The government is responsible for explaining its analysis of the causes and its plan to respond within a set period after publication. Answers are kept anonymous, and the law states that they cannot be used for other purposes, such as immigration enforcement or collecting insurance premiums. Countries that lack the money or the skills to run the survey use a standard set of questions shared internationally, so that countries can be compared with one another.
BenefitsPeople who were unseen show where the system has gaps
The biggest advantage is that the troubles of people who never appeared in statistics become visible as numbers. Because the survey asks separately why people could not get care, it can tell apart whether the problem is the heavy out-of-pocket cost of insurance, doctors being concentrated in cities, or a lack of interpreters and information. This lets one measure compare problems that are often discussed separately: insurance, ease of access, and securing health workers. Once it is clear which regions and which groups face the greatest difficulty, it becomes easier to decide where to send limited budgets and staff first. It also becomes easier to notice when a policy has missed, for example when more hospitals are built but the number of people without care does not fall. Because an independent body does the survey and publishes the results, and the government is asked to explain, those who run the system are held more accountable, and residents can join the discussion knowing the situation in their own area. If a common international format is used, it also gives a way to learn from the ideas of other countries.
DrawbacksA number based on feelings could distort the system
The point critics see as most serious is that the answer "I needed care but could not get it" depends on how the person feels. People who wanted a visit that was not medically urgent, or a treatment with little benefit, could also answer that they could not get care. So if this number becomes the first measure, political pressure may push the system to keep meeting every demand, and health spending may swell and harm the system's long-term survival and investment in prevention. Lowering the number could become the goal itself, and distortions could follow, such as a rise in light visits with short waits. Moreover, the people who truly find care hardest to reach may be the ones who do not answer the survey, out of fear about their residency status or because of prejudice, so the number could look better than reality. Interviewing the whole population takes a great deal of money and staff, and could drain resources that could be used for medical care itself. There is also concern that publishing results by region could lead to blame on particular areas or health workers, and to workers leaving those places.
Learn the background
People have often judged a health system by the number of hospitals and doctors, the size of health spending, and average life expectancy. But these numbers do not show the people who were sick and did not go to a hospital, or could not go. People who gave up because they could not pay, people with no doctor nearby, people whose income stops if they take time off work, and people who hesitate to see a doctor because they do not speak the language all stay outside the records. Around the world, aiming for a state in which everyone can get the care they need without financial hardship has been set as a shared goal, but the ways of measuring progress toward it differ from country to country. The three problems of how insurance works, how easy it is to reach care, and how to secure enough health workers tend to be discussed by separate offices and industries, so in the end it stays hard to see who is falling through the gaps and where. As populations age and health workers become unevenly spread, deciding where to direct limited resources requires a shared measure that reviews the system from the side of the people who did not get care, not from the side of the providers.
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This proposal was written in Japanese by AI (claude-opus-5-5, policy version 2026-10-15d) and translated by AI (claude-sonnet-5-5). Nobody has checked the facts. Read the original (日本語) How the AI writes