Ensuring access to government-provided basic services such as education and healthcare is vital. However, what ultimately matters are outcomes, and access does not guarantee outcomes. This is a lesson that we have learnt the hard way in school education. In many countries, the expansion of access to school education has been a hollow victory because learning outcomes including literary and numeracy are terrible. Learning outcomes have actually declined over past decades in many countries (e.g. India and Nigeria)1.
We should never forget that increasing access is an output objective, not an outcome,2 and that we need to focus as much on the effectiveness of basic services — their extent to which they achieve their intended outcomes — as on access.
It is remarkable how often increased access to basic government services is mistakenly referred to as an outcome. I have, for example, lost count of the number of countries where ministries of education define access to schooling as their key outcome. The Reimagining Public Finance initiative makes the same error: it identifies universal access to education and universal health coverage as examples of the “development outcomes”3 that it argues should be the cornerstone of an “outcome-led” approach to public financial management reform.
Universal health coverage (UHC) is an important objective in any country where there many people don’t have access to essential health services. But we shouldn’t make the mistake of thinking of UHC as an outcome. As the education story reminds us, it cannot be taken for granted that increased access to health services will lead to a commensurate improvement in patient health outcomes (i.e. reduced mortality and morbidity). Poor patient outcomes including avoidable deaths are commonplace in many low- and middle-income countries — due, amongst other things, to high rates of misdiagnosis and inappropriate treatment. It follows that, in many countries, improving the effectiveness of health services is just as important as ensuring that everyone has access to those services. It would be profoundly disappointing if we were to observe in health the same phenomenon of expanded access accompanied by deteriorating effectiveness that has, in too many countries, characterized school education.
Good performance measurement is a fundamental requirement for a true outcomes focus, as shown by the positive impact on education reform of PISA and similar instruments for measuring learning outcomes. Measuring health services outcomes is more difficult than measuring learning outcomes, and measuring health services quality – as a proxy for effectiveness – is also not easy. Much progress has nevertheless been made in developing standard outcome and quality indicators for selected health services (the OECD’s HCQO framework deserves particular praise). As emphasized by the Lancet Global Health Commission on High Quality Health Systems (2018) and others, what is needed now is more progress in implementing such indicators as the foundation for a stronger focus on the effectiveness of health services.
What ultimately matters in the public sector is outcomes. We achieve outcomes by delivering outputs, and this makes it very important that we focus on output as well as outcome objectives. But we should never lose sight of the critical distinction between outputs and outcomes.
- See L. Pritchard, “Addressing the Learning Crisis” in T. Beasley, I. Bucelli and A. Velasco, The London Consensus: Economic Principles for the 21st Century, LSE Press, 2025. ↩︎
- Services — e.g. teaching and medical treatments — are outputs. “Outcomes” refers to increased literacy, numeracy, longer lives in good health and other desired changes that result from the delivery of services (outputs). Expanding service coverage is therefore an output objective, not an outcome. The remains true even if we define our objective as increasing access to quality services. Quality refer to attributes of a service (output) that maximize the likelihood that it will achieve its intended outcomes. Correct diagnosis of medical conditions is, for example, a health services quality attribute, as is the delivery of a treatment that is appropriate for the (correctly diagnosed) condition. (see my discussion of the meaning of the term in an earlier blog piece.). So access to quality services remains an output objective. Historically, universal health cover was usually defined purely in terms of service coverage, with no reference to service quality. In recent years, the most widely-used definitions – those of the World Health Organisation and World Bank – have been revised to refer to access to quality services. ↩︎
- All of the documentation produced by RPF to date refers to universal access to school education and universal health cover as “development outcomes.” ↩︎