In PBF, we argue that the first objective for health systems should be to deliver all components of health (or educational) packages of good quality. The second objective should be to do this as efficiently as possible. Once quality and efficiency are in place, governments tend to become committed to maintaining their financing. Only then, as a third objective, can equity be applied effectively by creating third-payer mechanisms.

From this angle, there is little room for generalized, imposed free care that offers services regardless of income, as in Afghanistan, or for universal insurance that offers free services on paper but often lacks the financial resources required. The following questions should first be answered: “Who should pay the bill? How to achieve social aims in the most efficient manner?” and What is the opportunity cost?”