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 in the most efficient manner. Once quality and efficiency are in place, governments tend to become committed to maintain it’s financing. Only then, as third objective, equity can effectively be applied by creating third payer mechanisms.

Taken from this angle there is little place for generalised imposed free care that offers free services irrespective of the income such as in Afghanistan or universal insurance that offers free services on paper but often without 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?”