Across the world, health systems have made significant progress in establishing explicit guarantees: universal coverage, defined benefit packages, and rights protected by law. Yet effective access—the real ability to receive timely, high-quality care with adequate financial protection—remains an unfinished promise. This gap between what is guaranteed on paper and what patients actually experience undermines trust in public health systems and drives millions toward private spending, often with catastrophic financial consequences.

Waiting Lists, Quality, and Out-of-Pocket Spending

The challenge of ineffective access is not limited to low- and middle-income countries. The United Kingdom provides a striking example. The National Health Service (NHS), long regarded as a model of universal healthcare, is currently facing a profound effective-access crisis. In 2024, more than 7.6 million people were waiting for specialist care in the UK—the highest figure ever recorded, according to a recent independent report. The report further noted that these prolonged delays disproportionately affect the most vulnerable populations, exacerbating existing health inequalities.

Even more alarming is the human cost of this crisis. According to the Royal College of Emergency Medicine, lengthy waits in NHS emergency departments are associated with approximately 14,000 avoidable deaths annually—equivalent to 268 preventable deaths each week. This estimate is based on analyses linking waits exceeding eight hours with significantly increased hospital mortality. In other words, the lack of effective access does not merely diminish the patient experience; it can literally cost lives.

This situation has also led to a significant increase in private health insurance enrollment. Data from the Financial Conduct Authority show that the number of adults covered by private medical insurance in the UK grew from 6.7 million in 2020 to 7.6 million in 2024. In addition, there were 939,000 admissions to private hospitals, of which 664,000 were funded through private medical insurance, representing a 6% increase over the previous year.

An OECD report warns that, for most member countries, waiting times for elective treatments have either stagnated or increased over the past decade. This evidence reinforces the notion that effective access depends not only on a country’s wealth, but also on the ability of health systems to balance supply and demand, prioritize care based on clinical need, and ensure timely treatment. In low- and middle-income countries, where resources are more constrained, the consequences of these delays can be even more severe.

Delayed Care Leads to Illusory Financial Protection and Worse Health Outcomes

Legal coverage does not automatically translate into genuine financial protection. The indicator of catastrophic health expenditure—typically defined as a household spending more than 10% of its income on healthcare—remains high in many countries. In part, this results from delayed access, where patients who are theoretically covered by the public system are forced to seek care in the private sector without insurance coverage, sometimes even taking on debt to do so.

Yet this indicator fails to capture those who never access care because they simply cannot afford it. For this reason, many experts advocate incorporating the concept of unmet need as an additional metric to monitor effective coverage.

Moreover, lack of timely access generates avoidable costs. One study found that newly diagnosed diabetes patients who do not adequately adhere to treatment have up to 2.6 times greater risk of hospitalization and 2.4 times greater risk of emergency department visits compared with patients who follow their prescribed therapies. These largely preventable events, often attributable to insufficient follow-up and delayed care, substantially increase healthcare expenditures.

 

Public Metrics and Data Quality: Foundations of Effective Access

Achieving truly universal access requires that metrics related to effective access—such as waiting lists, quality of care, emergency department waiting times, out-of-pocket spending, and patient satisfaction—be publicly available. Only then can citizens meaningfully evaluate whether health systems are progressing or deteriorating.

However, such metrics cannot exist without high-quality data. Interoperability, continuous updating, and representativeness are essential prerequisites for measuring, comparing, and improving performance. Without reliable data, there can be no accurate diagnosis. And without diagnosis, there can be no solution.

According to the World Health Organization’s SCORE technical report, nearly 40% of countries do not implement clear quality assurance methods for the data generated by their healthcare facilities. This severely limits their capacity to assess system performance, monitor compliance with healthcare guarantees, and conduct reliable international comparisons.

Transparency in these indicators enables citizens, policymakers, and the media to determine whether legal guarantees are being translated into real-world benefits. It also facilitates benchmarking across regions, identification of bottlenecks, and prioritization of investments.

Artificial Intelligence and Digital Health as Key Allies

As I have argued in a previous column, artificial intelligence has the potential to become a powerful tool for improving effective access. From automated triage systems to predictive models for waiting-list management, AI can optimize scarce resources, anticipate healthcare needs, identify patterns of inequity, and support more personalized care—provided it is deployed ethically and with patients at the center.

Yet its effectiveness ultimately depends on the quality of the underlying data. Without reliable information, AI cannot generate solutions that are either useful or fair.

In this same context, digital health also plays a crucial role. Telemedicine, remote monitoring, and digital follow-up platforms can significantly expand access to healthcare services, particularly for underserved or geographically isolated populations.

Nevertheless, these technologies can only realize their potential when built upon robust and trustworthy data. This brings us back to the structural challenge of improving health information systems and ensuring data quality.

Political Incentives Versus Perceived Outcomes

Political systems often prioritize announcing new guarantees, benefits, or coverage expansions. Yet they do not always ensure that these commitments are implemented effectively. Patients’ perceptions are often clear: the system is failing, even in areas where universal coverage formally exists.

Ultimately, what matters is not the announcement of a guarantee, but whether that guarantee translates into a tangible, meaningful benefit that patients can actually experience. To achieve this—and to align incentives more effectively—high-quality data and public scrutiny are indispensable.

Conclusion

Effective access is not achieved through decrees, legislation, or political announcements alone. It requires health systems that work in practice; incentives that align policy with outcomes; public metrics that measure what matters; high-quality data that enable accountability; and a genuine commitment to listening to those who experience healthcare firsthand.

It is time for political systems to stop measuring success by the number of guarantees they create and start measuring it by their real-world impact on people’s lives. Only then will healthcare promises become healthcare realities.