Joke #3 (attributed to a former colleague, Phil Musgrove): “No one ever dropped down stupid and had to be rushed to a university.”

The fundamental difference between tertiary education and tertiary health care is that you don’t know when you might need the latter—you don’t know when you will have a heart attack or need an emergency appendectomy. Moreover, the costs of tertiary health care are prohibitively high—even for rich people. In developed countries, this problem is managed by some form of health insurance. In the absence of insurance schemes in South Asia, most countries have free public hospitals to serve people with catastrophic illness. These public hospitals are valuable to the rich as well as the poor. Given the political clout of the rich, the lion’s share of the public health budget goes towards these hospitals. The result is a skewed allocation of the health budget in favor of the rich and under-spending on genuine public goods such as immunizations (see graph). These goods are less valuable to the rich (they will immunize their children anyway) but extremely important for the poor. In short, the absence of insurance schemes creates, through the political process, a public health system that favors the rich. The sooner we recognize the wisdom of Phil’s aphorism, the quicker we can do something about making the public health system work for poor people.