The emergence of modern healthcare – drugs, technologies and treatments – offers us today a freedom from illness and death unimaginable just a century ago. Healthcare is perhaps the most concrete expression of the point where individual need meets societal response. How we are – or are not – able to access critical care will become, at one time or another, an existential question for most of us. Once we are past the point of prevention through action on the broader determinants of disease, the healthcare system is, in some form in every country on earth, the thin blue line standing between individuals and a world of pain and loss.

Over the 20th century, almost all industrialised countries pursued a collective, population risk-pooling approach to the development and provision of healthcare, from Bismarck's model of social insurance to the National Health Service (NHS) of Beveridge and Bevan. With escalating levels of technological sophistication, ageing populations, increasing demand and spiralling cost, however, most of these countries have started seeking alternative models to reduce the fiscal burden on the national budget (Schieber and Poullier, 1989; Busse et al, 2017).

Emerging out of colonial health services, many low-and middle-income countries entered independence with weak and underdeveloped systems of healthcare. In the ensuing decades, low levels of domestic investment, limited local resources, structural adjustment and aid dependence have constrained public sector leadership and the formation of public health systems, rationalising instead the necessity – and putative efficiency – of privately contracted medical services in countries roiled by high levels of mortality, disease and debt.

Over the last 40 years, it has become evident that neither the rich-nor the poor-world experience of healthcare, confronted with expanding need and escalating technological possibility, is practically or ethically sustainable. As a result, the notion of ‘reform’ has become a permanent feature of health sector policy making, and a battleground in the ideology of freedom – whether to liberate care, as a private good, into the hands of market provision and consumer choice, or to unify care, as a public good, statutorily accessible to all.