Making Fair Choices on the Path to Universal Health Coverage

In September 2015, 267 prominent economists from 44 countries published a declaration in The Lancet.¹ That declaration called on global leaders to prioritize a pro-poor pathway to universal health coverage (UHC) as an essential pillar of sustainable development. The economic arguments for doing so are compelling. UHC transforms livelihoods as well as lives and works as a poverty reduction strategy. The economic benefits of investing in UHC are estimated to be more than ten times greater than the costs.²

In health care, UHC is the ultimate expression of fairness. It means ensuring that everyone can obtain essential health services of high quality without suffering financial hardship. Resource constraints require countries to determine their own definition of essential. UHC cannot provide access to all possible health services. Resources in every country fall short of what is required to meet all needs, especially as the costs of new medicines and technologies continue to soar. Instead, UHC requires a comprehensive range of key services that is well aligned with other social goals. In other words, choices must be made and priorities must be set.

Since 2010, more than 100 countries have approached the World Health Organization (WHO) requesting policy support and technical advice for UHC reforms. This large number of countries, representing all levels of development, constitutes a vast and diversified laboratory that is experimenting with different approaches and producing a broad menu of policy options. Health systems are highly context specific; there is no universal path to UHC. But a commitment to fairness and equity must guide choices when priorities are set.

A THREE-PART STRATEGY

In 2014, the WHO Consultative Group on Equity and Universal Health Coverage issued its final report, Making Fair Choices on the Path to Universal Health Coverage.³ To achieve UHC, the report explains how countries must advance along at least three lines of action. They must expand priority services, include more people, and reduce out-of-pocket payments. Each line of action involves critical choices within the framework of a three-part strategy for countries seeking fair, progressive realization of UHC.

First, services should be categorized as high, medium, and low priority. Relevant criteria for ranking and categorizing services include those related to cost-effectiveness, priority to the worse off, and financial risk protection. The use of these criteria should take place in the context of robust public deliberation and participatory procedures. People are more likely to accept decisions that affect their health and well-being when they understand the grounds for those decisions. WHO provides a range of technical tools, including WHO-CHOICE, to help countries determine which interventions offer the best value for money.⁴ Fixed cost-effectiveness thresholds are limited as a decision-making tool; WHO recommends that they be used with great caution, if at all.

Second, high-priority services should be expanded to include everyone. Doing so involves eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. When seeking to include more people, the key question is who to include first. To include more people fairly, countries should first expand coverage for low-income groups, rural populations, and other groups disadvantaged in terms of service coverage, health, or both. Doing so is especially important for high-priority services.

This leads to the third part of the strategy: ensure that disadvantaged groups are not left behind. In the interest of fairness, out-of-pocket payments should first be reduced for high-priority services for disadvantaged groups. Also in the interest of fairness, mandatory prepayments should increase with ability to pay; contributions to the system should be progressive.

The report also alerts its readers to five unacceptable trade-offs when difficult choices must be made. It is unacceptable to expand coverage for low- or medium-priority services before achieving near-universal coverage for high-priority services; to give high priority to costly services when the health benefits are small; to expand coverage for well-off groups before doing so for worse-off groups when the costs and benefits are not vastly different; to include first only those with an ability to pay while excluding informal workers and the poor; and to shift from out-of-pocket payment toward mandatory prepayment in a way that makes the financing system less progressive.

Reliable data underpin fair choices on the path to UHC. Countries cannot manage what they cannot measure. They need good data on the disease burden and its distribution across society. They need to know what is being spent in a health system, what these expenditures are for, and what outcomes they bring. WHO has developed tools to help countries collect health expenditure data.⁵

PRIORITY SETTING IN COUNTRIES WITH ESTABLISHED UHC

Over the past 25 years, several countries, including Australia, The Netherlands, Norway, Sweden, Thailand, and the United Kingdom, have developed national institutions for priority setting for UHC. These institutions have evolved in line with the countries' culture, public expectations for health care, and political and health systems. Although the institutions function in different ways, many use similar technical tools.

Shared features include legislative frameworks for decision making about new technologies and services and their adaptation as needs change; decision making that considers both clinical and economic data; staff with skills in epidemiology, biostatistics, and the analysis of clinical effectiveness and cost-effectiveness data; and inclusion of the views of many different stakeholders.

How UHC is structured differs greatly in these countries. For example, England has decentralized implementation and budget control. The National Institute for Health and Care Excellence, with approximately 600 staff, provides guidance on what to do but has no fiscal responsibility. Sweden has 21 country payers but only one centralized agency that provides health technology assessments. Australia uses an advisory committee model, with academic groups contracted to provide appraisals of clinical effectiveness and cost-effectiveness data, with federal government funding of community pharmaceuticals. In Thailand, the Health Intervention and Technology Assessment Program is a semi-autonomous research unit established under the Ministry of Public Health. This program undertakes assessments of health technologies broadly defined to include curative interventions, individual and community health prevention and promotion, and even social health policy. These assessments then inform decision making.

These experiences suggest that no single, ideal institutional structure exists to guide priority setting for UHC. Each country has to decide what will best suit its needs, capacities, and the expectations of its citizens.

LEGITIMACY AND ACCOUNTABILITY

When pursuing UHC, tough policy choices and their enforcement can be facilitated by robust public accountability and participation mechanisms. WHO recommends that these mechanisms be institutionalized through each country's own tailor-made structures and mechanisms. One widely accepted framework for legitimate decision making is accountability for reasonableness.^6,7 The framework recognizes the reality of “reasonable” disagreements, within and between countries, about the values that underlie the inevitable trade-offs imposed by resource constraints. The framework has been explored in a range of contexts and can be crucial in facilitating fair and legitimate decisions on the path to UHC.^6,7

Though making fair choices is challenging, it is fully worth the effort. The evidence is now overwhelming that providing quality health services free at the point of delivery helps end poverty, boosts growth, and saves lives.¹ UHC cushions shocks on communities when crises occur, whether these arise from a changing climate or a runaway virus. Under normal conditions, UHC builds cohesive and stable societies and underpins economic productivity—valued assets for any country.

DISCLAIMER

The authors are staff members of the World Health Organization and are themselves alone responsible for the views expressed in the Article, which do not necessarily represent the views, decisions, or policies of the World Health Organization or Taylor & Francis Group.

DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST

No potential conflicts of interest were disclosed.