Making Fair Choices on the Path to Universal Health Coverage (World Health Organisation, 2014) offers an analysis of how low- and middle-income countries may follow a path to universal health care in ways consistent with principles of fairness. The report addresses three questions. Which services should policy-makers expand first? To whom priority should be given when extending coverage? and Should one shift from out-of-pocket payment towards pre-payment? In making these choices, the report argues that three main principles should be adopted. First, in extending coverage, priority should be given to the worse off. Second, a principal aim should be to secure maximum benefit for a given population. Third, contributions to pre-payment schemes should be based on ability to pay and not need. A particularly notable feature of the report is its willingness to define various ‘unacceptable trade-offs’. For example, it argues that it would be wrong to expand coverage for low- or medium-priority services, for example renal dialysis, before there is near-universal coverage for high-priority services, for example tuberculosis diagnosis and treatment.
Making Choices is a major achievement in itself as well as an articulate and thoughtful contribution to the question of how best low- and middle-income countries can secure universal health coverage in a fair and efficient way. Documents combining ethical analysis and policy relevance are hard to write. To be relevant in policy terms requires engagement with the messy detail of public policy choices. To be credible in normative terms requires being on top of complex conceptual arguments and, in order not to burden the busy reader, simultaneously hiding the light of your learning under a very large bushel. The report manages to combine these skills to a high degree. It is a document that anyone concerned with issues of justice in the allocation of health care resources anywhere in the world will benefit from reading; for those concerned with justice in low- and middle-income countries, it should prove both essential and illuminating.
Because of its importance the KCL/UCL Social Values and Priority-Setting Group – which brings together, on a regular basis, philosophers, lawyers, economists, political scientists and policy practitioners to discuss social values and health care priorities – decided that the report merited discussion and analysis. The group was fortunate in being joined by Dr Addis Tamire Woldemariam, General Director, Office of the Ministry of Health, Ethiopia, to write from an administrator’s perspective. The present symposium is the result.
The symposium begins with a précis of the report by three of those involved in its production, Alex Voorhoeve, Trygve Ottersen and Ole F. Norheim. They set out the main arguments of the report, showing how the principles that they advocate can be applied to priority setting for four possible interventions using Kenyan data. They then set out their unacceptable trade-offs, which include: expanding low- or medium-priority coverage before there is near-universal coverage for high-priority services; choosing to give high priority to very costly services; and expanding coverage for workers in the formal sector of the economy without including informal workers and the poor.
On the basis of Ethiopian experience, Tamire Woldemariam both welcomes the report’s emphasis on the importance of public participation but also questions the administrative and policy relevance of its principles. He points out that universal health care in Ethiopia is being developed by careful use of trained personnel, together with the employment of less skilled workers in some essential tasks. However, because of the demands that good quality care places on a system like that in Ethiopia, he questions whether it is really possible to implement ‘fair’ rather than ‘hard’ choices.
Peter Littlejohns and Kalipso Chalkidou also take up the question of implementation. They point out that, for practical recommendations to be relevant, much more evidence is needed on what institutions work and what the opportunity costs are of choosing one intervention over another. Although it is often assumed that a dedicated institution makes for good priority setting, they point out that Japan managed universal health care without such an institution, whereas Colombia does not even though having the institutions. They conclude by calling for the collection of low-cost data on what work and does not work in different political settings.
Benedict Rumbold and James Wilson examine the report in terms of its logic and philosophical approach. They point out that the report makes a strong claim in proposing to justify particular substantive decisions in the face of competing views about what a reasonable choice would be. They also point out that there are potential conflicts among the various unacceptable trade-offs, forcing policy-makers to confront hard questions, in a way that echoes Tamire Woldemariam’s comments.
Finally, in my contribution, I assess the report as a piece of practical public reasoning. I argue that the intellectual traditions from which the leading arguments of the report are drawn over-estimate the possibility of comprehensive rationality in systems of public administration and ignore the shadow of the past. The path to universality is assumed to come from nowhere, recapitulating some points of Littlejohns and Chakildou.
Voorhoeve, Ottersen and Norheim then reply to these reviews under four headings: equity and political economy; the significance of the starting-point for progress towards UHC; the identification of unacceptable trade-offs; and the need for more information on what works. They use their reply to clarify some of the detailed arguments of the WHO report as well as explain how their discussion of policy principles relates to empirical issues of implementation. For example, they suggest that equity means establishing priorities among those with serious health needs but with a different capacity to benefit, as well as seeking to clarify the nature of the unacceptable trade-offs that they posit. They also seek to make clear that, in terms of implementation, the force of the ethical imperatives depends upon certain conditions holding.
The whole collection was refereed by Michael Gusmano, of the Hastings Center, and all the contributors are in his debt for his review. He identified three issues that recur in a number of the comments that are important in themselves. The first is that there is tension between an aspiration to universal values, which Making Fair Choices involves, and the fact that all countries have different starting-points and therefore will necessarily have different trajectories towards universal coverage, even if that is their direction of travel. The second issue is that political constraints, as well as resource constraints, inevitably play a part in determining what is feasible, and there is no easy distinction between what is in principle justifiable and what can be accomplished in practice. The third issue is the importance of recognising the telescoping of health policy problems that typically face low- and middle-income countries, who have to deal both with infectious diseases and with non-communicable diseases like diabetes.
Readers will make their own judgements about the balance of argument over the various issues arising from this symposium. However, we all collectively hope that the discussions will prove illuminating in themselves as well as drawing attention to the importance of the most serious health policy challenge facing the world – securing universal coverage for all, including the least well-off.
