HHr Health and Human Rights Journal Three Case Studies in Making Fair Choices on theHHR_final_logo_alone.indd Path 1 10/19/15 10:53 AM to Universal Health Coverage alex voorhoeve, tessa t.t. edejer, lydia kapiriri, ole f. norheim, james snowden, olivier basenya, dorjsuren bayarsaikhan, ikram chentaf, nir eyal, amanda folsom, rozita halina tun hussein, cristian morales, florian ostmann, trygve ottersen, phusit prakongsai, carla saenz, karima saleh, angkana sommanustweechai, daniel wikler, and afisah zakariah Alex Voorhoeve, PhD, is Associate Professor in the Department of Philosophy, Logic, and Scientific Method, London School of Economics, London, UK and Visiting Scholar in the Department of Bioethics at the National Institutes of Health, Bethesda, US. Tessa Tan-Torres Edejer, MD, is Coordinator of Costs, Effectiveness, Expenditure and Priority Setting, Health Systems Governance and Financing, and Health Systems and Innovation, World Health Organization, Geneva, Switzerland. Lydia Kapiriri, PhD, is Associate Professor in the Department of Health, Aging, and Society, McMaster University, Hamilton, Ontario, Canada. Ole Frithjof of Norheim, MD, PhD, is Director of Global Health Priorities in the Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway. James Snowden, MSc, is Research Analyst at Giving What We Can, Centre for Effective Altruism, Oxford, UK. Olivier Basenya, MD, MSc, is Performance-Based Financing Expert in the Ministry of Health, Bujumbura, Burundi. Dorjsuren Bayarsaikhan, MPH, is Health Economist in the Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland. Ikram Chentaf, MBA, is International and Intergovernmental Cooperation Program Manager in the Cooperation Division at the Ministry of Health, Rabat, Morocco. Nir Eyal, DPhil, is Associate Professor, Department of Global Health and Population, TH Chan School of Public Health, Harvard University, Boston, US. Amanda Folsom, MPH, is Program Director at the Results for Development Institute, Washington, DC, US. Rozita Halina Tun Hussein, MPH, is Deputy Director, Unit for National Health Financing, Planning and Development Division, Ministry of Health, Putrajaya, Malaysia. Cristian Morales, MSc, is Representative of PAHO/WHO in Cuba, Havana, Cuba. Florian Ostmann, MA, is a PhD candidate in the School of Public Policy, University College London, London, UK. Trygve Ottersen, MD, PhD, is Research Fellow, Department of Global Public Health and Primary Care, University of Bergen and Associate Professor, Oslo Group on Global Health Policy, Centre for Global Health, University of Oslo, Bergen, Norway. Phusit Prakongsai, PhD, is Director, Bureau of International Health, Ministry of Public Health, Nonthaburi, Thailand. Carla Saenz, PhD, is Bioethics Regional Advisor, Pan American Health Organization, Washington, DC, US. Karima Saleh, PhD, is Senior Economist in Health at the World Bank, Washington, DC, US. Angkana Sommanustweechai, PhD, is a Research Fellow at the Ministry of Public Health, Thailand. Daniel Wikler, PhD, is Mary B. Saltonstall Professor of Ethics and Population Health, Department of Global Health and Population, TH Chan School of Public Health, Harvard University, Boston, US. Afisah Zakariah, MD, PhD, is Director, Policy, Planning, Monitoring and Evaluation, Ministry of Health, Accra, Ghana. Please address correspondence to the authors c/o Alex Voorhoeve, Department of Philosophy, Logic, and Scientific Method, London School of Economics, Houghton Street, London, WC2A 2AE, UK. Email: [email protected]. Competing interests: None declared. Copyright © 2016 Voorhoeve et al. This is an open access article distributed under the terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. DECEMBER 2016 VOLUME 18 NUMBER 2 Health and Human Rights Journal 11 Voorhoeve et al. / UHC and Human Rights, 11-22 Abstract The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting. Introduction features which apply to choices faced in many countries. Consequently, though they draw inspi- Universal health coverage (UHC) is at the center ration from reality, they are not an evaluation of of current efforts to strengthen health systems and particular countries’ decisions. improve the level and distribution of health and In what follows, we first offer a brief summary health services. The values that motivate this goal— of Making fair choices and then discuss three cases. improving population health, fairness in access to health services and in the distribution of health, and financial risk protection—should also determine Summary of Making fair choices on the the path to it. In 2011, the World Health Assembly path to universal health coverage called on the World Health Organization (WHO) WHO has defined UHC as “all people receiving to provide support and advice to countries seeking quality health services that meet their needs with- to move towards UHC. The WHO Consultative out being exposed to financial hardship in paying Group on Equity and Universal Health Coverage for them.”3 This definition leaves room for interpre- was set up to develop guidance on how countries tation. On the understanding adopted here, given can best address issues of fairness (or equity) that resource constraints, UHC does not require that all arise on the path to UHC. The Consultative Group possibly effective services are provided to everyone. issued its report, Making fair choices on the path to Rather, it requires that a comprehensive range of 1 universal health coverage, in early 2014. The report services, well-aligned with other social goals, is 2 has been widely discussed. available to all at bearable cost. After the publication of Making fair choices, To achieve UHC, countries must advance in at work began on a set of case studies intended to il- least three dimensions: expanding priority services, lustrate how the principles articulated in the report including more people, and reducing out-of-pocket apply to a diverse set of cases. To develop these cases, payments. In doing so, they face the following crit- the present group of authors, who are academics ical decisions: and health policy professionals, was convened. This paper reports three of these studies. • Which services to expand first? The case studies are drawn from experience, but have been simplified to allow key ethical issues • Whom to include first? to be discussed in a compact and accessible man- • How to shift from out-of-pocket payment to- ner. They have also been generalized, to highlight ward prepayment and pooling of funds? 12 DECEMBER 2016 VOLUME 18 NUMBER 2 Health and Human Rights Journal Voorhoeve et al. / UHC and Human Rights, 11-22 They also face trade-offs between these dimensions: broadly to include groups facing discrimination for example, between covering more services or and marginalization). covering more people. 3. Fair contribution and financial risk protection. Making fair choices recognizes that many val- Contributions for needed coverage and services ues are relevant to making these decisions and that should be based on ability to pay and should not their importance will depend on each country’s depend on individuals’ health risks or the severi- context. Nonetheless, it also argues that, in all con- ty of their condition. Moreover, impoverishment texts, the following three principles should play a due to ill health, associated expenditure, and loss central role in evaluating the available alternatives: of earnings should be minimized. 1. Health benefit maximization. This involves generating the greatest total health-related There are different acceptable ways of balancing well-being gain. This is measured in terms of the these three substantive principles’ requirements. total number of healthy life years added through Moreover, these principles are not exhaustive. an intervention. (One healthy life year is an There is no simple recipe for arriving at the right amount of health-related well-being that is just decision and there may be reasonable disagree- as valuable to a person as one year in full health. ment on which decisions are right. Under such For example, a person gains a healthy life year by circumstances, fair procedures for setting priorities living one extra year without health problems, or contribute to the legitimacy of decisions. Making by living two extra years with health problems fair choices therefore also endorses