How can we make fair choices on the path to Universal Health Coverage?

Achieving Universal Health Coverage (UHC) and thereby making high quality, essential healthcare accessible and affordable to everyone is a key priority for the World Health Organization (WHO). However, extreme resource constraints mean this cannot be achieved in one go and difficult choices must be made when deciding how to incrementally improve provision on the path to universal coverage.

How should governments and international organisations make these choices? And which principles should we follow when evaluating progress towards the goal of UHC? These were the key questions set out by the WHO when founding its WHO Consultative Group on Equity and Universal Health Coverage in 2012.

What has philosophy got to do with economic healthcare policy?

As an expert in distributive justice, Professor Alex Voorhoeve from LSE’s Department of Philosophy, Logic and Scientific Method was asked to join the group. “I work at the intersection between economics and theories of distributive justice. I use economic tools to make sense of questions of fairness and develop theories to inform policymaking,” he explains.

The committee consisted of 18 philosophers, economists, health policy experts and clinical doctors, who all brought very different perspectives to the table.

The WHO asked the group firstly for advice on the moral principles that countries should be guided by when making resource decisions about health coverage and secondly for illustrative examples of policies and institutions already abiding by those principles.

Professor Voorhoeve’s work focused on the former - the moral principles that should be adopted - and he advocated for a “pluralist egalitarian” approach. This approach brings together the ideas that we should improve individual health prospects, raise population health prospects, and reduce inequality between individual health prospects and outcomes. The upshot is a view that assigns special importance to helping the worse off.

The importance of helping the worse off

Professor Voorhoeve’s arguments for a pluralist egalitarian view of distributive justice played a central role in shaping the committee’s final report and represented a compromise between the committee members’ diverse opinions.

The report recommended that to achieve UHC, countries must expand priority services, include more people within health services and reduce out-of-pocket payments. To help make choices about which services to expand first, who to include first and how to shift from out-of-pocket payments towards prepayment and the pooling of funds, the report suggested services should be categorised into high, medium and low-priority classes.

This can be achieved using three criteria: (1) maximising total health gain by choosing the most cost-effective interventions; (2) giving special consideration to gains for the worst-off; and (3) fair contribution and financial risk protection thus minimising economic hardship from healthcare needs. These principles reflect the arguments put forward by Professor Voorhoeve.

Providing universal healthcare for all will be huge challenge – but it can be done

When it comes to achieving the report’s recommendations, he believes one of the biggest challenges will be increasing the number of people covered by health services. “What often happens is that those who need healthcare the most are the last to be covered by health insurance schemes,” he says.

“Often, the first to have health insurance are those working in the formal sector on stable employment contracts for large employers. This leaves out everyone in the informal sector such as street sellers and rickshaw drivers. Countries often don’t have data on these people so it’s harder to collect, enforce and track their contributions. These workers also lack political power.”

However, Professor Voorhoeve believes both formal and informal workers can be provided for and uses the example of Thailand, a middle-income country that has managed to achieve UHC, to highlight this point.

In the early 2000s, Thailand started a system of small pre-payments, large subsidies and large tax-financed contributions to raise funds and support a well-defined basic healthcare package for everyone. “Healthcare in Thailand was made very accessible by limiting what was on offer and being realistic with this rather than over-promising,” he argues.

The report has been endorsed and promoted by the WHO and several countries including Ethiopia and Norway have adopted its principles.

How can we ensure fair processes for financing health interventions?

The World Bank and the Norwegian Institute for Public Health have now also taken up one of the concerns highlighted in the report – the need for a fair, open and inclusive process for setting priorities - and have invited Professor Voorhoeve to participate in a project exploring fair processes for financing health interventions.

Instead of focusing on substantive principles of justice, such as distributive equality, which Professor Voorhoeve worked on in the WHO report, this new project focuses on fair procedures for setting priorities and raising funds. It explores the question of how we find the resources to fund universal healthcare and how we decide in an open and accountable manner where to get those resources from when there is disagreement about it.

This move from working on substantive principles of justice – something Professor Voorhoeve was very familiar with – to procedural principles has been a challenge for him. “I’m a newcomer to questions of procedural justice so I have had to learn a lot from others, but it’s also been very exciting,” he says.

The World Bank and Norwegian Institute for Public Health report will be out later in 2022.

Professor Alex Voorhoeve was speaking to Charlotte Kelloway, Media Relations Manager at LSE.