Making Fair Choices on the Path to Universal Health Coverage. Final Report of the WHO Consultative Group on Equity and Universal Health Coverage
(2014; 84 pages)


Since 2010, more than seventy countries have requested policy support and technical advice from the World Health Organization (WHO) for how to move toward universal health coverage (UHC). As part of the response, WHO set up a Consultative Group on Equity and Universal Health Coverage. This final report by the Consultative Group addresses the key issues of fairness and equity that arise on the path to UHC by clarifying these issues and offering recommendations for how countries can manage them.

To achieve UHC, countries must advance in at least three dimensions. Countries must expand priority services, include more people, and reduce out-of-pocket payments. However, in each of these dimensions, countries are faced with a critical choice: Which services to expand first, whom to include first, and how to shift from out-of-pocket payment toward prepayment? A commitment to fairness—and the overlapping concern for equity—and a commitment to respecting individuals’ rights to health care must guide countries in making these decisions.

The following three-part strategy can be useful for countries seeking fair progressive realization of UHC:

Categorize services into priority classes. Relevant criteria include those related to cost-effectiveness, priority to the worse off, and financial risk protection. First expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. While doing so, ensure that disadvantaged groups are not left behind. These will often include low-income groups and rural populations.

As part of an overall strategy, countries must carefully make choices within and across the dimensions of progress. These decisions depend on context, and several different pathways can be appropriate. Nevertheless, some trade-offs are generally unacceptable. For example, one generally unacceptable trade-off is expanding coverage for low- or medium-priority services before there is near-universal coverage for high-priority services.

When pursuing UHC, reasonable decisions and their enforcement can be facilitated by robust public accountability and participation mechanisms. These mechanisms should be institutionalized, for example, through a standing national committee on priority setting, and the design of legitimate institutions can be informed by the Accountability for Reasonableness framework. A strong system for monitoring and evaluation is also crucial for promoting accountability and participation and is indispensable for effectively pursuing UHC.

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