Bulletin of the World Health Organization

Making fair choices on the path to universal health coverage

Trygve Ottersen a, Ole F Norheim a & on behalf of the World Health Organization Consultative Group on Equity and Universal Health Coverage

a. Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway.

Correspondence to Trygve Ottersen (email: trygve.ottersen@isf.uib.no).

Bulletin of the World Health Organization 2014;92:389. doi: http://dx.doi.org/10.2471/BLT.14.139139

Universal health coverage is at the centre of current efforts to strengthen health systems and to improve the level and distribution of health services. It is high on the global and national agendas of many countries, many of which have already made significant progress.14 The compelling case for universal health coverage derives principally from the values of fairness and equity, and these values are also critical on the path to that goal. If universal coverage cannot be attained immediately, making progress fairly and equitably should be the main concern.

Motivated by this insight, the World Health Organization (WHO) in 2012 set up a Consultative Group on Equity and Universal Health Coverage. This initiative was also part of the response to the more than 50 countries that had requested related policy support and technical advice from WHO. The consultative group was unusual in that it consisted of philosophers, economists, health-policy experts and clinical doctors, spanning 13 nationalities. Such a composition helped the group address fundamental normative issues and difficult trade-offs in an unconventional way. The final report, entitled Making fair choices on the path to universal health coverage, was launched in London on 1 May 2014.5 The report addresses and clarifies the key issues of fairness and equity that arise on the path to universal coverage and recommends ways in which countries can manage them.

No country starts from zero coverage, and there is no single path towards universal coverage that every country should follow. At the same time, to achieve universal coverage, countries must advance in at least three dimensions. They must expand priority services, include more people and reduce out-of-pocket payments. The consultative group analysed how countries repeatedly face critical choices in each of these dimensions: Which services to expand first, whom to include first, and how to shift from out-of-pocket payment towards prepayment. To help countries make choices, the consultative group suggested the following three-part strategy for fair progressive realization of universal health coverage. First, categorize services into priority classes. Relevant criteria include those related to cost–effectiveness, priority to the worse off, and financial risk protection. Second, expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. Third, ensure that disadvantaged groups are not left behind. These will often include low-income groups and rural populations.

The consultative group identified several trade-offs that would not usually be acceptable when pursuing universal health coverage. One would be to expand coverage for low- or medium-priority services before near-universal coverage exists for high-priority services. For example, it would normally be unacceptable to expand coverage for coronary bypass surgery before securing universal coverage for skilled birth attendance and services for fatal childhood diseases that are easily preventable or treatable.

Several mechanisms and institutions can support the fair and progressive attainment of universal health coverage. In particular, effective public accountability and participation mechanisms can facilitate reasonable decisions and expedite the implementation of these decisions. The consultative group suggested that these mechanisms should be institutionalized, for example, through a national standing committee on priority setting and that the accountability for reasonableness framework can guide the design of such institutions.6 A strong monitoring and evaluation system is also essential.7

The findings and recommendations of the consultative group are highly relevant to everyone involved in pursuing universal health coverage. The guidance offered should be particularly helpful to governments. In addition, the analysis should stimulate further debate and reflection in the global health community about the choices and trade-offs that appear on the path to universal health coverage.


Other members of the WHO Consultative Group on Equity and Universal Health Coverage and contributors to this manuscript are: Bona M Chitah, Richard Cookson, Norman Daniels, Frehiwot B Defaye, Nir Eyal, Walter Flores, Axel Gosseries, Daniel Hausman, Samia A Hurst, Lydia Kapiriri, Toby Ord, Shlomi Segall, Gita Sen, Alex Voorhoeve, Daniel Wikler and Alicia E Yamin. WHO staff that contributed to the report and this manuscript are: Tessa TT Edejer, Andreas Reis, Ritu Sadana and Carla Saenz.