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<p class="MsoNormal"><b style><span style="font-family:Arial">Brief
summary</span></b></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">The
following three-part strategy can be useful for countries seeking fair
progressive realization of UHC:</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Categorize
services into priority classes. Relevant criteria include those related </span></p>
<p class="MsoNormal"><span style="font-family:Arial">to
cost-effectiveness, priority to the worse off, and financial risk protection.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">First
expand coverage for high-priority services to everyone. This includes </span></p>
<p class="MsoNormal"><span style="font-family:Arial">eliminating
out-of-pocket payments while increasing mandatory, progressive </span></p>
<p class="MsoNormal"><span style="font-family:Arial">prepayment
with pooling of funds.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">While
doing so, ensure that disadvantaged groups are not left behind. These </span></p>
<p class="MsoNormal"><span style="font-family:Arial">will
often include low-income groups and rural populations. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><b style><span style="font-family:Arial">Executive
summary</span></b></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Universal
health coverage (UHC) is defined as all people receiving quality health
services that meet their needs without being exposed to financial hardship in
paying for the services. Given resource constraints, this does not entail all
possible services, but a comprehensive range of key services that is well
aligned with other social goals. UHC was firmly endorsed by the World Health
Assembly in 2005 and further supported in the World Health Report 2010. Since
then, </span></p>
<p class="MsoNormal"><span style="font-family:Arial">more
than seventy countries have requested policy support and technical advice for
UHC reform from the World Health Organization (WHO). In response, WHO developed
a plan of action that included providing guidance on how countries can manage
the central issues of fairness and equity that arise on the </span></p>
<p class="MsoNormal"><span style="font-family:Arial">path
to UHC. The WHO Consultative Group on Equity and Universal Health Coverage was
set up to develop this guidance.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">This
document is the Consultative Group’s final report. The report addresses the key
issues of fairness and equity by clarifying these issues and offering
recommendations for how countries can manage them. The report is relevant for a
wide range of actors and particularly for governments in charge of overseeing
and guiding the progress toward UHC. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">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 choices. For fair
progressive realization of UHC, the three critical choices and the trade-offs
between the dimensions must be carefully addressed. </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Expanding
priority services</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">When
expanding services, the crucial question is which services to expand first.
Services can be usefully categorized into three classes: high-priority,
medium-priority, and low-priority services. Relevant criteria for ranking and
categorizing services include those related to cost-effectiveness, priority to
the worse off, and financial risk protection. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">When
selecting which services to expand next, it is often useful to start with
cost-effectiveness estimates and then integrate the concern for the worse off
as well as other relevant criteria. The specification, balancing, and use of
these criteria should take place in the context of robust public deliberation
and participatory procedures. This will enable a wide range of groups to
provide input to the priority-setting process and <a name="11"></a>promote
accountability for the decisions made. Countries will also benefit from having a
standing national committee on priority setting to handle particularly
difficult cases.</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Including
more people</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">When
seeking to include more people, an inescapable question is whom to include first.
To include more people fairly, countries should primarily first expand coverage
for low-income groups, rural populations, and other groups disadvantaged in
terms of service coverage, health, or both. This is especially important for
high-priority services. Fair inclusion of more people may call for targeted
approaches where these are effective. </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Reducing
out-of-pocket payments</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Many
countries rely heavily on out-of-pocket payments to finance health services.
Such payments represent a barrier to access to health services, especially for
the poor. In addition, for those who do use the services, out-of-pocket
payments are often a substantial financial burden on them and their families
and may even cause financial catastrophe. To improve access and financial risk
protection, countries should therefore shift from out-of-pocket </span></p>
<p class="MsoNormal"><span style="font-family:Arial">payment
toward mandatory prepayment with pooling of funds. A critical issue is how to do
so. Fairness suggests that out-of-pocket payments should first be reduced for
high-priority services and for disadvantaged groups, including the poor.
Regarding mandatory prepayments, fairness suggests that they should generally
increase with ability to pay and that contributions to the system should be
progressive. At the same time, the access to services should be based on need
and not ability to pay. </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Overall
strategy and pathways </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">A
three-part strategy can be useful for countries seeking fair progressive
realization of UHC:</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Categorize
services into priority classes. Relevant criteria include those related </span></p>
<p class="MsoNormal"><span style="font-family:Arial">to
cost-effectiveness, priority to the worse off, and financial risk protection.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">First
expand coverage for high-priority services to everyone. This includes </span></p>
<p class="MsoNormal"><span style="font-family:Arial">eliminating
out-of-pocket payments while increasing mandatory, progressive </span></p>
<p class="MsoNormal"><span style="font-family:Arial">prepayment
with pooling of funds.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">While
doing so, ensure that disadvantaged groups are not left behind. These </span></p>
<p class="MsoNormal"><span style="font-family:Arial">will
often include low-income groups and rural populations. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">As
part of an overall strategy, countries must carefully make choices within as
well as across the dimensions of progress. These choices will depend on
context, and several different pathways can be appropriate. However, when
pursuing fair progressive realization of UHC, some trade-offs are </span></p>
<p class="MsoNormal"><span style="font-family:Arial">generally
unacceptable:</span></p>
<p class="MsoNormal"><span style="font-family:Arial"><span style> </span></span></p>
<p class="MsoNormal"><span style="font-family:Arial">Unacceptable
trade-off I:</span></p>
<p class="MsoNormal"><span style="font-family:Arial">To
expand coverage for low- or medium-priority services </span></p>
<p class="MsoNormal"><span style="font-family:Arial">before
there is near universal coverage for high-priority services. This includes </span></p>
<p class="MsoNormal"><span style="font-family:Arial">reducing
out-of-pocket payments for low- or medium-priority services before </span></p>
<p class="MsoNormal"><span style="font-family:Arial">eliminating
out-of-pocket payments for high-priority services.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Unacceptable
trade-off II: To give high priority to very costly services whose </span></p>
<p class="MsoNormal"><span style="font-family:Arial">coverage
will provide substantial financial protection when the health benefits </span></p>
<p class="MsoNormal"><span style="font-family:Arial">are
very small compared to alternative, less costly services. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Making
fair choices on the path to universal health coverage</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Unacceptable
trade-off III: To expand coverage for well-off groups before doing </span></p>
<p class="MsoNormal"><span style="font-family:Arial">so
for worse-off groups when the costs and benefits are not vastly different. This
</span></p>
<p class="MsoNormal"><span style="font-family:Arial">includes
expanding coverage for those with already high coverage before groups </span></p>
<p class="MsoNormal"><span style="font-family:Arial">with
lower coverage.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Unacceptable
trade-off IV: To first include in the universal coverage scheme only </span></p>
<p class="MsoNormal"><span style="font-family:Arial">those
with the ability to pay and not include informal workers and the poor, </span></p>
<p class="MsoNormal"><span style="font-family:Arial">even
if such an approach would be easier.</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Unacceptable
trade-off V: To shift from out-of-pocket payment toward </span></p>
<p class="MsoNormal"><span style="font-family:Arial">mandatory
prepayment in a way that makes the financing system less </span></p>
<p class="MsoNormal"><span style="font-family:Arial">progressive.</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Mechanisms
and institutions</span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial">Fair
progressive realization of UHC requires tough policy decisions. Reasonable
decisions and their enforcement can be facilitated by robust public
accountability and participation mechanisms. These mechanisms are essential in
policy formulation and priority setting and specifically in addressing the
three critical choices on the path to UHC and the trade-offs between dimensions
of progress. These mechanisms are also crucial in tracking resources and
results. To properly play these roles, public accountability and participation
should be institutionalized, and the design of legitimate institutions can be informed
by the Accountability for Reasonableness framework. </span></p>
<p class="MsoNormal"><span style="font-family:Arial">A
strong system for monitoring and evaluation is also needed to promote accountability
and participation and is indispensable for effectively pursuing UHC in general.
</span></p>
<p class="MsoNormal"><span style="font-family:Arial">Countries
must carefully select a set of indicators, invest in health information
systems, and properly integrate the information into policy making. The
selection of indicators should be closely aligned with the goal of UHC and in
most settings include at least four types of indicators: indicators related to
the priority-setting processes and indicators of coverage, financial risk protection,
and health outcomes. The latter three types of indicators should reflect both
average levels and equity in distribution. </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
<p class="MsoNormal"><span style="font-family:Arial"> </span></p>
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