LSE research making the case for a pluralist egalitarian approach to universal healthcare has helped to shape a landmark report by the World Health Organization (WHO).
What was the problem?
Universal health coverage is a priority for the WHO and part of the United Nation’s 2015 sustainable development goals. However, because of resource constraints, countries must make difficult choices when making efforts to improve healthcare provision and achieving universal coverage.
In response to requests from more than 70 countries, in 2012 the WHO founded its Consultative Group on Equity and Universal Health Coverage to provide guidance on how to make these choices fairly – that is, in accordance with compelling principles of justice. This guidance needed to balance different perspectives on principles for determining healthcare priorities. Prior to this initiative, much of the WHO’s advice had emphasised cost-effectiveness criteria alone when designing public healthcare policies.
What did we do?
The consultative group established by the WHO to consider principles of universal health coverage consisted of 18 philosophers, economists, health policy experts, and clinical doctors of 13 nationalities. Professor Alex Voorhoeve was asked to join because of his expertise in distributive justice. The group’s report, “Making Fair Choices on the Path to Universal Health Coverage”, was published in 2014.
The group members brought different views to the process. Some were utilitarians, who advocated an exclusive focus on maximising health-related wellbeing. Others were purely relational egalitarians, who held that the health sector should help ensure that citizens are free from domination, discrimination, and marginalisation, but were not concerned with distributive equality as a value in itself. In contrast, in a series of articles, Voorhoeve and co-authors, including LSE’s Professor Michael Otsuka and former Lachmann Fellow at LSE Professor Marc Fleurbaey, have defended a pluralist egalitarian theory of distributive justice, and applied this to priority-setting in health and the design of health insurance.
This pluralist theory integrates and balances (when they are in tension) the concerns of the utilitarians and relational egalitarians, while supplementing them with the distributive egalitarian aim of reducing inequality in both expected wellbeing and wellbeing outcomes. Voorhoeve grounds this theory in a concern for improving wellbeing and for its fair distribution, as well as in respect for both the unity of the individual (which directs us to do things that maximise the quality of each person’s prospects, as utilitarianism requires) and the separateness of persons (which directs us to give extra weight to helping the worse-off, as egalitarianism requires).
Voorhoeve’s articles and contributions to the committee’s deliberations played a central role in the report’s endorsement of a form of pluralist egalitarianism. They showed how apparently competing concerns could be integrated in a consistent and well-grounded overarching view, which also represented a principled compromise given the committee members’ diverse viewpoints.
The report advised that, to achieve universal health coverage, countries must advance in at least three dimensions: they must expand priority services, include more people within health services, and reduce out-of-pocket payments. In each of these dimensions, they face a critical choice in terms of which services to expand first, whom to include first, and how to shift from out-of-pocket payment towards prepayment and pooling of funds.
The report recommends a three-part strategy for making these choices fairly. Firstly, services should be categorised into high-, medium-, and low-priority classes. This is done using three criteria: maximising total health gain by choosing the most cost-effective interventions; giving special consideration to gains for the worst-off; and fair contribution and financial risk protection, so that economic hardship from healthcare needs are minimised. These principles embody the pluralist egalitarianism defended by Voorhoeve.
Secondly, countries should concentrate first on expanding coverage for high-priority services to everyone, which includes eliminating out-of-pocket payments for them. And thirdly, countries should ensure that disadvantaged groups, such as those on low incomes, marginalised minorities, and rural populations, are not left behind.
Professor Voorhoeve’s arguments for a pluralist egalitarian view of distributive justice shaped this landmark WHO report. The report – endorsed in full by then Director-General of the WHO, Dr Margaret Chan – has directly led to a change in the WHO’s policy guidance to member states. It now advises them to consider not just cost-effectiveness but also egalitarian criteria when designing public healthcare coverage.
The WHO and its agencies extensively promote this report, particularly in Latin America, where it has helped to inform training, highlight inefficiencies and inequities, and provide a principled basis for selecting health interventions in numerous countries, including Chile, Argentina, Colombia, Costa Rica, Mexico, Peru, and Trinidad and Tobago. The World Bank has also joined the effort to ensure uptake of the report’s principles, discussing how they might be applied to health financing more broadly.
Public health agencies in several countries have adopted the report’s principles for priority-setting. One prominent example is in Ethiopia, where Professor Ole Norheim (lead author of the report) was commissioned by the Ministry of Health to advise on the country’s review of its essential health services package in 2018/19. Together with Ethiopian collaborators, he ran an open consultation which resulted in the adoption of seven priority-setting criteria, including the report’s three main criteria. These were employed to rank 1,018 potential health interventions and classify 594 of them as high priority. The Ministry of Health then committed to providing 540 of these free of charge.
The Ethiopian government further asked members of the report’s consultative group to give research-led advice for its expansion of health insurance and to provide long-term capacity-building in priority-setting. To this end, it has set up the Center for Medical Ethics and Priority-Setting at Addis Ababa university. The programme is funded by a GB £5 million grant by the Gates Foundation and NORAD (the Norwegian Agency for Development Cooperation) and encompasses Zanzibar too. Members of the consultative group, including Voorhoeve, have provided training in Ethiopia twice per year since 2017, covering medical ethics and priority-setting.
A second key case is Norway, where the report’s principles were followed in an advisory report to the government, also led by Norheim. Its pluralist egalitarian approach to priority-setting was endorsed by the Norwegian Parliament, and it is now employed by the Norwegian Institute of Public Health (NIPH), which carries out health technology assessments for the Norwegian government. It is also used to support NIPH’s advice on priority-setting in lower- and middle-income countries and in global institutions.
The report’s principles have also led to concrete changes in the way specific health interventions are evaluated by organisations. For example, GAVI, the Vaccine Alliance, which helps to vaccinate around half of the world’s children, has appealed to the report’s conception of equity to motivate investments to boost demand for immunisation among individuals and communities.
In sum, the widespread adoption of the report’s pluralist egalitarian principles has led to a marked change in the evaluation and prioritisation of health interventions around the world. This will help secure more equitable access to healthcare in many countries, including in the Global South.