Countries around the world are setting out on the path to Universal Health Coverage but there are difficult choices to face along the way. Philosophy can help.

The importance of Universal Health Coverage

I live in the UK. This morning I caught two trains and walked from the station to the Department, crossing several roads. I do this almost every morning, sometimes with my mind on other things. It’s not unimaginable that one day I will be injured on one of these trains or whilst crossing one of these roads. What would happen to me? Assuming my injuries aren’t fatal, I would probably end up in hospital where I would receive the necessary medical care and in receiving this care I would not be exposed to financial hardship. Which is reassuring.

Medical care can be expensive. Even a relatively straightforward injury, like a broken leg, could require ambulance transport, initial consultation, diagnosis, pain relief, setting, crutches etc. These costs quickly add up. Imagine being responsible for the cost of your medical care at the point of injury. Not a nice thought. Now imagine being one of the millions of people around the world living on less than $1 a day and being responsible for these costs.

Luckily for me, in the UK everybody is eligible for the same standard of health care and the welfare system ensures that nobody is excluded from care for financial reasons. The UK has a system of Universal Health Coverage.

Universal Health Coverage is both fair and equitable: everybody, no matter what their social status or financial situation, has access to the same standard of health care. I take the existence of this system for granted. Unfortunately, in many parts of the world people can’t.

Two kinds of question

So why isn’t Universal Health Coverage more widespread? Well, for one thing it’s expensive: health care services need to be paid for and many countries just don’t have the resources to expand all of their services in one go. This presents governments with a difficult choice: which service to expand first?

This may seem like a practical concern but there’s also another element to this question. Something that philosophy can help with.

Consider these two kinds of question: what can be done? What ought to be done? The first of these we can call a practical question. The second, a normative question. Although these questions may have the same subject, they do seem to be asking different things. Of course, the answers to these questions are often connected. If I say that you ought to do x, this often implies that x is one of the options open to you: that you can do x. On the other hand, in asking whether you can do x, it’s appropriate to also consider whether x is something that you ought morally to do. However, these questions need to be approached in different ways.

Take the question of which services to expand first on the path to Universal Health Coverage. A satisfactory answer to the practical question – which services can be expanded first? – could proceed by listing the different options open to the policy-maker: the path to Universal Health Coverage could begin with the expansion of, say, coverage for the prevention of diabetes and heart disease or coverage for kidney dialysis. The practicalities of each of these options could then be considered. This procedure is best left to those with the right knowledge and expertise in medicine, health-policy and economics.

Now consider the normative question: which of these services ought to be expanded first? Although one of these options my be more or less practical than the other, practicalities are not the only things that need to be taken into account when deciding what we ought to do.

Let’s suppose that both of the options are equally practical, now think about which ought to be chosen. To answer the normative question we need to think about what of value can be brought about by our choice. Not monetary or practical value, but moral value. In this case, the policy-maker needs to consider the extent to which either option will lead to an increase in well-being by alleviating the suffering brought about by ill-health.

So, to answer the normative question we need to work out which of these options provides the greatest increase in well-being. This sounds easy enough, but it may not be. Consider this: although the expansion of dialysis services will help alleviate the suffering of people in extremely poor health now, the expansion of preventative services for diabetes and heart disease is likely to prevent more people from becoming ill in the future.

On the one hand we have relatively few people for whom we can provide a large increase in well-being immediately (the dialysis option) and on the other we have a larger number of people for whom we can prevent a potential decrease in well-being levels in the future. How is the policy maker to decide which of these options ought to be chosen? How should they weigh current against future well-being?

As you can see, answering the normative question is not a simple matter. In facing the choices that arise on the path to Universal Health Coverage the policy-maker is likely to encounter questions such as: on what basis ought you to choose x over y? Is x of greater moral value than y? These are exactly the kind of questions that the moral philosopher can help to answer.

A fairer path

With this in mind, the World Health Organization established the Consultative Group on Equity and Universal Health Coverage in 2012. The group consisted of philosophers, economists, health-policy experts and clinical doctors from 13 nationalities, including moral and political philosopher Alex Voorhoeve, Associate Professor here in the Department.

The group’s final report, Making fair choices on the path to universal health coverage, argues that the difficult choices that arise on the path to Universal Health Coverage should be approached with a commitment to the principles of fairness and equity. From this commitment the report offers recommendations for how to answer the kinds of normative questions policy-makers are likely to encounter.

By bringing together experts from so many fields, this report has been able to recommend ways in which governments can and ought to proceed on the path to Universal Health Coverage. Let’s hope that with their help the existence of a system of Universal Health Coverage will soon be taken for granted by all.

By Ewan Rodgers


Alex Voorhoeve is Associate Professor in the Department of Philosophy, Logic and Scientific Method. A record of his work on the World Health Organization’s Consultative Group on Equity and Universal Health Coverage and of the impact of their final report is available here.


Featured image credit: United States Mission Geneva / CC BY 2.0