Since 2010, more than one hundred countries have requested policy support and technical advice for universal health coverage (UHC) reform from the World Health Organization (WHO). 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 by offering practical recommendations.

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. Countries can do the following:

  • 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
  • When doing this, 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 needed to promote accountability and participation and is indispensable for effectively pursuing UHC.

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